10 VINNIN SQ - BUILDING INSPECTION EITY-OFSALE —
r' PUBLIC PROPERTY
DEPARTMENT
F:ISQIFJILEY DRISI:OLL ,�� �����`�
MAYOR //✓ I-V WASHINGTON STREU•SALF.K y� CHLS6l-IS 01970
TtL-973-745-9595•FAX: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: F4a0S0n l a¢ a Building:
Property Address: p 0t✓\n1
'AetA 9AA- ot9 �O
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
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
Brief Description) of Proposed Work: L f
5'f'"? oci5t1 +'If too gCec.� IrtS�G�I /�lvl �IySPt� yR� �s7� �nS��4T�,
ntA./ rA6 kr1wtowlor�r� ra� ,Ily
Mail Pelmet to: ti �c f K
ecdices C Esc, erSo. e
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What is the current use of the Building?
Material of Building? heck :'t&hoA, 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# 95;<9 HIC Registration#
Estimated Cost f Project$ 00 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 above stated f
specifications. Signed under penalty of pedury X
Date
of
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CITY OF SALEM
'.. PUBLIC PROPRERTY
DEPARTMENT
MAYOR
lio wwvm•e,ne,stsesr•suit,Mw�Csarareso197o
TM-M745-"" •Pax 9W 0.9W
Worlten' Compeneadon Insaranae AlSdevW Bu ldeyContrectorjWeCtriefaaWr tubers Annikant Informadon II Pie e.Print Legibly
Names
Address•— gL & ersor\ Lolnt)e-
City/sta cump:T_ 9A- w90, Phone
Are you as empteyerT Cbeek this appropriate bon
1.� 1 am a employer with 9 4. 0 I am a Soma aoottacoor and 1 Type:Nco:,�(�'
�P1oY«s(lhll andla par�tims)• have hued the dao ❑ srtttctioa
2.❑ I am a role proprietor or panmeo listed on the attached sheet t 7. OR Has
ship and have no employees These wb conpaepoes ban L
working for me in any capacity. wwkma'comp,inanancL ❑ oa
(No workers'comp iowrana 3. 0 We am a coeporsdan tend its 9. addidanrequired) ofilcros have exercised their 10.0 l repaire or additions
3.0I am a homeowner doing aB work rightofm anaptim per MOL 11.0 repaita or additions
myself(No workers•comp. a. 1S2.41(4),and wo have no 12.Jgain
insurance requhv&j t emPWYeaa.(No workem•camp ;sumacs 13.0
t H�aa•ar+m r6asiralt ai eelarvrro ter�a•aeetlaa twbw sender teals w•raaa•snpapdae edtry,ebnmeaa
reamaebs ur ehsk dda fate sates rmea a plos ap an nods d Om ids aeoft amaacwa mote mash a now atlidab indkeft a&
dae6ia sr tear ddr a►eem•sts d teak nabs•coma v�iosasatlaia
'ram as naoiopp that lr provfd/nj woriraa'compewaadow w 4uwnwee/Lrjormadem '/� MY rxWAVa•s 901~Isrba pft a and/ob stirs
Insurance Company Name: rNlk
Polity N or self-ins.Lie.N:_Lrffi.r-C 0 7
Expiration Date: 4
!orb site Address 1rkm i c ty a_ te2ip:Ilet 9YA- a�1"76
c; is
Attach a copy of tie workers' ompeasatba policy dalantlon page(oho r
Faihtre to secure covens �the Policy number and exptradom dau)6
fine up to 31,300.00 andor one required
i modes meek 23A of MOL a 132 can lead m the;mP041id a of criminal pea eld"of a
of up to 3230.00 a a Y e t as won as civil Penalties in the form of a STOP WORK ORDER sad a fies
�Y the ai ce or. ra advised due a copy of this mteso m may be forwarded to the ORlce of
lnvestigatiom of the DIA for���•AM.
coverage verification.
!do herebycord, awder o10 and ptnddp ajparjary that rite/w
^ /onwodow provided above is bwa and ended
ESiti�CVl
� 3 � , z o
Dlrtcid wra on!!t Do wit wd&in tb4 area,m be eosp/arad by city of toww ORIcIal
City or Town: PermlN[deease M
suing Authority(circle one):
1. Board of Health 2.Building Department 3.CllYl1'8wa Clerk 4. Electrical Inspector S.Plumbing Inspector
ti Other
Costact Person:
L
Phone N.
