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 $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date
y
d � �
9 �
V 00
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u ti, a
F
CPTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MAYM uo VA""OrOMSTmaaT a SAUK MAXAOW41M0lW0
TM-WW45-939S a FAM 97 40-9M
Workers' Compensation Insurance APRdavtto Bv0ders/C6ntraetors/E1
Ano)icant informadon a lsrint r 4lib ly
Names ): �/1l % i�c r frz��f e rr�dic� c
city/stata0P:���.� ,�,os.S �/z�rr/ one#. _ 7L/
Am yom as employer?Check the appmpetaft boss
1.® 1 am a employer with C Q I am a gemral contractor and I ��•t Pro) (wgalydj:
empk►yeea(ra andter pa�dme).• have hired the wb.txmtraeoors 6. ❑NeA'consettctiaa
2.831 am A sole PrnP bdW or Parmms listed on the atmohed shoat.t 7. Q Remodeling
ship and have no employes These atb.00ntracton have 8. Q Demolidat
working for me in any capacity. workers'comp,insurance. 9.
[No workers'camp.imnteanee S. Q We am a corporation and its Q n8 addition
required.) officers have exereited their 10.0 Electrical rspaits or additions
3.Q I am a homeowner doing all work right of exemption per MGL 11.13 Plumbing rapain or additions
my"M[No workers'c0034;L c. 152,410),and we have m
imanance m4u�)t employees.[NO workers' 12.Q Roof repairs
oomp.insn ae ) 13.Q i 1 /
1Any *A drdr ban al sat$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
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III&sm74&*W•r.SWM74& w
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(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:
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