22 SAINT PETER STREET - B-07-763 REROOF 2 SECTIONS CITY --
''' PUBLIC PROPERTY
DEPARTMENT
Kl.%MFJLLEy DRISCOLL / h
MAYOR 120 WASHINGTON STREET•SAI.E MASSACHI;SE'M 01970
14L 9-&74S-959S 0 F m 97&740.98"
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: S*f J'c 4 - .1, 6 e� I Building:
property is located in a;conservation Area YIN !✓ Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: Zni2/ w;1i1&�� -vt�l/4 X'r
Telephone: /, a itL/ ,0 G'
3.0 COMPLETE THIS SECTION FOR WORK IN EXIAXING 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 L
Brief Description o[f.Proposed Work: r u ,; w✓ rr c f!`�- r /d/
J(14vii( Y11 L�/ W! �S A! �//w l��C) ✓I/7 � L! �Trt�' l�vJ/�//L
Mail Permit to:
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name ,AZ
Address and Phone
Mechanic's Name �/,/.
Address and Phone
Construction Supervisors License# Ch% �P)2 HIC Registration#
Estimated Cog off PJroject$ `ML Permit Fee Calculation
Permit Fee$�L`=� Estimated Cost X$7/411000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly 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
Date v
0
r
a
rQ n
F' o L V ` >
96
r
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Knr.ealattxustou
MAYOR
12o VAgel=WSMW s UL 4,11"MOnnars01970
T1[L-9711445-"" a FAX 978+740AW
Woritera' Compensation Instarance Affidavit: BniiderWContraetorsMectdcllulplambm
Applicant Information
Name i duap: r-,l r7,1
Address:— 0-,O 'S
City/StMeMp: f 41r,2 i/ Phone#
Are you an esphsyart Cheek the appropriate boss
1.[�1 am a employer with 2 4. Q I am a yeoeral tractor and 1 �of project(r"u"o.
employes(tinB andlor patFl3me}a have=the a�drs�tra a ❑New eooateuctfon
2.Q 1 am a sole proprietor or pattser. listed on the attached sheet t 7. Q Remodeling
ship and have no employees TLw sub•conhaema have 8.
working the me in any capacity. watkms'comp 7wohm
❑Demolitiaa
corporats 9.
(No workers,camp iascanq S. ❑ We ars a s addltian
mq��) otflcros have exr 10.0 Electrical repairs or additions
3.Q I am a homeowner doing an work right of asomptioL 11.Q Phrmbing repairs or additions
Myself[No workers'comp, C. I3Z#1(41 anno
insurance )t employees.[No workers' 12.[�Rooftepaim
camp,insures required,) 13.Q Other
;A2r oppiieemr am abeb boa 01 mod des 1W ma the swaaaa Maw aim"nolr wakes,oospowwawo Daft Imesmmlaa
ttameswm a40 mbma ni eelbvlt bsmty a,wy.p daiq d.adc d er hie asWaw amaaamw man rabmk s rest eledwra
rCoenwCae tbm Auk Mks bas most mwodW aedaldamt them Amiga at moms*(dosed erk aarbrw'wR te�bnatea s,
f ate ow easPloyer that lsPmvld/wg worlws•compassadoa Gaaraacefor mp earp/oyres Below b tAe
informadaft Pof7 andjob sAsr
Insurance Company Name:-2✓✓/L// /w
Policy M or Self-ins.Lie.M
�/ Expiration Date•. �/i/G �
Job Site Address _ 2 if .S/t f` /`
Attack a copy of the workers'cons cation ry tete/Zip�4 Y�>
Pe Pohoi'declare a Page(showing the policy number said expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 132 can lead to the
fine up to S1,300.00 and/or one-year imprisonment,u wall as Civil mepoaitian of Criminal penalties of a
of up to$250.00 a day against the violator. Be advised that a penalties in the form of a STOP WORK ORDER and a fiae
Investigations of the DIA for i ropy of thin statement maybe forwarded to the OBke of
tnwraoce coverage verifieuion.
