24 SOUTH ST - BUILDING INSPECTION What!&ge arrant use of the Building? how many units?
Material of Building? /&e D(j� If dwelling.
Will the BuMV Con brm to Law? 1l Jr Asbestos?
ArehROWS Name 1
Address and Phan l
Mechank:s Narrn
Address and Ptw M
Construe+ Supervisors Li can" y[s, n 9 3 E!O HIC Regtstratforn s��- ` —
Es*nded Cast of Proje 00 PemUl Fee Caladatlon
Permit Fee i U Exilmated Cod X$7/:1000 Resider"
Es*naWCostX$41/:100ACom�---- -- - . .
An Additnal$5.00 Is added as an
Administrative charge.
Make sun that all fields are properly and legibly written to avoid delay@ In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
spscitications. Signed under penalty of Penury
Date 20
x
qv J
..
F
1
FEPAR
0'PP'fQ TMENT
KMORKav or+saxi
sKry wr:AoKsrYfs 01970
11L M7454M•FAm M7409e0
APPLICATION FOR THE REPAIR RENOVATION. CnNSTRUCTION
DEriOLTTION.OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING_
STRUCTURE OR BUILDING-
lea SITE INFORMATION mom
Location Nome: k Bui10(ng:
Property Ate----
O�
Properly Is locnied in s;Coraervalon Area YIN Hietodo 010M Y/N "V
2.0 OWNERSHIP INFORMATION
2.1 Owner of La"
Name:
Addyem l / SOk,T %
Telephone: p
3.0 COMPLETE THIS SECTION FOR WORK IN EIIISLNQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change In Use New
Demolition S Existing
��rC Leos
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brie[Description of froposed work: 0 Td
cSib/�(Ly pa(e� �l �bh1�C44��c� .nU oo -7W7t/oyt
61w
---- ---Mail Permit to: Crf
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R 13
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ststnsatr:Yuttcttaxi
MAYtte 12CVrnvuwratySMEETaSALZM.111. an.v'n'is0197C
AL 9711.743.9595 •FAX:9M•740-9946
Workers' Competlsadon Insurance Affldavit: Builders/Contractors/Electriclans/Plumbers
Applicant Information Please Print Leeibly
Name t8umneulOrganizationtl tvufuuq:
3 l S7�lr,1 T.AJdreas• �
city/srardzip:L,�� 62/3�O Phone
Are you an employer?Check the appropriate boat: Type of project(required):
1.Q 1 am a employer with 4. ❑ 1 am a general contractor and 1 6, Q New construction
dowlOyces(rut[and/or part-tine).• have hired the sub-contractors
2 �D4 am a sole proprietor or partner- listed on the attached shed. : 7• ❑ Remodeling
ship and have no employees Then sub wnvaetors have S. Q Demolition
working for me in any capacity. workers'comp. insurance. tyyl.
(no workers'comp. insurance 5. 0 We are a corporation and its 9' ram+ �utldittg addition
required.) officers have cxercisod their 10.Q Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
inyself. (No workers'comp. C. 152,§1(4),and we have no 12.Q Roof repairs
insurance required.) t employees. (No workers' 13.❑Other
comp. insurance required.)
•A,q applicant that chucks boa MI muss also All oos the section Lwfiaw dlowing that workma•cumpentatfun policy in6tnn uieq
' I Iumw,wrwR who submil this affidavit indicating they am doing all work sad than hie onside eommc o ,most autnnil a new amdavil indicding uuk.
:Camracars that c►csk this boa mum anachad at additiarml Amin Jawing the cam orate wbcontraclon and their wurbsts'comp.policy iniMmance.
I our on employer that Is providing workers'compensadon/nrarance Jar trry empluyetz Below is the polity,and Job sire
injarmutiaa -
In uranrx Company Name: _-- _
Policy 4 or Sclf-ins. Lic. 0: __. Expiration Date:
Job Site Address: Cityistatuzip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Scction 25A uf.IGL c. 152 can lead to the imposition ofcriminal penalties of a
tine up to S1,500.00 and/or one-year imprisomncnt,as well as civil penalties in the form of a STOP WORK ORDER and a riot
of up to $250.00 a Jay against [lie violator. Ile advised that a copy of this slatemunt may be forwarded to the Office of
lavcaugaimns of the DIA for iniurarcc covcraga tcriftcatiun.
