10 SCOTIA ST - BUILDING INSPECTION What is the current use of the Building? j)u-&.n e✓15 j"- 4 1 d et e-P
Material of Building? a X U If dwelling, how many units?
Will the Building Conform to Law? Asbestos? /l1C)✓t/
Architect's Name
Address and Phone
Mechanic's Named r✓1 C&q'-jl� 2 c J
Address and Phone ,,44 G yvea'Ja (e 2 ,
Construction Supervisors License#C5 00 k'1 d� HIC Registration# J S / 726
Estimated Cost of Project$ OU Permit Fee Calculation
Permit Fee$ Estimated Cost X$71$1000 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 P eQrY u
Date / (j 7
of
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01
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93
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PUBLIC PROPERTY
DEPART bfE1�1T
Kmamiu.EY DRISCOLL
MAYOR 120 WASHING"S7AEEr•SALLK MASSAon;Skn-M 01970
Tri 979-745-9595•FAx:978-740-9346
APPLICATION FOR THE REPAIR,RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
r
ATION co �V�; Building:
10 -SCo �a S'1 �( AAA
ed in a;Conservation Area Y/N � History District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: £ Lj of G, pimp-- N P-rA z r
Address: 10 S co kio IVXA Q 715.
Telephone: 1-7g - 7 t(`( " ) 91
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition X 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:
w�P OJIt- Roof &Lre P a she>
Ard
Mail Permit to:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xnaatu m uancott
MAWS
M WASFOW- Mft=T a SALFy MA%Aaars n01970
Worl ars' Compemadon Insurance Affidavit Bnil4ders/Cootractors/Eh etti ApeHCso! Ils_formadon cians/Plnmbers
11
Name l ):�r t✓ L L 12-e d4.�Y-C,
Addrens�a o a u of d cl, C • 19-0 6
City/StatWM— CA e/✓1 M A- r) 1 S?y Phone ? d`- 1--5 V
Are you as employer?Cbeek the appropriate frost
0CJ 1. I am a employer with_Q 4. ❑ I am a gemal contractor and I �d wised( .
2.❑ (lltB mdla paR-time)• have Mead the 6• ❑New ceostrttctlm.
proprietor or Palmer* Bated as the attached cheat t 7. PkRemodeling.
ship ad have no employes These 1r,,
working for me in any capacity. workers'on 8. lk Demolittm
(No workers-comp insurance !. We an a corporation and id 9. ❑ i addition
gl
Kam) officera have asaraiaed'ths� 10.10 Electrical rapsira or additions
3. I am A homeowner doing all work right of a xamp�pat MOL 11. plumb
Myself.[No workers'comp, e. 152.11(4).and we have no employeas.[No workers, ❑ a>additions
msuraau '' �hums ce requked j 13.0 Other
'Any eYVlkem cut eareb ban al man ire all am 16e eearlat tubes rhorlaa asks ama�a'
4--M �do dwk We bes amr"W in& mdmd heat*sw"jaa&Ogd
a®e WWWOs awn a b"a curt al0devY fedkatlagraelt
mbsaeaaetme rd ihrtr rarkaa•camp Donny bAnmetlaa/ew an emP/oyer that/aPmvWng workers'eo
/wformadma• wPenrotfow 4erwrawe,j,r wl saeP/oyeea ROAM Is tkePoJlry awlJok ghat
Insurance Company Name e M gev4- fiUY A
Policy N or Self-ins,Lie hk S (U C C N I< <I d 7 Expiration Due: v' Q f
Job Site Addreas:��(', rs-�-I g S�-
Atrach.e o[«r wo CiWseate2ip_( i !YI l4 O/j 7U
oP7 rken'eompeaaatlon pulley declaretlo■wa(showing the
Failure m eeoara covers err Pogcy number and expiration daft}
coverage required under Section 23A of MGL a 132 can lead to the imposition of criminal
fine up to S 0-00a day
against
st t Year imprisonme n,as well as civil penalties in the form of s STOP WORK ORDER and oes f flu
Of up to 5250.00 a day agaioat the violator. Be advised that a
Investigations of the DIA for insurance coverage verificadon Y of this statement may be forwarded to the Office of
/do hereby rernt� end pewah/p ofi*?* 'that eke/w jonwadow ptrw/de/a L ante and correct.
Of CW We OAIA Do not wdte ba this arrs,to be eoArP/ete/bp c/h,r taww ogle/wL
City or Towne Permlt/Lkeaft N
Issuing Authority(circle one):
1. Board of Nealtk 2.Building Department 3.C(ryRown
6.Other Clerk 4. Electrical Inspector S.Plumbing Inspector
Contact Persos:
Phone*
l_
Information and Instructions fortheir employ«L
h„aem General caws chapter to to provtds worken compenssu� of hire.
