2A RUSSELL DR - BUILDING INSPECTION —_ C=OF3ALEM
PUBLIC PROPERTY
DEPARTMEINT 1 ��
"M.04 NAtuasst-rrs 01970
'Rai 97S-74S-9S"*FNc 976-740-95"
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: %cam Gn c� Building:
--
sa,(e .-, 011k. mcoo
Property Is located in a; Conservation Area YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address: M
Telephone: - crZk-'14 i - a't 41 C— 50$-43a- a14 i
3.0 COMPLETE THIS SECTION FOR WORK IN FYIIIIIN = BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing 1
Approximate year of Area per floor (sn Renovated
construction or renovation
of existing building I I New
Brief Desccrip�tion of Proposed Work:
�(
` � t
pet(acp w� l- vtnox
hoc -�b inJ0 C— cS\��e SJcroigls Woo fYlante)
Mail Permit to: Myt M�,
What is the current use of the Building?
Material of Building? LO eo If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone /
Mechanic's Name O21&}O
Address and Phone C) �x 5 3 ll r'
Construction Supervisors License# HIC Registration#
Estimated Cost of Pla,t,ed��$ ate'0, ao Permit Fee Calculation
Permit Fee tr Estimated Cost X$71$1000 Residential
-- -- - _- --- Estimated Cost X$1141000 Commercial
AnAdditional $5.00 is added as an
Administrable 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 state
specifications. Signed under penalty of perjury
Date
i
CIO
I� y�
\\11vv\\
n
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
rtaaaEatsY natsca L
MAYOR IM WAS OCTONSTRW a SALEK MASSACHUST1s01970
TEL 9A-745-9595 a FAX-972-740.9W
Workers' Compensation Insurance Affidavit. BnildeWContmtorgMect idansgq mbm
Applicant
Print
^\ _ 1Name(BusireaslOrgatairadottlhtdivithtai): � �li5 �9C:��1 �YJPC�Q, '�S 1 9'1 C
Address:. d
city/state/zip:C+gym, Yh C -1 g Ph..a: 7 a(- G to 10
Are yam an employer?Check the appropriate be= Type of pro]set(required):
1.® I am a employer with 9 4. ❑ 12019 Smell contractor and I 6 (�New construction
(1611 and/or part time).• have hired the subcontractor
2.❑ 1 am a sole proprietor at partner- listed on the attachad sheet t 7. Remodeling
ship and have no empktyeas Theca aubeontracsor have S. ❑Demolition
working for me in any capacity, workers'comp.instance. 9 Building addition
[No worker'comp.insurance 5. ❑ We are a corporation and its
required.] Other have exercised their 10•0 Electrical repair are additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.[I Plumbing repairs or additions
myself.[No workers'comp. c. 152.41(4).and we have no 12.0 Roof
insurance required]t employees.[No workers'
insurance require j 13.00 Other QcP t C `c�ce�
*Any Wpliosr dui dreb lose el a0nt seen as cut the mcdm tutor dosing ado wedca'eoetpaaadm
Itameovea who ch check
unitNo ban affAnowt nit a they a dahq all radt and due hbs otmide Maaemn tart saiait a am alRdeek hdlutb�ned,
rCoeesebsa that died[tlde hoe map attacked an odditlmd done shoving the sane of the ntbeoeenesn"and unk voeka'cusp.pdisy hegmaadm
/am an ewrployer that 4 providing workers'cosrpenrodow Wwance for cry empbsyeas Below lr tha policy ead job she
iwforaadkra
Insurance Company Name:
Policy s or Self-ins.Lie.N_ w C O!� 6 to a 6 (, Oy TT-3
0
/� Expiration Date:_
Job Site Address: � R-v5:;C1 D r' - awstaterzip.3&6—m LM 01q,7,0
Attach a copy of the workers'compensation policy declaration pave(showing the policy number and expiration date).
Failure to secure coverage As required under Section 25A of MGL a. 152 can lead to the'mom �' truss of criminal
fine up to 31,500.00 and/or one-year imprisonment, penalties a i
Y prisonment,as well as civil penalties in the form of a STOP WORK ORDER and a ine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to this Offte of
Investigations of the DIA for insurance coverage verification.
/do hereby earri under''Ae and penalties o rJwwlgqr that riot inforswdow provided above L trot an/corrsd
Sinature• l� Q Dl�' �i` �i)l()I nn Date! 0-2
Phone 4:
F
66 Do not writs iw tb6 area,to be conepistsd by chy or towno,(Jlcinj
Permlouccuserity(circle one):ealth 2. Building Department 3.Ciryfrown Clerk 4. Electrical Inspector S.Plumbing Inspector
Caatact Person: Phone q:
information and instructions
Massachuscus General Laws chapter 152 requires all employers to provide workers' compensation for their employees,
pursuant to this statute,an employee is defined an"..'every pin in the service of another under any contract of hits,
express or implied.oral or wnttm•"
or other legal entity.or any two of more
An enupfoye►is defined as"an individual,Partnership.association.corporation veer of a deceased employer,or the
of the foregoing engaged in a joint eoserpriae.and mchdmg the legal representatives However the
association or other legal entity.employing emp Y
owner of a dwelling boom� �00qmtescats and who resides therein.or the oaupad of the
dwelling souse of aaothar to do maintenance.eonst<+w�a r worh on arch dw ham
elling
who employs thereto shall not because of such employment he deemed to be an empbyar"
or on the grounds or building appurtenant
that"every state w local geensing agency shag withhold tb•Italian"or
MGL al Of
152.$25C(6)sasses mate a business or to construct buildings in the eommoaw*&"for&W
acceptable evWw*of esmPgaaes with the huuranes oovoraga requ�"
renewal o[•Ilcemt or permit
apptkant who here not produced 152.d estate«Neither the commonwealth not any of its political aubdiviaions shall
Additionally.MGL chapter e p $25C(7) le avidenee of compliance with the insurance
enter intoreq any centiact for the performance of Public work until acceptable
uiremmb of the chapter have been Presented to the contracting authe"ryw
Appueana
affidavit completely,by eheciting the boxes that apply to Your situation and,if
Please fill out the workers'cot on addteaa(es)and Phone number(s)along with that certificate(e)of
necessary.supply sub-conuactor(a)name(°), with no employees other than the
surancLimited Liability Companies(LLQ or Limited Liability Partnerships(If an LLC or LLP does have
mmbers' equired to carry waken m coma istion insurance.