/Jo Aunby Ca#Jfr ender thePalntpdjoexaftim 0JPrr/a7'oiar the lefarmadMRry 1dd thaw/s&"ow eorr"%
siemature- �f-i /a2 �i /z Dots zLl/U >
F609ker
eW are osljt Do not write Ix&js area,to be eompArte/by ebp or town o pleial
or Town: PermltJLleew N
ng Authority(circle one):
ard of Health 2.Building Department 3.CIryf1'owa Clerk 4. Electrical Inspector S.Plumbing Inspector
Contact Person:
Phone p•
Information and Instructions ation fay
%fassechusetts General Laws chapter to vide worlro f other under
a
Pursuant to this statute.an sasPfeyes u defined as �P�n'n ft Se ice°f another under any wnn+rrt of hue..
express or JOP>A"or ante'
a other legal eatig,or any two or mort
An 9AWd er is defined s. an individtsd.partnership,bAng the �veer of a deceased MPWYW- �
of the foregoing engakleA to a� association
at ether Ind salty.wploying e�°yess
waiver at utuw of m tm hxvi g per' Moments and who resides�wo Or rke Omol"of dw
on such dwelling house
isoaue having not nseaa tM0 three
o, of as�wbe e�Ys persons to do msintmanee. be deemed to he an emplaye
dwelling dmcw don net because Of such emploYeuOt
or on the g�cc building aPPOS°Oi°s the bgesow W
Mt&chapter 152.12SQ6)also stew « State er fetal atIEW I s the wlthhotd
eft business err a esasotasx balidleV V the cet>.aasaweatlh tK asq
reeewal Of a tleeeae a<parsit to epees stele evkdeaee d Compllaw WIA the kasursaee pvarage required."�
watt wM W net p rsammed the�monwealth ear any of its political Subdivisions
applicant hs(iL chapter 152.$25C(7)states« work u acceptable et'idEety of eompliseee with the Wsum"
enter u �of chapter a e presented to dm contracting audror*Y *
req
APPmenu npWt*.by checking the boxes that applY to year sitontioss sod.tit
necessary,fill out the sc° a�0e phone n ���� s)other dum the
Limited Li bWW Companies(Li.C7 Or Limited LiahiiirY PasmeraW
1.we net mpircd ro carry workers'eompenssti00 iruf a if a ep err mUnCIA Of Iy�tneisi
employees,0d s,a is pwmm re9uired Be advised fn&vk may Abe be Mai ts�a"daa t The a8tdevi<should
Accidents for Confirmation lieation a license is being regt�ted,ad dw aworkers Of
far she permit
to the ctry the law err if you are required
returned their
be tegardiug enter
have any 4�OOr should
Should Yes► -insured eampanias
. Salt
Ltdttsenal si policy.plasm can the pe�®t at the number listed below
sasion
seconveowsneslicense number on due floe.
or Town tilmeleb
CUY ,�»��has p��a space at the bottom
please be sure that the affidavit is compleu and plated logIh• has to contact you regarding the applicant
of the affidavit for you W fill out in the event the Office of Investigations
please affidavit
sure m till in the p°rm+�Cnes number which will be used 0 a reference mtmber. In addition,an applicant
applications is any even yeas,need only submit one affidavit indicating �Y Current
that must submit multiple prrmi c ft..dm(if necessary)and «fib Sits Address"the applicant should write-elk locations in---(
0 or marked by city a town may be provided to the
of
ww4-A e the� dW has been ffifm&stao�ponnim es licenses. A new ao&svx must be tilled Out each
applicant as proof dui a valid affidavit is on tale filed� not related to any business or commercial vowin
year.Where a home owner or citizen is obtaining to complero this affidavit
(i.e. a dog license or I�u to burn leaves cots)said person is NOT required
The Office of Investigtione would like to thank You in advance for Your cooperation and should you have any guastione.
please do not hesitsm to give us a call.
The Depactmest�s address.telephone and fox mrmber.
The C n m vle"of IALWWINSCM
Deputug Of Industrial A=dentg
of ft Of Iava igiftm
600 WAAW&M Sftd
Boston,MA 02111
TeL #617-727-4900 W 406 or 1477-KkS8AFB
Fans 0 617-727-7749
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