Loading...
7 ROSLYN ST - BUILDING INSPECTION Crry-Br SAL 1 — PUBLIC PROPERTY DEPARTMENT KIMBER EY DUSCULL MAYOR 120 WASHINMM STREET S.'�MAAncxt;st-rIs 01970 TU--978-745-959S 0 FAY:97&740-9846 APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION. DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: Building: Property-Address: -- Property Address—!j �p S L y,,j�i r-ee - 0 f q ?O Property is located in a; Conservation Area Y/N_ V Historic District Y/N Al 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: - U.._ P 5 Address: e0.5 1Yeel .1/7 - ✓alel-1I - 129aC Telephone: q o 3 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: (qep10,cP,ne.Ali �I IAIDO W) Mail Permit to: What is the current use of the Building? �Z 8 S /Ole,Al � N "i Material of Building? `� % V C G If dwelling. how many units? oZ Will the Building Conform to Law? YC'S Asbestos? Architect's Name Address and Phone ( j Mechanic's Name �'c � ' ; ` 13 Ct Address and Phone Construction Supervisors License# CS o?y3d,5 HIC Registration# Estimated Cost of Project$ =00 Permit Fee Calculation Permit Fee $ Estimated Cost X$7l$1000 Residential ---- - — — — — — Estimated-CostX$11/$1000-Commercial— An Additional $5.00 is added as an Administrative charge. Make sure that all fields are property and legibly written to avoid delays In processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury X Date y d � � 9 � V 00 � O v •• �' 't7 L u ti, a F CPTY OF SALEM PUBLIC PROPRERTY DEPARTMENT MAYM uo VA""OrOMSTmaaT a SAUK MAXAOW41M0lW0 TM-WW45-939S a FAM 97 40-9M Workers' Compensation Insurance APRdavtto Bv0ders/C6ntraetors/E1 Ano)icant informadon a lsrint r 4lib ly Names ): �/1l % i�c r frz��f e rr�dic� c city/stata0P:���.� ,�,os.S �/z�rr/ one#. _ 7L/ Am yom as employer?Check the appmpetaft boss 1.® 1 am a employer with C Q I am a gemral contractor and I ��•t Pro) (wgalydj: empk►yeea(ra andter pa�dme).• have hired the wb.txmtraeoors 6. ❑NeA'consettctiaa 2.831 am A sole PrnP bdW or Parmms listed on the atmohed shoat.t 7. Q Remodeling ship and have no employes These atb.00ntracton have 8. Q Demolidat working for me in any capacity. workers'comp,insurance. 9. [No workers'camp.imnteanee S. Q We am a corporation and its Q n8 addition required.) officers have exereited their 10.0 Electrical rspaits or additions 3.Q I am a homeowner doing all work right of exemption per MGL 11.13 Plumbing rapain or additions my"M[No workers'c0034;L c. 152,410),and we have m imanance m4u�)t employees.[NO workers' 12.Q Roof repairs oomp.insn ae ) 13.Q i 1 / 1Any *A drdr ban al sat$doe tID os on ncdm blow dow'"6*ws, ,aerPMrtlm pa8ay Hamaorews who adhrdt this alildaoa bdkedas htw an dole$as ash rd diss No , i m,a �ashdl a Maw afahhartt tCaanaetss eaa Chock 114 box Mart Aftd d m adntlead Aw Aswle$dw saaw ardor sbCOanscim aW dwk watbhha'coo*PORM btasaw am am 8AMPAW tkat 4 provMut workers'rn In/orwwdorawpewsadow 6tsrraweeJor say rwp/oYees Blow b rk000lkl awdJel sit$ Issuance Company Name:-_ G Polity M or Self--ins Lis N_ L eij -- 92 /C 11A GEapiation Date 0 6 Job site Addraa: Qo,; /YM Attach a Copy of the worken'compeandom policy dselandin Pags(showing the Polley member,stool sapleaftom daft)6 Failure to secure coven 8s a.required under Section 23A of M fine u to t GL c 132 can lead to the ttnpoaitiee of criminal S 00 oft p ,500 and/or ores- P� of u to 5230.00 a day a Y����as wetl at civil pemltia in the form of a STOP WORK ORDER and a line P Y t�the violame Be advised that a copy of Ibis swemem may be forwarded to the 08ke of Investigations of the DIA for insunoce coverage veriRpdon f do kereby cord&awder As pains and o/pePhone r/ tke iw/orawdowMov/dd above b trw sort eorrret 791— 760 —S/ O,Q?elwi wse o-ot Do not write to tkit weft ft be cosP/eted by cAp or town opk&L City or Town: Permluticense M Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.CitYfrown Clerk 4. Electrical Inspector ! Plumbing Inspector 6.Other Contact Person: Phone N Information and lnstrucuum under e Laws chapter 1$2 requires b{asaacbusetas General ns all employars to Providd compensation far their m*MPUYm u defined as"..Avery Perms in the serviceworke o!another nds any conti+cg tibbias,h% Pursuant to this statute. .