47 SCHOOL ST - BUILDING INSPECTION ------ - CITY-OFSXLEtii-
Pl BLIC PROPERTY
DEPARTNiENT L,7-23
L
MAYOR 130 WASmN G rw hmFxr•SALk.%k Xnstnc„Lsk'1-rs 01970
TIEL 97L715-9"S • FAX 976.74&96"
APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EMSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 4-- Sdoo( !Ej- 4� Building:
Property Address: 4 4- Sr t.,00l
Property is located in a; Conservation Ares Y/N Historic District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: �P�' JtJ C �st 2 { u C ✓
Address:
Telephone: 1
3.0 COMPLETE THIS SECTION FOR WORK IN EYISIING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing poa
Approximate year of I Q c c Area per floor (sf) Renovated
construction or renovation
of existing building New
ariet Description of Proposed Work:
CtCMo1j'1-+0+A.
Mail Permit to: -ai SL l 5{ a >ti-- #
What is the current Use the B uilding?
O 1r
Material of Building? 14) A- If dwelling. how many units?
Will the Building Conform to Law? -PT— Asbestos?
Architect's Name
Address and Phone
Mechanic's Name - ;v„ - �e '
Address and Phone
Constriction Supervisors License 0 HIC Registration 0
a Estimated Cost of Project S i3,)D Perma Fee Calculation
3 Perna Fee i Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$100o Commercial
91 An Additional $5.00 is added as an
G Administrative charge.
(p -D o Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit Zd to the above stated
specifications. Signed under penalty of perjury X
Date
96
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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TaL 97L743•9595 a F.vx:9M740.9IN6
Workers' Compeasadom lasuranee Affidavit: Builders/Coittncton/EleetridsiWPMmben
Applicant Information Please Print Legibly
Name Iauaine:arOrpni:catii9WVI VwhxJ): ,/1-/.1c6L.i ox4-i �,LC
Address: q a A•I'✓ I K )�. .
City/State/Zip: uA " 1�(� a14D4 t'Aotoe#: U I a i3D(.e q 1
Are on as employer?Check t approprla
I 1 am a employer With. 4.�am a gcnozal contractor and 1 . ofew consject(r coon d).
employees(full and/or pan-tune).• have hin--d the sub-cumnctors b' �❑/�'e��w�c�a�uaruetiott
2.❑ 1 am a sole propricsor or partner- listed on the attached shaft 1 7. lam+ °`�feling
ship and have no amployues Thane su4 eonaaesor have g Demolition
wairinj for nta in any capxity, worker' comp. insurance. 9. 0 &ukiins addition
f No workea'camp. insurance S.,ff We are a corporation and its 10. r
required] officers have exercised their ❑Electrical repairs of additions
3.0 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152.¢1(4)•and we have no 12.0 Roof repair
insurance required.) t :mploycc&[No worker' 13.❑Other
comp insurance requiraL]
Any"t plicant flog cWtAs boa et mar alw 1i11 out are warm 4•low dgwiaa their wato'aeep"MWkM puliry iobaalalie` -
I Iwtatwnwa wbe subw qua alflftrm Iad"ims"Y ate&*I all work ace lam boa oaraida CoalraCpa ntaal NOaal1 a paw atftdava intaaliaa YN'b.
T,tmtxwra 1fog Chet aaa ttm nut machei w adduiaW Jam.bowily Ibe nmw of ale sad lbeir werkaa'case•Darcy mMnmba
/oar un etnpAWe that/s pruviding workers'eawpettwdoe Grsmranae for my employees Below is the puNry and fob sire
inforwatluas 1
Imurance Company Name: IT- be-c ),, -`
Policy 4 or Salt-ins. Lie. N: (r1 IDy Dt ^/ �I .J*� Expiration Date:
Job Sire Address:4 2- 5e 4-Dvt .i— City/Slatet2lp ✓`F D/y�[
attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure w x:cum coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties oft
fin.up u)S1.500.00 and/or one-year imprisomncnt,as well as civil penalties in the form ora STOP WORK ORDER and a fine
of up to S250.00 a day 4gainst the violator. Ile advised that a copy urthis sratemunt maybe turwarded to the OQice of
111% .Ifl,J11Ulb uI the DIA for hhurance covcra,;u verifrc4tion.