Information and Instructions
tta General Laws chapter l52 requires W
provile workers• compensation fa their etttploytsa.
Msssaebusc is defused as"..every Peres°in the service er another under any Coneact of hitep
Ptusuent to this statute,an ewpley
expeess of implied,od or writtao
a ocher legal entity or an)I two or mere
as"an individual•pattmembip.aeroeuacs-�O° va of a dtxet►sed employer•a the
An ewpr�is engaged
d m aioint 1*00sim .and m d dma the thQ� employee, However the
of tbs foregoing engaged , . sssatiatlan a other le;a1 endtY.emPlOY1O�
receiver air trustee of an
owner of a dwelling bowo havntt� "Oat�m to do m osnc e. of ° darallia{hsoM
d11"M house of atinlhsr whn empinYs�ereoo shall not becau"of such anPloymeer be deemed to be an empbye•'
or on the a�at building WWO=b a"Ww"d tr beluga or
MGL chapter 152.4�(6)�a state tbu"eve slab w Wed tleaeaiug jMV in the eommosaweaW tar aq
renewal of a tlaw Psi fO acceptable Of emprsnee with w�� �' shall
aporam business Or to cGiffishmer alma.
ant"be has net psrodoeed subdivisions
�AddietioosRy,MGL cbspter 152.125C(T)seem" the eom ncefeabb of oompliance with the insurance
ester into acy
of shin ciuPter have P WOd to she contracting vldwfit -•*
rWuirsOMMIS
APP d Cbecldna the boxes that fly Wyatt$itss "atsd,tf
Please fill a* the a s dross(es)�pbwe number(S)alum w> s)LF)with no employees of thm the
necessary.supply
IL6o Liability C (LLQ or Limited Liability Pu uor umhips(L
Wip not_W catty w�.eat°°msuranee ]fan LLC of to die Dqmuncnt of Industrials
houM
employees,0 Po or lley'a Be B A dds�Wndsnn W AW and noy,be dddate the a�davi6 The aBldavB
fee the permit or Hear"is being requ ted.not the Depattined of
peeidanb for O°°f 1°��eOf to"dat the W obtain•worktsn'
be returned Should you have any qussk s regarding the law or if you are iced end
Ltdttatrial at the numbs Bsted below. Sel�iosured comanlee s4ouid enter thtrh
Policy.pbeaa call the Dgwuna t
Self- menConvae license maObat the �•
City or Town Omrlati has provided a vace at the bounce;
Please be sure that the affidavit is Complete and pntited legibly. The Dcparwmw
has W contact you regarding the applicant
of the affidavit for you W fill our in the eves wW&will be as a usedrefer amber, In additions an aPPbc�
Please be sure W fill is the P°��C0D0 Micenso lications in say given yes,need only submit one affidavit indicating currentcW
that must Pima policy inf,�Multiple a te)a under"Job Site Address"she applicant should write"an locations o_dt(he
s marked by she city of tetra may be provided to the
town)."A copy of the affida dnt has been officially
stamped Marled
A now aM&vu nOW be filled out each
applicant as Proof that a valid affidavit is on file for Am"Parmib not tee W any business or commercial Won"
year.Where a home owns Or citizen is obtaining a Haws°er perm* W skis affidavit
(i.e. a dog license or Perm*to bum i aves eee.)said parson is NOT required
of lnvesnganons would like
to thank you in advance for your Cooperation and should you bave any questions.
The Office
please do not hesitate W give to a Call.
The pe wt•a address.telephone and feu nmer:ub
The COMMnWealth of Massachusetts
DCPUUMM of hdilstitial Aceiaents
OMft of hM8 t&ftU
600 WLAW&M Sftd
Bostoo4 MA 02111
TeL #617-727-4900 Wd 406 or 1-877-MA"M
Fax#617-727-7749
Revised 5-2&05 WNM1y,nlaS pv/dia
GJ,4e-�a-nvraasw�ealD��✓�amdc%�wel� .
1 Board of Budding.Reguletlons.aed Standards ,.
IE t, Construction Supervisor License.
L!eense�CS 75259'
1 Birtltdete t' 14/1965 '
,. Tr# 6599
( xpon,-4yJT�472008. i,
t Kastttetion.�� p�
BRAD LEY J SONTZ`o
7 McKINLEY RD
�. MARBLEHEAD,MA 01945 Commissionef �;
Crry OP SALBt
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