�, «implied.oral«wnttm express,cc eorposatim or°�legal entity.at any two«moeti he An 60000 is defined as"m individual. M and including tp the legal representatives of a dcontsed MpW empa& IlOr wavo the o!the foe fioini g of an i 1di ° association at legal coat -msP'OybN C°°P1oYO0a receiver at tntstte of m indviduals of owe tmp. and who resides tingaia,or the occv. rat of the owner of a dwaSing bonne bavmg°°g man than tht� at nuts wort on such dwelling boow dweirwg bmw d anther wbo en VIVA persons sal not because o!arh employment h° to be anempbyer* or an the grounds or WAdin$Vruuum thants MGL chapter 152,4?SC(�also sates toss state er ices!licensing army sham wit6bold do isstsr�a� of a Hesaaa K per"to open"a business W tG eeaatrast btslldtap"Wu�sa commonwealth�n�. applicant suite bat sent ptredtsead aarePtnbL 1 WWMO� nor mY o(its political subdivWOOS� Additionally,MGL chapter 152,125C(7) wa&until Lr of comPlianoe with the iaatuatiw colm,imo,any contract of We cbaapterr have pr the esented to contacting SRAG Y requirements Appdeaatt cbwJdng the boxes that apply to your sitwsion end'it Phase fill ont the wodren'co conq Y phone wish then urtifinte(employees other then the a number(s)along s of supply subocovers""ce(s) al.C)or Limited Liability (LLP)with no in , I mns If m LLC or LLP doss have esembon«partners,art nag vxp*ed to rAt[y w compensation of hadnaorw "d employe0,a Policy is segWM& He advised that this affidavit may be submitted to the Department covaags. AIM be sue"SIP and date the affidavit, The afdavit should Accident f« of 10�0 application,for the permit of Henn is being regoed4 not the Department of be ramied to the city the law or if IndusUild Accidents, hSharl cc ldd You have the�4t► at*A number breed below ySel�mau wmrum °Om then oompeaaagfon policy,plea"call�Dapr»>tao< IhM. Self-insurance license ntttobac at the Cky W TWO Offickis lets and printed legibly. The Department has Provider a�°u the bottom Please be sure that the affidevit is comp has to contact you regarding the applicent of the affidavit fee you to fill out in the event the Office of Investigations number which will be used as a reference number. In addftia4 an applicant Please be son to fill in the P°n'W�0 liaationa in any given year,need only aubmit one affidavit indicating came°[ that must submit multiplernnWilcense "Job Site Address"the applicant should write"all locations m�.-(cttY« policy inf«mation(it has hem officially stamped«marked by the city Or town may be provided to do town).*A copy tithe affidavit that u m file for fimtie permits«Berates. A now aM&vu msst be filled out each applicant m Proof that a valor aidzen i ' net related to any business«commercial vsWUM ear.When a home owner«citizen is obtama)s a Po nss is permit (i.e.a dog Beene or Parnell to burn leaves etc.)said person is NOT regaircd t c�PktO thin affidavit The Office a[lovearigations would like to thank you in advance f«your cooperation and should you have any questions, Please do not besim"to give us a call' The Is address,teleph«ie and fa:oumbers the COtomoaW Wth Of Massach U40 Depatnag of bftsvid A=dt me O®a of yavadzu"ae 600 WASW910 shed Bea MA 02111 Tel. M 617-727-4900 ea 406 Or 1477-MASSAFE Fur 0 617-727-7749 Rtviscd 5-26.05 Www.IIIimVv/dig CrrY op Smma PVBuc PROPERTY DEPAITMENT w..o. 136at .s�o�x..noaasz,aot+re III&sm74&*W•r.SWM74& w Comsbrnctbo DArb Dbpead AlWavit (naA"itw as demmom s and move"wadi) 1s aooaoda a wl&me skif OMMIR dmo ShOl 9100AM Coder 790 C MI sedan 111.! CW ak and mepmvWkWA dIM 04010 Sq SWUNG INN 0 is beard va m•comet"mat dw dob momm0 Don Fhb arat!slWl ee disposed db s p�opw% lbmead waoe dispoed bdggt mo daQeed by MM e 1 11.3 LlAA. Ilse d�Ms will bo Otaaspo�0ad byt 5hOQIcornpeay Ile�i�e Wr eFle" The dabde wiU be disposed dle: S�o P pL,w. �Ac' ' Cfbcr e- wAM (same aL•Ire+�thrf ... . .... ` . - (yld.m d hsui�» Sigmas.of 1017