73 SUMMER ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KI.UHERI.EY DRISCOLL
MAYOR 120 WASHINGTON SlRE6r♦ SALE N,MASSACHI:GEl1S 01970
1�t 978-745-9595 • FAX:978-740-9846
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: Building:
Property Address:
Property is located in a; Conservation Area YIN �Historic District Y/
2.0 OWNERSHIP INFORMATION /
2.1 Owner of Land r c _._1 s-�'A c�
Name:
Address:
Telephone: `;' ? S -,) ?�S S/,
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing -
Approximate year of Area per floor (sf) Renovated
construction or renovation
New
of existing building
Brief Description of Proposed Work:
Mail Permit to:
6- v
What is the current use of the Building? c� Lf M /
Material of Building? ,/ If dwelling, how many units? v-
Will the Building Conform to Law? / Asbestos? l
Architect's Name
Address and Phone ( )
Mechanic's Name c aG f n t�
Address and Phone cC /1 Cr/ w o ,¢ c� V---
Construction Supervisors License# 621 L 2) HIC Registration # log oc
Estimated Cost of Project $ d Permft Fee Calculation
Permit Fee $ Estimated Cost X $7/$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 st d
specifications. Signed under penalty of perjury X
Date 16IJ
N
O
C�i 7
o
i
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOIl,
MAYOR 120 WASHINGTON STREET♦ SALEM,MASSACHUSL=01970
TEL-978-745-9595 ♦ HAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anittlicant Information F Please/Print Le ]bl
Name (HusimWOrganizatiosVindividual): ,11 r A—el Q' G
Address: l 75-11 Iwe57D°/ -I v
Cit /Statc/ZiP /r�
� ] hone {/:_ lc2
Y ��/ �
:%rc you an employer? Check the ippropriate box: Type of project(required):
1. dm a cmpluycr with 4. El am a general contractor and 1 6. ❑New construction
employees(full and/or p� rt-tine).' have hired the sub-contractors 7 ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have S. ❑ Demolition
Working for me in any capacity. workers' comp, insurance. 9, ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required) officers have exercised their
- 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.(No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. LNo workers' 13.❑ Other
comp. insurance squired.]
•Any.applicant that checks box MI mtul also till out/he xeclion below showing their worker'cuntpensation pulicy inturmation.
'I lomcuwmrs who submil this affidavit indicating they are doing all work and Ihm hire outside contractors must submit a new al'ridavit indi"ing such.
=Contracums that check this box most attached an additional Aeo showing ttw name of the subcontractors and their workers'comp.policy informadun.
I an; an employer that is providing workers compensation insurance for my employees. Below is the policy and job.site
is/unnutic a O
Insurance Company Name: o
Policy is or Self=ins. Lie. #: Q _�S._
Xis Expiration Date:
Job Site .address: do eX`Y City/State/Zip: a � e
Attuch a copy of the workers' 11�compensation policy declaration page(showing the policy nwnbcr and expiration arts).
Failure to secure coverage as required under Section 25A of.'vIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. fie advised that a copy of this siatement maybe forwarded to the Office of
Investigations ul'the DIA for insurance coverage verification.
I do hereby certify undo the pains an pe tics pe ury that the information provided above is t e and orrecG
ienamrc: - Dj t : O
Phone is
Official tine only. Do not Ivrite fit this area, to be completed by city or town of/iciaL
City or Town: __-- Permit/License# --
issuing r\uthority(circle one):
1. Board of Ilealth 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other —
Contact Person: Phone#:
CTTY OF SALE.M
PUBLIC PROPERTY
DEPARTMENT
w�,R�a►o.e�t,.
t4rca 130 WAti011t.I M smear•sAtilt,MAtt3AOR-MM e1970
Tn.M745-9S9j•FAm M748.9M
Consimcdoa Debris Disposal Affidavit
(required tar aU demolition and renovadon work)
In aeeordaoce with the sbuh edition of the Stets Building Cods.780 CMB section 111.5
Debri4 and the provisions of MM a 4%g 54I
Building Permit 0 is issued with the eordidon that the debris mmuiting E:oas
this wort shill be disposed*(in.a properly lit UNd wasp diapaed thcility as defined by Mf$.s
I 11.S 1SO&
The debris will be transported by:
The debris will be disposed of in:
("SA of ftdltyy�
(address of Wdity)
sfaaaoae of p,mw Wheam
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