6-10 UNION ST - BUILDING INSPECTION EOF�L --
' PUBLIC PROPERTY
DEPARTMENT .J
AISMEUX-Y DRISCOLL
MAYOR 120 WASHING ON SIXEEr•c"LEW MA.ISACHLan-3 01970
TE:978-745-959S 0 FAx:978.7J0-98" C
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: /fjpv - Building:
Property Address:
,:,-All
All
Property is located in a; conservation Area YIN IV Historic Dlstrkt YIN A_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: re
Address: ,� ---/0
Telephone:
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 D
Brief Description of Proposed Work: �1,),,r - �-5
/4 Ol
Mail Permit to:
What is the current use of the Building?
Material of Building? /71U rLC If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name �� (—t- fr _Z/I
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ cL322`— 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 properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building;Permit to build to the stated
,,,specifications. Signed under penalty of perjury
Date
I
IONA
`o
0
M N
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
o,�ou
MAYOR
'M WA.tIm4"CNSUW a SALn%MAM 0k970
TM-WS-74S9M a FAs:9M740.9846
Workers' Compensation Insurance AiBdavit: Bullders/Contractorsmeetriciam/ptombers
Applicant Information `� / Ple son mint eidbly
Name ttiv.iecwo�a,;an odividaoiy D,1 ✓� /, /.aCam!zif9
Address: �! /-� 7
City/State/Zip: /31- Phone#: /7 9
Are yaw an employer?Check the appropriab boss
I.❑ I am a employer with 4. 0 I am a general contractor and I Type of Prefers(��]'
employees(hu and/or parwimem have hired the sub-contactors 6. ❑New man"suction
2.fc�'I am,sole proprietor or Farmer listed m me attached sheet i 7. ❑Remodeling
ship and have no employees These ntsb•oontacmr s have 9- []De molitlm
working for me in any capacity. workers'comp,inammen,
corporation and its 9'
[No worker'comp, iuettran¢e 3. 0 We sre a Building addition
required.] offices have exercised their 10.0 Electrical repair or additions
3.0 I am a homeowner doing all work tiklht of exemption per MOL 11.0 Phtmb;og sepsis a additions
myself [No worker'comp c. 132.41(41 and w e have no 12.0 Roof repair
insurance required]t employees.(No work=,
comp.insurance requirdd,] 13.0 Othioa-: p,-TC r�oiaT
� o eowneo whMd o
logs el mat Cleo as out the sac"bdow shming their walteo'
Homeowners erke nthdl Wa ellldevk undcadol They an dttky dl vak rod tha hto ouwb coobmc a mrt adrek a saw NMdwtt 6diwNea aeL
'Coo todo s the cheek We boa moo seeebed on rddieadl shot dweina the oeme w ne ab-eooneeras end their wartaw'oaaR Policy fetbraetlaa.
1441 am e yloyp that Is providing workers cowpeaaodow
HZeeeneeee
Informsrlaa Lmurance for my employees Below Is the poky and Job slq
insurance Company Name:
Policy#or Self-ins.Lie.4 tic c; Expiation Dater/ 5r
Job Site Address: C-10 0XlOtt% i7 Ciry/StatdZip: j fi�E/s J /�/J
Attach a copy of the workers'Compensation policy declmdoa pap(showingthe
Failure to seem covers as PolieY number and espp atloa data
ore required under Section 23A of MGL a t 32 can lead m the imposition of criminal paultip of,
fine up m S 0.00a d and/or one-yea lahns. omnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up m f230.00 a day against the violamr. Be advised that a copy of this statement may be forwarded m the OtRce of
Investigations of the DIA for b uraoce coverage verification,
/do hereby c P the an p<noltles of perJwy that the lnfonnadon provided above Is dna and correct
t
-7f'
o lefaf use on'A Do not write Ge this area,to be completed by city or town oJJlefat
City or Town: Permit/License N
Issuing Authority(circle one):
I. Board of Health !.Building Department 6.Other 3.City row,Clerk 4.Electrical Inspector S.Plumbing Inspector
Contact Person
Phone*
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide woAcW of bite.
