26 1-2 VALLEY ST - BUILDING INSPECTION - eI`I'Y-OFS'�LE1C --
PUBLIC PROPERTY
DEPARTMENT
KlsatFJLL.6Y DRISCOLL
MAYOR 120 WASHINGTON STREET•SAIkjku MA.\SACHLShTIS 01970
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APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
r1.0SITE INFORMATION
Name: Building:
Address:
rty is located in a;Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
L
tiq,v s1JUn 97, 7-,,dl j- e/
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 (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
CZ E13t>zc� fc�ti.� S t�s25
MailPerrnitto: /
What is the current use of the Building?
Material of Building? If dwelling, how many units? b
Will the Building Conform to Law? Asbestos?
Architect's Name _
Address and Phone
Mechanic's Name�T���h`a� '*� z�ss C' c, ... a�b S L'ca
Address and Phone :2 I 1�O[ v�o.�i�rs �2 l��iai3v�)�i /�� •Gi9G-o
Construction Supervisors License# CS C)F 3 546 HIC Registration#
Estimated Co;.t of Project$ d Permit Fee Calculation
Permit Fee$ 00 Estimated Cost X$7/$1000 Residential
Estimated Cost X$1141000 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 stated
specifications. Signed under penalty of perjury
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MAYM tZ WAtlmVc MSTMT•sAc,?,t,htASAcrttneTrs0l97o
Tat:973-74S9S9S .FAX:9M740.9s46
Workers' Compensation Insurance AtBdav(t; BuRdOWContractoramectriclaaa/p(mnbers
Annlicant Information te..t t r Mtl~M
Name(Husioesf/Orsaniaeamtnmvidual): 0 P 9 oz.,s., r --[gc rCe)
Address: e2 / ble L�• _ '_ . - e-p„
CityState/Zip: 1 F-9r3r9t' /
Are you an employs?Check the appropriate Post
1.Q I am a employer with 4. Q I am a general contracts and I Type of Project(required):
employees(fWl and/or part-time).• have hired the subconttactmf & ❑New construction
2.Q I am a sole proprietor or partner. listed on the attached sheet,t 7. ❑Elition
deling
ship and have no employees These sub-contractoo hew S. ❑working for me in any capacity. workers'comp,inavance.[No workers'comp.insurance s. Q We are a corporation and its 9- Q ng addition
required.] officers have exercised their 10.❑Electricai repair or addido"
3.Q 1 am a homeowner doing all work right of exemption per MGL 11.13 Plumbing repairs or additions
myself[No workers'comp, c. 152,11(41 and we have no 12.❑Roof repaid
insurance required)' employees.[No workers' 13.Q Other con*insurance required)
-Any amMmo the Awka bag at maw vat AD am the swd=blow dowhea err waka s .
Aanaowtm who wbmr mb afadwk stay=dolts al waft sad d as hat ouW&mo am at6mk mwa alltdtvk
rCamrwm tba lock mitt bat mat a wAW a adridaui dam davits tb aama of ma sari sissy a 111 aimR bceft xL
tlaa,
rnforaaarlota a that&provldlms worker'eoapertsadow lnsansnceAP my earphryeea Below&alb po&7 amdida slit
Insurance Company Name:_
Policy M of Self-ins.Lie.S: Expiration Date.
Job Site Address ! �rI City/State/Zip:
Attach a copy of the worker'compensation policy declaration pegs(showing the policy number and expiration dab)6
Failure to secure coverage as required under Section 25A of MGL a 132 can lad to the imposition of criminal penalties of a
fine up to S 1.0.00a d and/or one-Year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$2s0.00 a day against the violates. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for intux-mme coverage verification
Ides hereby cerdp under the palms and panaides ojper/m,7 that the injoneadon provided above tr arse and correct
l�
� 5
EBoard
Only, DO not write In this area,to be compfetad by ciq or lawn oafeAd
n: PermiNLieensehority(circle one):
Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector s.Plumbing Inspector
son•
Phone*
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' hi
compensation for their tmnp t%
a defined as"...every person in the service of another under any contract of Kira,
Pursuant to this statute.an tarPloyee `� ..
express or impliC4 oral or written"
u"an individual.Partnership,association.corporation or other legal entity,or any two a more
An satPfeYa is defined including the legal representatives of a deceased employer,a the
of the foregoing engaged in a joint enterprise. However the
of an individual,pumasbq%association a other legal entity.employing employees.