members at partners,are not & Beadvised that this affidavit may be submitted to the Department of Iadudsvit
employtrid
a pow u coverer Abe be sure to sign and date the aflidsviL The affidavit should
Accidents for eonfirmation of i °an fce the permit oc license is being requested,not the DOP��Of
be returned to the city or the law a if you are required to obtain a workers'
l dustrial Accidents. Should you have any que�a regarding theenter their
cempenaa a policy,ptesse call the Department at the
fo number listed below. Self-insured companies
self- mm"license number on the
City or Town Oteelab
the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Please be sue that ns has to contact you regarding the applicant•
of the affidavit for you to fill out is the event the Office of Investigations o
Please be sure to fill in the permit/licrose number which will be used a,a reference number. In addition,ic applicant
that must submit multiple Permighcenes appltcanoos in any given year.need only submit one affidavit indicating currant
policy information(if necessary)and under"Job Site Address"the applicant should write'all locations ----(Cityor
or marked by the city or town may be provided
townca t copy of the of valiidiffld has hem officially stamped or licenses. A new af"-&vu must be filled out each
applicant as proof that a valid afRdsn. u to file for aliaeaae a mits�t not related to any business a commercial venture
yea.Where a home owner at citizen is obtaining this affidavit
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required ro completeI`
The Office o[investigations would like to thank you in advance for your cooperation and should you have any questions.
please do not hesitate to give us a call.
The ghparmaent's address.telephone and fax numbee
Thu Commonwealth of MmWIRMas
D"a uum of lnthlsirial Accidents
Ofiiee of Iavatlpflona
600 Wa bin(M Sftd
Boston,MA 02111
Tel. #617-7274900 ext 406 cc 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www. um&ov/dia
Crry OP SALE►m
PUBLIC PROPERLY
DEPAR1MFNT
1M 97&7464M&fats 97►74NW
— Consbvedos Debris Dblmd AMult
tEer ees dsaoQdos sod nasvades
is moidma week dw sisof sdidos a[d*st ft OWMI09 CWk 7M C!I,,loch 111.5
lodmik d dr p wAdow dMOL 444 s SM
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digoul dedggt s dsQad by!�.�
1 u.s 1lAA.
�debris wiu b.tr.dpaoea bye
U�1
IU debia will be disposed of in:JJ
COos6
the yp . oak C . tmeJ24pp ,
f�ranrse! � p21?lo
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r 11'oi l:c rr corti�+::u�ll,n
Construction... ,t,, I
—Pe ox i3
I c�lion oC Hot.ci tc:
MA. 02180
__ I ir., t:oauos�arcr�rforaring ill r�otk myxlf.
I an, so!: proprietor ind hiovc no onc Hotl_ing in any car city.
c:nploycrpro•,�ding NNotkCcs' comp:tv.ation for r.:y unyloytu ,cotl_ing on t'ilzj-!c,
corn;any runic: Phone
!nn=ncc company: Policy:
1 a:n so!c propri:lor, gcnual contractor, or homeo�.ncr (circle one) and h_zve hired the con��aaoa
li;;cd U-low ticho h„'c ncC folloMng wo[kcrz' cord,action policy:
Company name: Phonc
cc::.pany add:c-Ss. —aty: Sta(c:
s com many: ----- _--- Poliq: ---- .---
Cc:i�pany a,mc: Construction Specialties Phon: �F-< -6 s —mot a
��: • ._sP.O. Box 93stow, M
eliam --- --
aty: Sta,
i M& 02180 — ----
In:urancc Policy:
i
^.tta ch addiuottil shcc is i(nccusary'.
P+ilic to s-cure covcragc as rc,uircd under Scclion 25A of MGL 152 can Icad to the implcmu::atioa of
cri:niral p-rnaltics of a fmc up to 51,5w.00 and / or onc years' imprisonment as wC11 as civil p-nelucs in
C,c fora a 'STOP 1VORK ORDER- ard a fin: of 5100.00 a ny agai" m:. '1 undrlsland tlut a copy of
hL state r.,ent nuy tx fot�.ardcd to the O?icc of Invutigalion or the DIA for coverage vcrifi�- iJoa
ccr6�51 VIlder the pninr and perm!lies
Sirrv-:_urc of application: �c�, ,w,.�„ _ Datc:
�INL F( N_w Phone ?fir_&
0^_i._!,l Ucc Or''ti" rIi(: in tlu: Pi:-a — to t.- co;,plctc.! by city or lo',v:I
Ci'y or "1'b..�r __--_.__—_____— __ ._ Pcn •Jt M: — _I>'-"?C __--