/do hereby certify it�udej the pains and penulNes if perjury that the iujarmatlon fled ub ve true im9l correct
tii,•aasurc' Date,
Phimcl�
OQicial use only. Do not write in thir area,to be courp/eted by city of town o1jic•1uL
City or Town: __. Permit/License M
Issuing Authority (circle one): -- -
1. Iloard of lteahh 2. Building Departineot 3.City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Cotllacl Person: Phonc q:
Information and Instructions
,Massachusetts General Laws chapter I52 requires all employers toworkers'
service erof ' compensation
unde any ctheir
n russet of lu�
pursuant to this statute,an employee is defined as"...every person
oaptess or implied,oral or written."
An employe r is defined as"an individual.Partnership,association.corporation orother legal entity.or any two or mom
of rho foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,parmuship,association or other legal entity.employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein.or the occupant of the
do maintenance,construction or repair work on such dwelling house
dwelling house of another who employs persona to
or on the grounds or building appurtenant thereto shad not because of such employment be deemed to be so employer."
hIGL chapter 152 a325C(6)also stares that"every state or local licensing agency shag withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commouwealth for any
applicant wbo has not produced acceptable evidence of compliance with the insurance coverage required."
additionally.MGL chapter 152,§25CM states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub eontacror(s)namt(s),addresses)and phone number(s)along with their certificate(s)of
insurance. Limited)Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. Iran LLC or LLP doss have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
ur
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
1,lcuse 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 or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
I i.e.a dug license or permit to barn leaves etc.)said person is NOT required to complete this affidavit.
I'hc Otii,x of 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 Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oak*of Invasdgildeos
600 Washington Street
Boston,MA 02111
Tel. # 617-7274900 ext 406 or 1-977-MASSAFE
Fax M 617-727-7749
Revi>cd 5-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
br' AmA'll
�L,u• lie
VI.�eI�Y::onS?ER•S�IF>r.Navctu.tc11a;:9Y
'ha:~45--n" •F.%m 97ti 4w"
Construction Debris Disposat Aftidavit
(requiml for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda 7So CNIR section 111.5
Debris,and the provisions of vtGL c 40,S St
Bttildins Permit 0 _ . I_ is issued with the condition that the debris resulting ftm
this wart shall be disposed of in a properly licensed waste disposal facility as defined by%1GL a
I t t. S 150A.
The debris will be transported by:
z &a�M� I --
fhe debris will be disposed of
f a.me ut iaclluy)
• it.
4 441�
k _ �`k 111111Ls':
SUBDIVISION PLAN OF LAND IN SALEM
8 � ' From
V`V, R.egiaKdt
Carter & Towers Engineering Corp. , Surveyors (Sheet 1, G'
j E dune 4, 1970 ?.
I
51 42
L C. Plan 856C
aCert. No. 120
s tena
� t
of tk
SOUTH STREET
d'n S 390 58„ Z� 00SC9c/ f u!
I _
_ /
' E5
t 7728 ., - ` _- 7 28 - -, 1 - 728
LU
i 3 'SOUTH:
"SOUTH'
O
i
All of s
drawI
proved-er
�Gtific
on'laat..
a � , - - - - - - - - I - - - - - - - - - - - - - - t$.# Therei
m Utility Easement (20.00 i We
all
a 76.83 77. 2E - - -- 7777 �x
S 390 -561' 00' -E /55.05 rR a YPart.'of
said-pla
m I "July 14;
188 i \ � 0
r .
•� o°o( 62
R=6000 178
- 20.28 _ 29 .0� /� �+ /�'T o
p N33,32' R'3U. IvREJCEN i W!••,.
'a,30' W
o Sewer_B Dram;
~ - — 75 00
a S 360 40' 44 F ,
Sr _ _ G t.
,
m Easement(2000lNi w3
�(89
f /79 I' tVAnd'
., /84 , ;
I 1 s , and It)
t (SEE SHEET 2) n° .'
/B3 k saTdl land
Ash ��e$1sr fis� �
Subdivision of Lots 301 thru 306 �q%� y eix'ofl`e
it Shown on Plan 856G sheet
r Filed with Cert, of Title No. 2926 RE I D
South Registry District of Essex County `' ' °I
With Certificate No. >
Separate certificates of tit/e may be Issued for land
shown hereon bs 19t s_J_77_Thtu /B9_____
- -- fl i
By the Court. COW d,
LAND� REG/STRAP" � „.
c MARCNI e ' Att
uc�it�?�_�• Scale of the plan ¢' -
M------a1- -----Reco r.
ARCH28 97� R[ Woodbu�kfn
II P.A.R.
( � Form LCES3. 7SW-1-71
,