15 SYLVAN ST - BUILDING INSPECTION �Iry S V
` 104 t PUBLIC PROPERTY
DEPARTMENT
KIMBOU sY DR CC" a�
MAYOR 120 WASMNGmN S-MEET# 'SALEJI,N.LiSAQfLSETM 01970
'[4i 97$-73S-959S#FA7t 979-740-9846
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: /� 5'qLuA,141 sr- Building:
- Property-Address - — - -- --
/S S sT-
Property is located in a:Conservation Area Y& Historic District Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: -p e. h BA+4tY S
Address: /
_ >S S'yLU/s/ ST-,
Telephone: '7k/ ` S� - SaZJ�,s
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY/
Addition Existing
Renovation r"" Number of Stories Renovated
Change in Use 3 New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
fePig"C StJ on lvdd�b ar®rcG(/
941,w M4er c4"Y
c,/ -e(,fi 4 ,'�� ll✓,rK
Mail Permit to: S-0 A T' iy r t l)110 5F
What is the current use of the Building? ✓W e��'�
Material of Building? L'VdOe' GrLAY"Z if dwelling. how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# CS h!2156 HIC Registration# i:3 c,9 y7
Estimated Cos�t o''f rgqyy��cctt$ C4 faa,0 Permit Fes 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 to the above stated
specifications. Signed under penalty of pedury ..�L�
Date /kx
l2 Dh
"yam N
.+
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. - CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xnraeataYtatncatt
MAYON 110wA2@4CT0N SREXT a SAI DA MA%ACHL=rrs()IWO
'Ikl:9W45-""a PA3b 97W40.9W
Worken' Compensation Im1ir M AMdavtt: RWdwWContraeto
Aootleant Informatton Etuse Print Legibly
Name( )• Pa.+r Y&5 (' a
Address:_ SS La. . -fog, A-Ve -
City/state2ip: t e4 4 M4, Phone#: ?Q/— �Qci—
An you an employer?Cheek the appropriate boss
1.al am a employer with_2_ 4. p 1 an a iteemew connector and IF1�3BWldlng
employees(1W1 and/or Pa t-ttma).w have hired the subsoopaeoonNownscyaa
2.0 1 am a sole proprietor or pater. listed an the auschod sheet,t g
ship and have no employeas These mb4oubaceom haw
waddug for me in any capacity. worker'comp,insurance.
[No worked Comp insurance S. 0 We am A aorpoRttm and its tion,
Rom) oEkem have exercised their 10.0 Ekc&kW repaim or additions
3.0 I am a homeowner doing all work right of exemptim per Mt3L I I.O Plumbing repaim or addition♦
Myself.[No workem'comp, c. 132,t1(4),and we have no 12.0 Roof mpaim
insumace ]t emPloY�.[No workam' 13.0 Other
comp.ioauaoce mquited.]
;AM 4PPAMN AN dodo bat et mar am®ow as aaenrw twor rAodaa seek watum
ltamroa "Mha aulmk Wee affidavit had mdae fay m dosed week set am tda omtlMMMNNEEEW� em s a6aY a sees C0afaarar aW Ctlmh ad/list teat atmehad ie addidaml alwt rhralae as same daw aabcombsc tie and**Marla'tarp o0aftotObraWt4.
l ore an earpAtye►th,W hprovldbaj urorbenI cowpewradow&"pawoafoi eery employees Bebtw lot tha
L�enrarlaa / po T /fah r/Ar
Insurance Company Name: �4J-�1! eQL�� N,
Policy A or Self ins.Lie MT q "c / n Fxpiratiw Date
Job Site Addmw Ciry/Shtell3p
Attack a Copy of the workers'comPtumdon policy declared"Pap(showing the Polley number sad expiration date)6
Fadum to swum Covemgs as requited under Section 25A of MOL c. 152 can lead to the
fine up to 31.500.00 andlar one-year' motion°f criminal ponaitice ota
y unprisonme vi as well as Civil Penalties in the form of a STOP WORK ORDER and a fine
of up to f230.00 a day against the violator. Be advised that a copy of this stateaumt may be fotwmdad to the Ofllee of
Investigation of the DIA for insurance coverage verification
Ida herebp cord*under the paten awrpewaWw olpwrimy alas the lwjormaden provldet oboes it aw and correct
Phone A —
FBoard
twill 00 AW wrkt L thk are;to be cowtpkW by cloy or town of CIAL
n: Perminkesse N
hority(circle one):
Health 2.Building Department 3.City/Tows Clerk 4. Electrical Impeetor 5.Plumbing I Spector
Coataet Penon• Phone N:
Information and lnstrucuum
fa their employee.
