22 WALTER ST - BUILDING INSPECTION i
-
PUBLIC PROPERTY
DEPARTMENT
KI%UIFJLLEY DRISCOLL
MAYOR 12o WAsHINGTOIV STREur•&u.E \AS&AcHLs6'TIS 01970
TE :979-745-9S9S* FAX 973-740.9646
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: ding:
Property Address:
property is Located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION (34 f erg
2.1 Owner of Land 1'�, C
Name: _
Address: s� �—
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 r Area per floor (sf) Renovated V 00
construction or renovation
of existing building New r
Brief Description of Proposed Work:
4�1�frO Un
--- — ---Mail Permit to: w a14
What is the current use of the Building?
Material of Building? 1-)N) l If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ? OOY�r,V 3—(4119EDz -(WO
Mechanic's Name �1 e 2�y^ —EA r- '
Address and Phone 2 3 Akcl<<nlcq Gvk
Construction Supervisors License# CS CGS HIC Registration# 11 19'R
Estimated Cost off}Project$ 1 0t� Permit Fee Calculation
Permit Fee$ 0 Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an a l
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to th1e�above stated
specifications. Signed under penalty of perjury X e
Date _ i
co g
� of
1 y
e+ N
00 T 4,
\V' V
� v' per, •3 � � o u
7 V q 41
� d
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRnC= -
MAYOR 120 VAUM4f'Y. ON STREET.sAtEta.MASSAC}tr7dgTrs 01970
TE L-M745."95 a FAX 9M740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractorsmeetrictana/plumbers
ADDNcant Information Please Print Leidlity
Nance(amwess/OrsaaintioMndivi"y __1�a11� � n Co r�r
Address: 21 M
City/state zip: bwe-,A j Ma . Pl,o,u#:_ 9-7 K `I2Z COO —
Are as employer?Cheek the appropriate bezt Type of —
1. I am a employer with�_ 4. ❑ I am a general contractor and IE13.[3
i�( '
employ"+(hu and/or part-time).• have hired the sub-connacton construction
2. I am a soh pmprietor or parmar- listed on the attached sheet t lil*
ship and have no employees Then sib-contractors have lit,
de
working for me in any capacity. workers' on
comp,insurance.
[No workers'comp.insurance 5. ❑ We am a corporation and its Building addition
require&] o$Scaa have exercised their ical repairs or additiosu
3.❑ I am a homeowner doing all work right of exemption per MGL ing repairs or additions
myself.[No workers'comp. a 15Z$1(4),and we have no
insurance required.]t employees.[No workers' epairs
comp•insurance required)
*Any WHOM the checks hex#1 mast acorn An out dw seedm hdow showing make wa -eonpmsaloa io�y bkematlos.Haaoawm a who a t"this aladwa hrmmbn shay on doing sn wak sad than eke ouotids omtrn'mn mutt suhmk a am aflidwil todlpdng sort
rCowwaeton 1st chock dsb tea must o teehed to sddidood shop sbowmg ms ones of tlr aodeootrappa snd malt wskpl WOIA trey folic modua
lama an employer that k providing workers'conspemsadee bsusramcijor my emsployses. Below k
tnfai We polfry andJob sift msadow
Insurance Company Name
Policy#or Self-ins.Lic.# �.11 _ (t C5L 1rl �� X) Expiration Date: M
Job Site Address City/Statemp: 5n III ' 1 'A �q Z�
Attach a copy of the workers'compensation policy deek dos page(showln the
L poky number and ezpiratba date
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the
fee up to S 1,500.00 and/or one-year imprisonment, Of
TP W criminal penalties of i
Y prisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violaoor. Bo advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verificadom.
