3 TRADERS WAY - BUILDING INSPECTION PUBLIC PROPERTY
s
DEPARTMENT 2 -Op 1q.%Y1FJ.6V DRMsra
MAYOR 130 WASWNGTON S'r1FbT#Sna&w MASSACtIL5hTI5 01970
'Ikl 970.745-959S• FAX 97b740.98"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION
DEMOLMON, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 9�06L&A tr Building:
Property Address:
3 Trades w�
Properly is located in a; Conservatlon Area Y/N Historic Dismal Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: Jaea
Address: 6 f 0 �(d °i o!I� ��, J 2 n(� r �r� PA' I C)q aY6
Telephone: z.I S —6 . —
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
of existing building New
9dd Description of Proposed Work:
FL
30 -cfg
_-� -- - _---Mail Permit to: — -
What is the current use of the Building? �
n rt7
Material of Building? c If dwelling. how many units?—
Win the Building Conform to Law? Asbestos?�1f
Lt 8,�d fiS
Architect's Nam*
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License S 866 7 9 HIC Registration#
Estimated Cost of Project 5 l l o 0 o Permit Fee Cale won
Permit Fee S ? 6 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 Id d I in processing.
The undersigned does hereby apply for a Building Penn to ui to above stated
specifications. Signed under penally of perjury X
Date S 0
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CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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riot M74S."" 9 Fits:97L740.9946
Workers' Compensation Insurance Affidavit•. Builders/Contractors/Eleetridans/PIumbe»
Applicant Information Please Print Legibly
dame ISuunessttktasizattoNlndlvidlmiY Qtn`tg 6etr �4
Address: RF, J.tnl r (4,41e-
City/StateiZip: Al l ugh. IZ A: i'hone q: 7X l K 3Z b—SS 7 S
Are yam to employer'Cheek the appropriate boa: 'type of project(►egelred):
LET 1 join employer with fA 4. Q 1 am a Sara al contractor and 1
employees(full amUor put-tine).• have hired the auk-cotunctors b. New construction
2.0 1 am a sole proprietor or partner- listed am the attached sheet. t 7• Remodeling
ship and have no omployums Them wbconaaeton have al. ❑ Damolition
working for the in any capacity. worker'comp. insurance. 9
No worker'tom ❑ Buiddingrdditim
f p insurance S. Q W�am a corporation and its 10.Q Electrical repair or additions
required.] ot)11cm have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.(No worker'comp. c. 132.¢I(4),and we have no 12.0 Roof repair
insurance required.) t employees.LNo workers' 0.❑Other
comp. insumnro required.]
•Amp,ppliead Ibrr Chucks ben/I Moo abo tit wa are ochre 1xWw Aawiea:heir Wa the ajMpW"fuw pdi y idamw"liva
I lasnvnwrswa who submit mire Ngdavk indim ma"are J"all wart and Ma WIT out"=Wf mbn mast•uhmit a new am,tavit inJi0aina swh.
:C.o min that sleek Utm bm mum a Reid ant addalond+twat J owitta toe name of am sobeonamers and chat wurkem'mnp•policy udbmnlua
I um an mrsp/oytr that Ir providing workers'compensaden hisaranee for my emplayttim Below Is the policy and Job site
iuforkvut".
Insurance Company Name: 66 6ASVJ
1'nlicyaorSclf--ins. Lic.0:_)Nt �t7fZI 6L1.2g( EspirauonDate: 6 30?
Job Site Address: 3 7r&rs W, CityistataZtp: S9.]cn^ MnsS r719�o.
Attack a copy of the workers'compensation policy declaration page(showing the policy number and espirativa date).
Failure to wcue coverage as required under Section 25A uf.1GL c. 152 can lead to the imposition of criminal penalties of a
vine up rl SI.S .00 an or 7e-year tinprinmmcm,m well its civil penalties in the form of a STOP WORK ORDER and a fine
of up in i250 a day Cal the violator. Ile advised that a copy urthis statement may be forwarded to the office of
Ins;aiguuu 'the I ° r insurance covara,;e vcriftcstion.