Massuhw s Oertad Laws chapter t S2 mgWma all employee to Provide worlceM'comPedaer any contract of hire.
pursuant to this stentte.an ewpl"to defined""••XvM P�1e the service of anotha under am
expmw or Implied."a(or wRttan.
ameiation.corporation or other legtl C°�'or my two a mow
An etepfeYa is defined as a individual.ise. a im tba�representative of a deceased employer.or the
m ayoitot enterptiar.and tscludittg employees. However the
m si f 0trust engage, . . aasoeiatiae at other legal entity.employ"therei
meeiver a tettstes of en iedtwdnai.act
mo em` and who insides tberaie.a the otxupsst of the
owner of a dwediss how havtef O0t mots ow wdo mains.co seftwdos a Moak wodt os such dwelt s hew
d.saws bolus of another who employs P� sal net because of such employow he dgwa d to he to empbye:
or on the gtotmda or busildbtg aPPuttewt
mGL chlapter ts;425C(6)alas stew thee"every glee er local daubs agtuseyb tiro�.seuw"M las fur aq
renewal of a dew K Persil to"Waft a buslws o<t/test smack htlddlap average requires'"
appWWA wM bas net predseed acceptable eddesa of ampdrw of its political subdivisions shad
Additionally.MOL chapter 152,12SQn MAN"Neither the eotamonweabh>eptable svidgw@ ot�PhaOe with the inaunoos
ante ituo say eootnet fbr the performaarA ono"�° a, osi<y'
Mq,�ews of this cbgm have boon ptamted
Appdeaab ehecki, the boxeshat t apply IA ymt siatatiaa a sd,it
Plea" fin out the wodtaa'eon est"I'oa of wevit e01°P y' s wigs than ustitteate(a)of
accessary.supply a)name(a).W*as(e)and phone number( )alone other then the
nece w• � "Q or Limited Liability ParmasbW OLlin�m _
o carry w�'COOp�ou W==W& If an LLC or es hawanaracpsired isi
employee..a Is a He ad 1 „that this&M&vk� $q*I b" The affidavit should
Aceiamra for cone of insuattm coverage.to the permit er]hues"is being Mtpteaoed,net this Dsp mown of
be returned to de city or own that the aPP�ahO° the law or if you are required to obtain s warkeM'
indu> Aaidead Shoctldyo have any gttat[oerMgerdbs
eompenaatiee Policy.Pre"call*�DePsttmm't Iteba�. nttsber listed below. Self-in"red companies should eater than
felt-inwno
vaa"Umosa number os ft
ap
City or Tows Of lelab a space at the bottom
Please be win that the affidavit is complete and printed legibly. The Dquanent Pt yOu t to
of the aiidavit for you o fill out in the event the Office of Investigations has toco°tset you Yerding the applicant,
number which will be used u a mferenee number. In ad&d^an aPP�
please be sure to fill in the permirAican" lieatious in any given yew,need only submit one affidavit indicating current
in that must submit multiple pami)sled under
aPP
pommy bdbr radon(it d0eagry)and under Jab Site Adtfre"" er a or own wayepron� or
o the
wwn)"A copy o[the affidavit that bee boa OtllciallY camped ms*ed byor licm"a theA necityw afudrvu smut be filled out each
applicant as prootthat a valid affidavit is en file fac fibre Parmtte rat Mated to any business or c�macal vacs'»
yew.Where a home owner at citizen is obtaining a liccansse OrPtrmit
(i.e. a dog licen"or permit to bum lave cu.)said person is NOT mquited to complete this affidaviL
The Office of Imrestigtuions would like o thanit you in advance for your cooperation and should you have any questions.
MEMOMW
phase do not hesitate to give ua a cad.
pamm�ens's address.telephone sad fez number
The ;;
Th0 ComlmnwaM Of M&gS1ChUSCIb
DqUlZnOAofWaWWAwdexft
Offift d I1vadget00s
600 WUhMPA Street
BQSN^MA 02111
Tel. #617-727-4900 w 406 to 1-877-MASSAFB
Fax#617-727-7749
Revised 3-26-O5 wwwxuas.gov/tlie
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