15 TURNER ST - BUILDING INSPECTION Crry
PUBLIC PROPERTY
DEPARTMENT �nR
Kl.%WFALEY DID5(:OLL 0 V/
MAYOR 1WWASMNGrONhnR •&M.E ,MASSACHL5L17M01970
TM-97&745-959S 4 FAx:97&740.9846
APPLICATION FOR THE REPAY- 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/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: _
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FYicTING BUILDINGS ONLY
Addition 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:
(a."
—1
Mail Permit to: �� z --
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Nam ^"
Address and Phone-1-1 Pscc�or
Construction Supervisors License AQfz- `SQn.y 1 HIC Registration#V".�4-\C f\
Estimated Cost of Pro' Permit 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 property 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 perjury ,�—
DateC 1\ ONO
U
cal
OI
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b Y
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
aaaaeautt uaraca t
MAYOR t20 VA¢art WNftW a SAUK MAS&ACHLWM 01970
Tpt 97W43.9W♦PAs:97W40.98K
werkM9 Compensation Insuraaee Atsdavitr Bupdawcontraet0rR/Eiettrldanw7hunlim
A
Name( _
Addrew:—I'l c �
:[]
am a®ptgyar?Check*0 appropriate best
m a employer with 4 ❑ I am a general contractor and I ePpreiaee( :
:'eaa(!Wl astd/ar patbtima).• have hired the subcosttractas ❑New eaoabtnctiast
m a sole proprietor or pottage. listed an the attached sheaf,t 7. ❑Remodeling
p and haw no employees Then atb-conaaamo haw 8. Q Demolition,
ddng for me in any aapsciry, workers,comp insurance.
o wodkers'comp,ivaumnee J. Q we am a emporstiue and its 9. Q i addition
uis 1 OtlReaeS haw mumetsed their 10•0 Mw&icai rspain or additions
m a homeowner doing an work right Of MOmPdm per MGL 11.(]Plumbing repairs or addition♦
aeit[No workers'comp a. 132•¢1(4),and we haw murance requited.)f employes[No workers• 12.Q Roofrepairs�p �aoa required.) 13.QOtbw- riot chosen boa el now an M am do secdo o blow,showing Ihdt wmke'am9.rtlea eotiey Innovations.
Namoownma who submit VU af!ldooit Indication day an doing m wads and tb.him Gum&n.saetma ma oo6eY a eA nfedtvtt
tCamlaw an eatpileyer memm tint dy tan man rKhd.admdaml ohm c6owlng sirs anon otthn .d dWr warbmS'mmR tnbtmstle�s,
o►maa4aa that kjorovld/nj warners'compenrogio n Luswnee joy my onol i yee, Below is dboalkj andjob rAer
l
Insumuce Company Name
Policy 0 Of Self-ins.Lia M Expiration Due
Job Site Addmm Ci fy/Sta W74
Attach A copy of the workers'compensation Policy declaration Page(Showing the policy number and aspiration day).
Faduce to secure coverage as requited under Section 2JA of MGL a 1 S2 cost load to&a imposition of esimioal penalties ofa
fine up to 111,500.00 ad a against
one-year imprisonment,as wen as civil penalties in the form ofa STOP WORK ORDER and a ling
Investigations of up to f230.t30 a day agaistst the violator. Be advised tins s copy of this statement may be forwarded to the Otllce of gations of the DIA for insurance COversge verificstios
[do bareby cord*wader andpaugAd"ojper/rry that the/a/ormodoaProv"d oboes br era and genres
� b
Phone
OfJleld rrr on6% Do not write/a this a►rg•to be coatolehd by city a gewa o(Jfe1oL —
ciq
or Town: PermiAleesss ay
aag Authority(eireb one):L1. ard of Health 2.Bonding Department 3.Ci1ylrows Clark 4. Electrical Inspector S.Plumbing Inspector
k Other
Contact Person: Phone 1J
Information and InstrucUUM
Massachusetts General Laws chaPtaa 132 Mesass all employers to
Pion&workers'comp�n fat their employee
pursuant to this statue.an s+ePl'Ys''
is defined "---every person in the service of anether contract of hire.
express or imPlied.oral of written."
as other le eauty.of any two a mots
An sasPfeYs►ie�f1O0d""ne individntsl.par R� entati�ogal f a dceessod employer•or the
of the forgViD$eeVPd in s joint soterpsieei auoai aoa er ocher lswl sty. yin;employees However
tbe
receiver a mums of an individual.psrtuarship• aed who resides drrsiu.er the oecupset of the
owner of a dwelling hound°Ot Mare dust three a ersons do mai On adeeme to be dyer•
repair wadt an euch dwelling house
dwelling boon of another appurtenantompbye dwab span net because of such employmenta on the grounds or building
ha wkbb*M the brasses OF
MOL chapter 152.42(6)'im dame that"'vim stab er local fiaegiK� the eessenwealtb far a"
renewal of Ei a sen K psi to operate is business er to construct bdldtn0
with the lasurance ewer's rMnhrod."
not Codes"apAddicansllnt y,MGL chePet MWho has "Nett�vidence of n�until ��evfdenat of compHenoe sea any of its political w th f�
enter into any canusce the Per him negpre �public
the contractingauthority."
ragtriramenm of ibis chapter have bees presented
Applicants affidavit completely.by cha der the boxes that apply m Your sipoatlon and.if
please fill out the wotiees c sN edghm(n)and phone munbar(s)along with their catdscude)of
(I.LC)or Limited Liability Partnerships(LLP)wnh no®sployea other than the
insurance- Untited Liability(WAmberS a pacmms,are not required to Bury w=ters'°°mpeoe�O°tnsurnaee If as I I C a LLP does have
to the DOPutnent of bWuslrid
employees,a policy is required Be advised diet to ip addate the a91 IU �
Accidents for A°hf inatnance coveMS pasted,not the Department of
be mourned to the city a mwn that the application for the permit isl a isw or if bettara required to obtain w�*1mn�
indu trig raq
A Should you have any quva>���below. Self-imund eomP�should eater t�
comPensadon policy.Pines all the Department liar
self-ioaMan"Room aasmbetonthe
City or Town Of chats
let and printed legibly. The Department has provided s space h the holism .
Please be sure that the to
it is comp has to contact you regarding the applicant
of the affidavit for you b fill out in the event �°w�be used as s reference member. In addition.an applies
Please be sum to fill m the permtdliceosa m any given year.need only submit one affidavit indicating MUM
that must submit multiple pamit/lieeam applications
policy information(if aecestaty)and under"Job Site Address"theamarked by city or town provided todie pplicant should write"All IOc&dOn§in---Ic"y ortown) -A copy of the Sfildevit daat bm bet officially stamped or or liaaoset A new aPudrvm most be filled out cab
appliam n proof that s valid+afdavit is on fibs for More permit not mb►aA a any btuiness a commercial venture
year.Where a home owner of citizen is obtainingi p sae or Perms to complete this affidavit.
(i.a. a dog►ieeaat or pe:mot a bum leaves ere.)said person is NOT required
would like to thank you in advance for your cooperation and should you have any questions.
The Office of Investigations
please do not besiege to give us s esfi
The paarament'a address6 telephone and
•1U CO MMMWMM tl[Massach»se
Depatnet of bill aaW A=denb
O®fe td Isvediga u
600 WL*09"ShVd
lit^MA 02111
TeL#617-727-4900 CA 406 or 1-877-MASSAFE
FU N 617-727-7749
Revised 5-26-05 www.>ZwmVv/dig
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