compensation fro their employees
Pursuant to this statute-ass
tatute-as easployse is defined as"...every Person in the service of another under any connect
express of implied.owl or written."
aSaOCiitip4 m of other legal entity,of any two or tnor'e
An saepfoYa is defined m"m individual,parmersbnc ves of a deceased employer,or the
of the foregoing engaged in a joint enterprise,and mehidmg the to ees However that
receiver err mated
of as individua4 Pasn�house having not __ non at other spartmastift kV1 o raides therein.or the o�W�moths
owner of aehouse
t amWr employs persons do D0ai°�Oce.construction m�deemed to be o wo*an such f
dwelling house or building appurtenant thereto shall not because of such employment
or on the grounder shag witbYold the issuance or
MGL chapter 152.12SC(6)also states that"every slats bhp W commonwealth for any
to operate a business colt►W isaurasea coverage required."
renewal of a ticosse or permit acceptable avidenee of comptlaaes political subdivisions shall
applicant who has not produced th not any of its po
Additionally.MGL chapter 152,12SC(7)states"Neither the commonweal
the of public work until acceptable evidence of compliance with the insurance
enter into any contract far P °CO
requirements of this chapter have been Presentedto the contracting authority"
Applicants the boxes that apply to Yoer situation and.if
Please fill out the wodme compensation affidavit completely,by checking with their cecti6aate(s)of
necessary,supply s64ont'actor(s)namc(s)-addreu(a)and above numberehi along with no employees other than the
inauwnce. Limited Liability Comp!sias(LLC)or Limited Liability ParenershiW(LLP)
to carry woritee'compco union ma matted If an LLC or LLP does have
mambas or Poll i are noteeqrB�ed that this affidavit may be submitted to the Daparnsest of Industrial
employees.a Poles is Hof insurance coverage. Aloe be sore to nip and date the a®davlt. The atidavit should
Accidents for confirmation that the application far the Permit or license is being requested'net the Department
be returned to the city or townShould Yon��any quad s regarding the law or if you are required to obtain�arkeW
Industrial AccidentL enter theit
compensation policy.Please call,the Department number lisped below. Salt-iwured companies
self-insurance Hem"mrmber on that
City or Town Oflkisb a at the bottom
fete and printed legibly. The Department has Provided a spat
Please be sure that the affidavit is comp ore has to contact you regarding the aPPlieam.
of the affidavit for you to fill out is the event the Office of Investigations
Please be on m fill in the peimtdlieense number which will be used as a reference Wombat. In addition.an applicantg crt
Pietha moat submit multiple permit/licenaa applications in any given year.need only submit one affidavit indicating current
policy information(if rise dial
and under"Job Site Address"the applicant by
rwrite
a town maylocations e Provided to that er
town).^A copy of the affidavit that has been officially tramped es or lieeases Anew af,;drvir moat be filled out each
applicant as proof that a valid affidavit is on filer for fimtn Fermi or commercial venture
year.Where a bolos owner a citizen is obtaining a license or permit not related to any business;
� (i.e. a dog license or Permit to bum leaves ate.)said person is NOT required to complete this affidsvit
The Office 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 Cpnunonv Wth of IMmachusetts
Department of lnda uki Aeeitlents
OnUe of IDvadgWOOg
600 wa llw9 On Street
Hostoa MA 02111
Tel. #617-7274900 Cd 406 Of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 WWW.InASLVv/di1
CrrY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
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Construction Debris Disposal Aflldavit
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Bullft Mail S %ism"with as eoadid"dui*A dab&reaWes has
tldt,wort elan be disposed of is a properly Ueded waste d qmd AdIIt1t as deemed by M®.a
111.s 1JOA.
The dabs will bj transported by:
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The dcbs MU be disposed of in:
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