/do hereby If r t pain and penah&r of perjury that the informadon provide above Irma and correct
�i•n:u ur•' I} s '�PJ
PM pie:7:
121)Wtd use&PHIA Oo not write in this area,to tlo rompletod by elry or town o/Jlelid
City or 'rown: _ Permit/lJcesse Y
Issuing Aulhurily (circle one): ——
1. Iloard of llealth 2. Building I)cpartincnt J. Citylfono Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Gnuact Person: _ Phone p•
F
Information and Instructions
their YML
Uassachusetts General Laws chapter 132 requires all employ in provide u�e of thK�urn.iti anyoconaaet of Airs,
CMPIO
Pursuant to this status,an eeyfp'ee is defined as'...every person
eapress or implied,oral or written
h
.. aneeianGIL corpaanoo or other legal entity.or any two or more
.an eiiV&yd isddleed an-as ibdli tut.parOrfttp. employer-or the
Of the foregoing engaged in a joins enterprise.and ioehtdittg the legal reprcsentativer of a deceased ee& Y
assoeiatiea at other legal eatity.employing etnPloYeea However the
receive of trustee g o individual,pefo more
slot a and who resides tbereim or this occupant of the
owrter of a dwelling Acts having tat rnoR than thttea aparatnenht
dwelling boors of another who employs persons to do maintenance.cunbauctian of repair want on such dwelling house
or on the grounds or building appurtenant tbaeeo SW net beus ea of each ampinymmit be dteemed to be ter employer."
,%iGL chapter 132.12SC(6)also leays that"every state or local licensing sptxy sbag wkbbeM the issaaeee or
too raft a business or to eotastruet buildings In tlft coaameawsaMh for any
renewal of a Uceaae or Perd`ed septabM evidence of cosptlaaee with the Insurance coverage required."
spptieaat wbe ban net prod
Additiomlly.MGL chapter 132.123C(7)states'Neidter the comutwnwealth am any of its political subdivisions dull
enter roan any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have bean presented to the contracting authority.'
Appltoanas
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and.if
sub.conracmr(s)nan*s).address(es)and Phone number(s)along with their certiflcate(s)of
necessary. Limit tes L or Limited Liability Partnerships(LLP)with no employees other than the
insurance. Limited Liability Compaq (L C) insurance. if an LLC or LLP dose have
members or pottges,are not required to carry werken'eompenestian
employees.a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage' Abe be sure to sign sad date the affidavit. The atridavit should
be returned to the city or town that the application for the permit or license is being requested, sot the Department of
industrial Accidents. Should you have any questions regarding the low or if you are required to obtain a workers'
as number fisted below. Self-ins w
Self-insured companies should enter the
compensation Policy.pleas call the Deps:maent
.cif-insurance license number on the line'
City or Tows OHklab
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 OfTtca of investigations has to contact you regarding the applicant
1'Icase be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple petmiulicense 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 licensee A now affidavit most be tilled Out cub
year When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bun leaves ere.)said person is NOT required to complete this affidavit
fhc t)t iix of Investigations would like to thank you in advance for your cooperation and should you have any questions.
please Jo not hesitate to give us a ta11.
The Department's address. telephone and fax number:
The Commonwealth of Massachusetts
Depafanent of Industrial Accidents
OWee of Isivastlptlelaa
600 Washio61011 Street
Bostont MA 02111
Tel. N 617-7274900 ext 406 or 1-977-MASSAFE
Fax N 617-727-7749
Rev i.cd >-2G-U3 www.mass.jov/dia
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CM OF SALSA
PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposal Affidavit
(regttired hr all darwut M and eerwvatias wart)
is mcordanea w idt dw she edition a(dw SIM 8ui14h*Cads6 710 CNIA soction It 1-5
oebrie.tttd dw provisions o(M- M a 406 9 sk
Build %Pon dt• _ is issued wilt dw ceodidoe dW the dd Xb moiling doss
,his work dull be disposed of in s prope ft licensed wasa disposal fbcility as dented by M. GL a
111.! I"A.
The debris will be traesported by:
_ 2S 15 o5w�
(aortic l+a.led
rho ckbris will be disposed of in
hc+rae ur'fxd,tyj
�15 gbJ�li 5}.. u, nnA 0z3zz
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