/do hereby certi t♦ and penaltka ofperlary that the Injormadam provided above Is Orr"and coneet
fl�yll Qh�
Phone 4:
Opkla/use only, Do not wrltt Gs.thk area,to be coaspleted by cdy or town oQfclaL
City or Town: Permivuceme M
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#
information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees'
pursuant to this statute.an ewployse is defined as"...every person in the service of another under any contract of bite.
w
of implied.Ord or w"C's
express more
en"an individual.PartaersWP.assoeW'^corpond u oche legal entity,or any two or
An earPJoyer is defined ves of a deceased enrplOYe?.Of the
of the foregoing engaged in a joint eotaPrise.and including the lsga � employees. However the
amoeMon or other legal entity.employing of the
receiver or trustee of an individual.nagPartnership,
more s than aed who resides therein.Or the oCCuped
owner of a dwelling boom bavise employs mess tons three apartments construction Or�wodc on such dwelling house
dwelling beese of asotbar who employe Pepe s al maintenance,of such employment be deemed to be an employer."
or on the grounds of building appurtenant fit°shall not because
MOL chapter 152.125C(6)also states that"*very state or local pees aieg ageeey shag withtold the lsenaeee or
too a business or to eoastrrtet bulldings is the commeewes"for it"
resswal of a license or Permit aee le*vldeees of complluee with the insurance coverage required.
applicant who bet sot Pre IM" -Neither the commonwealth as any of its political subdivisim shah
Additionally.MGL chapter 152,$25C(/)states work until acceptable evidence of compliance with toe insurance
at into o ��ban him presented to the contracting autho t -*
pPPneanb
mPao that aation affidavit completely.by checidng the boxes at apply to Your situation and.if
Please fill out the workers'co
necessary.supply sub.conttaCror(s)name(*).addresa(est and Phone number(s)along with employees
s)o�than the
Limited Liability ComPIMM(LLL7 ter Limited Liability Pasmershmps(LLP) no at LLP does have
are oat required to carry workers compensation insurance•
If an LLC members of parmarb He advised that this affidavit may be submitted to the Department Of ledustrial
employees'a Policy ls tegdred coverage. Abe be sets to sign and date the amdavlL The affidavit should
Accidents for confirmation of insurance ge. not the Department of
be returned to the city or town that the application for the permit or ncease is being requested.
Lrduattral Accidents Should you have any questions regarding the law or if you are required to obtain a workers'
compensation Policy.Please Call the Department larms�numbs listed below. Self-insured companies should enter their
self-insurance license number on the
City or Town Officials
sate that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fin Out in the event the Office of investigations has to contact you regarding the applicant
Please be
license number which will be used as a reference number. In addition,an applicant
Please be sure to fill in the permit/i in any given year.need only submit one affidavit indicating current
drat must submit multiple pemaiNcense applications
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in__(city Or
or marked by the city or town may be provided to the
town).'* t Copy of the affidavit validaffid has been Me
officially stamped or licenses. A new at ,drvir must be filled rout each
applicant as proof that a valrd aftiidani u os file for fbture o Permits ant related to any business or commercial venture
year.Where a home owner Or citizen in obtaining. s i person
is permit
(i.e. a dog license or Pew
to burn leaves
etc.)said petsou it NOT required to complete this affidavit
The Office of Investigations would like to thank yo
u in advance for your cooperation and should you have any questions,
please do no hesitate to give us a Call.
The Depummenes address,telephone and fax number.
.The Commonwealth of Massachusetts
DeparUnent of Industrial Accidents
Office of Investigation
600 Washington Street
Boston*MA 021I t
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26.05 www,maaa gov/dia
CITY OF &uEm
PUBLIC PRopnxy
DEPAfrTUMM
C®ssbvdka Debuts Dbpad ANdsvit
(�iwd�.�damlidss�rrwnias�
is aooaedsaas wilt so PwAdow add a`!sy•sdldt°S colt 7e chat�O.u1!
°gy��� tobndvAh*AoomMmmatswdadbrmd li fi -
Lhy wok*0 e.d1lPowd Otis o pov.b SomM vw dhpmd edit as dsAwd by WIS o
�►t.s 1sa.
Tho ddwb wM bs WwApGdM bP
aa•a�
tN dells win be dfspmW*CIO:
e C-64,,•t
("dmoofs9d »
lipm a ofpwa des