receiver a trustee erect who resider therein,a the oeeupaat Of the
owner of a dwelling house baying not mere than three sparuoenb eonsonretion a work such dwelling hoax
cc e�boom of another wlte employs t persons�notbecause such employment be domed to be an empbYa•w
a on the grounds a budding appurtenant
that"every state or bed Blessing agency,*4 withhold th o W"O"er
MGL chapter 132.$23C(6)also states in thin commeaweaM for ouy
to operate a busiaaa or to eosstetict baiidle¢���coverage regaired•w
applicant of a e hiss
et permit acceptable evideam et compasaee
apptleant illy, teas net Fred° stater Neither the commonwealth not any of its political subdivisions shall
Additionally,MGL eliapter 132,$25C(77 le evidence of compliance with the insurance
into,any contract for the performance of public work until see awl
reqrequirements of this chapter have been presented to the contracting aWhornry
Applicants
compensation affidavit eomplet4ly.by checking the boxes that apply to your situation and,if
Please fill out the Wrakera'
necessary.supply sub"iur )name(°).addr Limit and about number(s)along wnw'th no employees other than the
w ursine. Limited Liability Companies(LLC)a Lionised Liability Partnerships(LLP) does_
members a partners,are not required to carry workers'CO on insurance. If m LLC a of Lidustiial
Be advised that this affidavit may be submitted to the Department vn should
cmpw,*,a
policy is required• coverage Ales tea sun to sip and date the atIIdsvit. The affids
of ina rence P Department Of
Accidents fa confirmation application fa the permit a license is being regnestA not the
be returned to the city a town that the aPp' the law if you are required to obtain a workers'
Industrial Aaiderd. Should You have my quell d regarding
a e Wombat hated below. Sett insured companies should enter than
compensation Policy.Plow call�Deparmsost a th liner
seltinauance license mnnber on the a
City or Two Off cisb at the bottom
legibly. Department has Provided a spaceThe
Please be sure that the affidavit is complete and printedhe event the office of investigations her to contact you regarding the applicant,
of the affidavit for you to fill out ew number which will be used as a roference number. In addition,an applicant
Please be sure m fill in the permi applications in any given year,need only submit one affidavit indicating current
that must submit multiple PermiNlceDfOin
policy information(if necessary)end under"Job Site Address"the applicant should write"all locationsrovided to�a
or marked by the city a town may be p
town).w A copy of the affidavit_that has teem officially stamped a licenses. A now af„drvir must be filled out each
applicant as proof that a valid affidavit is on file for fiuture permits no related to my business a commercial venture
ear.Wham a home owner a citizen is obtaining a license a permit
y to burn leaves etc.)said person is NOT required to complete this affidavit.
dog license a permit
os would like to thank you in advance for your cooperation and should You have any questioner,
The Office of Investigation
s
please do not besitsm to live us a caU.
The Depactmcnt's addressw telephone and fax number.
The Commonwegth of Massachusetts
De uwleat of 1ndtlstrW Am&nts
Of&*of fa esgggtiolla
600 Washington Shed
Bouol%MA 02111
TeL #617-7274900 cd 406 of 1477-MASSAFE
Fax#617-727-7749
Revised 5-26-05 W WW.m11mgov/dia
CrrY of SAmm
' PUBLIC PROPERTY
DEPARTMENT
mavoll 130WA08MGMSTUM�sILLO�YA.Aaa�[isolrn
tti:mr�esss.FNe mr+►sw
Constmedoo Debris Dhpad AMdsvit
(kaquirsd fix all demoMm and ranovades work)
Is Woudaooa with the"adidon otdw Shins 8uHd1WS Coda.780 CMR saadokt 111.5
pebd4 and die psovisioes of UGL a 406 S 541
Sudan$Farrah N _ is iss ed with the eon0itme dms the ddxk rmuldss dos
M woA shall be disposed of in s p I bi Seemed wassa disposal beitttlt as denser by MGL a
i 11.S 1JOA.
rte debts will be transported br:
(aams dtrulsr►
The debts will be disposed olin:
(name of lleilitfd
(added of htwo)
a1Wa afpwtit apylk; }
due
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