I do hereby certify an kr the p ties penalties m1perfary that the iaforwation provided above is Irae and correct
U/J!s iel ant oa/jt /hog nor wdr la thir area,to be completed by dry of/owtr ofj/t•Imi
City or Tnwn: Permitil.Icense s
Issuing Autburily (circle one): — —
t. Ifltard of itcaith t. nuildinig Department J. City/foaa Clerk 4. Eleetricil Inspector S. Plumbing Inspector
6. Other
Gtntact Persil-. _ Phone p:
Information and Instructions
Masstchusctts General Laws chapter 132 requites all employers
provide the etvwilorkero'ce of a tcottur under any ompensation for thck a of hits
pursuant to this st auto.an eoyteyee is defined an'..-every pe
repress or implied,oral or wrirved'
aYoeiWa�nor eased or outer kQal eased tmgay two or tttore
O f employerf"Co is defined as t a i>savriU24sserp p�s�tV. the le representatives of a deceased employer,or the
Of the foccgoing engaged is a Joint ��i and including However the
receiver or tusteo of an individual.o marsh dust
or other d w entity,amp rein. emploY�
owner of a dwelling bouts b+tnnf++t tine tbtn three apartments and who tetidaa ebtnei4 or the aattpant of the
such"ailing hcum
dwelling house of another who employs persons m do maintenance.cunstrttttiat or repair ve earned to be ra employer."
of on the grounds or building appurtensat tbtneso shad net bK=m of such metployattsot be d
er
�iGL chapter 152 4 (6)+�states that"every state or local Mcgredug agoe+y shag witbbebt the Bsuaaeo
too rase•business or to tosser""buildtn¢Is else eesssaoawts"for any
reaevrd of a tleetasa or permited steep "widens of compdoee with the Insurance coverage required"
spptlesnt stye GL chapter
prod of its meal subdivisions shall
rime ions an MGL chapter a performance
a of
public
work
the oil acceptable
evidence of compliance with the insurance
enter into any contract far the performance of public work until accepub
requirements of this chapter have been preserved to the contracting authority.-
Applicants
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and if
s)nortte(a),addmmKcs)and phone number(s)along with their certificates)Of
necessary. Limit LLP with no employees;other than the
insurance. Limited Liability Companies(LLC)or Limited Liability��(if an LLC or LL�does have
members or partneM are not required to carry workers,compensation
aired. Be advised that this afildavit may be submitted to the Department of Industrial
employees.a policy is req
.Accidents for confirmation of tur2wc caveaae Also sun to sip and dote the amdavit The Department
should
be returned to the city or town that the application for the permit or license is being requestsd. not the Department of
industrial Accidents. Should you have any questions regarding the low or if you are required to obtain it workers'
compensation policy,please call the Deparmmem at the number listed below. Self-insured companies should enter their
.elf-insurance license number on the appropriate lam•
City or Tows Offieleb
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at am botwm.
of the affidavit for you to fill Out in the event the Office of Investigations has to contact you regarding the applicant
t'Icase be sure to till in the permitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in__(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits at licenses. Anew affidavit must be tlfled out each
year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e. a dog license or permit to bum leaves ate.)Said parson is NOT required to complete this affidavit
I'hc l)I1i:0 Jf Im'C,ti.. tions would like to thank you in aJvance for your cooperation and should you have any questions.
picaae Jo not hesitate to give us a:JII.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Depatttnedt of Industrial Accidents
OAka of lavestlpiloaa
600 WaahinQton Street
Boston, MA 02111
Tel. Al 617-727-4900 ext 406 tx 1-877-MASSAFE
Fax#617-727-7749
ZcviacJ 5-26-05 www.num.8ov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMI ENT
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?L��•a l t1'7.�Y N::JMf 7iaT•UL:ti VAILMaS*all
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Construction Debris Disposaf Aindavit
(rayuined IN an dattolitiast and rertoetsd"Wert)
la mmdaam with the sk&aadw of dw Sam Bu Wh*Codes 7S0 MR satioa It l.!
oebri%sad the pmvisiam of M. CL a is 9 54
Building Pon tit _ is ismuM wide the eoodWom dtst du debris rauldnf ft e
this wok shall be disposed otin s pmVaty licansed wasp disposd facility a dented by%tGL e
t11.Sis"
The debris will be transported by:
�' rt�t1•er�r,,��P4 f,w�
rho -bris will be disposed orin :
_ Mna>a uY fsaGty)-
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