Massac s defined as".
..ay person in the service of anahec under any COp°
Pura►aat to this smote-an e don express or implied.Orel of writtm" or other legal entity,Of any two Of teas
An asrpfeye►'s defined swan individnd,pn a"POCR va of a daeaaad 'at the
Mweven
of the foceVint engapd in!ioiot afsacias m or other h:pl CUMAY-MOM*'mg of the
receiver owner ofat trustee of an a dweOWS bonssCM
md►vtdnv.PstmaaND ro"to do ansin"AM41,CWAMC" ��c suo6 dNe
dweilitK house of mother who o0°PIOYs thereto Shall me becanss of such employment be deented to be m empbyer'
or on the grounda of but�nf 20wt i°t Nnehold the issaas"or
MGL chapter 152.12=6)go Made dW" o� hdt�p V t 8 eounmewud��.
of a a""or Pew to°perata wl&tb twurmea eeverap eq.
ramewd appilegmt Nbe has net predua aeeaptsble soldaeW of eneapgaace Of iu poles�Y mauanet
Additionally,MGL chapter 152,;25C(7)sucontract for do m W the comp
work until acceptable "
enter of dtis chapter haw presented to the eons wmg su&ca t-
mq
APPltsata chaclting the braces that apply to your i°d'ut
CO�aation am" •by numbar(s)along with their eerdficste()at
pnecessasy- � enypscoor(s)natna(s).add<cas(°a)and pb Pa:ma<shlpf(yam with no amploysas other thm the
q Limited Liability Companies(LLC)of Limited Liability insurance, If m LLC or LLP does have
mamma"emsbas er pan°0Ca'a1°O°t�a to carry wc*gtB'rhea this en �en�t�to the Department of 1>s�
e�lay"s.s policy is required cov Abe be sate to sip and date the afsdavl6 Then affidavits old
Accidmta fee�nmtlm the city Of m°f�SM for the per>tdt Of license is being req WtA ogi ate requirmi ",be a wotkara'
be returnedIndnatrial Amite, Should You have my 1 �meted below dw law Of if y3elf-mated comPmee Wd 0O�their
compsa,don policy,plow call the
Deputned at
calf- ►(emaey=pb@randue
as Una.
City or Town Omdeb ww has provided a at then bottom
please be sure that the afiYdm is complete and primed w�>Y• The contacttions has to you reprdiog the aPPlWWL
of the affidavit for you to fill out in the event °�be t reference mate a�°' ate �
which
Pies"bs sure to fin in the Permit�icenae licati�in my Sivm year,need only swbmit a
that moat P&n*�1tiPle Parono1C6na0
pommy inf«mation(if ne¢eatary)and under"Job Site Addrera"the applicant Should
City
writs all town
locations o_.��y
o er marked by the city a town may be provided to the
town)."A copy of the affidavit that has been aW Idavit is On of lcislly for�stssta�a or liceoaaa A new af,"tdrvu must be filled out each
at c. . an itit obtaining a hem°r parmn n°t related to my business err eommerc1el vanau+
year.applicantWhere as P<O0fowner lore this affidaviL
year.Where sham Permh rb bran leavq ere.)acid Peron is NOT requited to cone
(i.e. a dos liceoae and sM W you have my question*
The Office of lnveatptiona wonW like to thank you is advance far your caoparation
please do not hesitate to give ices a call
.s ate,telephone and fens numbers
1 he Department rm COMM MWUM d MLWWbLsem
DePubned 0fid Accidents
oft*atbvuftt&u
600 WMbIlIg"sweet
Bos00%MA 02111
TeL #617-n7F900 mt 406
�49 MASSAFE
Revised 5-26-05 WWW.m mpv/aii
Crry OF SALBm
PUBLIC PROPES'i'Y
DEPAATDa T
OWRILWOMML
Cos,tiroedod► Deeir� Ddpodal AAldsvit
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APPROVED
Subject to approval by a—,y c:�iz;r
authority.ha&-gj=k3dictiou.
CITY of SA.LZB6,IM:-I
BY
PLANS AP€APPEkOY 9=Ct�� ( �tl'.,:T C. "`
7 FE AND LWTION OF
£L. FRS:PAWN PE DEVICES ^ l- A
[: .;L TiT AtiD!NSPECTION..OR COIvir ^'� -y .I-
S ANGI WITH THE FIRE CODE.
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