0029 WASHINGTON SQUARE NORTH - BPA-07-486 EOF-SAL 1 ---
PUBLIC PROPERTY
DEPARTMENT
AYOt �/ ,/ a.i�� 1 W,�SHINCTON 5'csEET t"'�Y,NtiUc3il:sG1'�S 01970
14y 979-745-9595 1 FAX 978-740-9846
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: 10Mu ,&=It-rAAd,4ovCeBuilding:
Property Address:
a 9
property is located in a; Conservation Area Y Historic DistrictY/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
L
tc M O c N
n
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation tom- 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:
�t �viLp I=JCIST��/!r /O.x/b .Pl-FG
Mail Permit to:
What is the current use of the Building? STe OkA a t 91.16 D.
Material of Building? LAPO If dwelling, how many units?
Will the Building Conform to Law? \ E S Asbestos? %✓O
Architect's Name
Address and Phone
Mechanic's Name SAt yard RLr Sr r a a I
Address and Phone ' LAuRnrLEE �'rQC SA��VS G`1/h o /geb
Construction Supervisors License# ('S 0-104C HIC Registration#
Estimated Cost of Project$ /.2 eaa, ad Permit Fee Calculation
Permit Fee$ D/ Estimated Cost X$741000 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
specifications. Signed under penalty of perjury
Date
of
* N
G N
o T
4 9 u ti� a S
Cur 01 -—
CTTY OF SALEm
PUBLIC PROPERTY
DEPARTMENT
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The debris will be disposed of in:
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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MAYM IM WARMCMMSTREET a SALE4.MASSAcmrpt-rs01WO
TW:M745.959S a FAX M740.98%
Workers' Compensation Insurance Affidavit: BnIIders/ContractorsmecMcians/Plnmbm
Applicant Information PICA"Print Legibly
Name(Busioeat/Orpeiradodfn"dosly &.)AA Do N tF C/ FC T'r2 /e— Cate 0
Addmw: /o O G/ NC 41 'S T G A
City/Stat&Mp: M f O R5A D fW A oa/c-r Ph0ne
I.WanAre yo o employer!Cheek the appropriate boss FQjGno&Iing
aemployerwith � 4. 0 I am a Stmeral contractor andIemployees(W and/or part-tims).e have hired the sub 400trauon uodon
2.❑ a sole proprietor patmer- on the aaached sheet f ship and have no 06-contracron haw worlting for me m any capacity. workers'comp,insurance.(No workers'comp,insurance 5. 0 We are a corporation end its dition
required) otAcan have exercised rhea 10.0 Electrical repairs or addidn"
3.0 I am a homeowner doing all work right of exemption par MOL 11.0 Plumbing repair or additions
myself.(No works='comp. c. 152.I1(4),and we have no
insurance worker
ance )t employees 12.0 Roof repairs
COMP,insurance required) I 13.0 Other
;Any apparent the chocks boa et meat ahto IW out the aedon bdow,shoring 6*wwkm
Homaoraen who subma this aladavk they as 4064 d wo*sad ism hha oow&cooftaw I awe�am sine tt
tCoawecton 60 check this boa mW Beached on aditowd shove showing fir game of the sodcomavan sod thdr watkae'oo0* Wk nmaoo.
I am an emphryer that fs prov/dhrs workers'compemadom Insurance for my employeaa Behnv ts the podey and Job alp informadon.
Insurance Company Name: F/ L(�
Policy 4 or Self-ins.Lie.M Expiration Date:
Job Site Address: or/ City/State2ip:SALfn i-')^
Attach a copy of the worker'compsnsadoa policy declaration pap(showing the policy member and esphratlon date
Failure to secure coverage as required under Section 25A of MGL a. 152 can lead to the ' &
fine up to 51.500.00 and/or one- ear ion u°Porl�°Icriminal pefWda of a
y priaonment as weU as civil penaltip in the form of a STOP WORK ORDER and a Lion
of up to 3250.00 a day against the violamr. Be advised that a copy of this statement may forwarded to the Otlim of
Investigations of the DIA for insurance coverage verification.
f do hereby test r pains d pana/des oj
gnatureo per/ary'her the injafmadon provided above/s dug and Cerra"
Phonett:
OJJleld use anl�t Do not writs 4 this area,to be Completed by Clfy of towns oQk1al
City or Town: Permit/License M
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person:
Phone*
Information and Instructions
Massachusetts General Laws chapter 152 requites all employers to Provide workers' compensation for their employees puntunl to this statute.an employee is defined as"...every person in the service of another under any conttad'of him.
expeese or 1mpHA oral of written." taro or,rpore
as an individual.Partnership, O4 O°°r other legal amity.m any
or the
o f her for yea n defend and including the legal rePm+mtaaves of a deceased employer,
of the foregoing engaged in a join[ea rtneish association m other legal entity.emPl°Yi°i employees However the
recaver m trustee of m individual,partnership. and who resides therein,or the°ocuPsm of the
owner of a dwelling bouss having not mare than thra apatmmenm comstoicti°n at repair work on such dwelling boom
nfi e° appurtenant therein shall not because of such emPloymeat be deemed toat
be an employ
or on grounds
m building appure
or on the grounds a shag withhold the Issuance or
MGL chapter 132.$ (��O states that eV�state or lo cal scenting in the commonwealth for all
to operate a busWss or to toashvet hnildh n0�ur�coverage required•,•
renewal of a o sa or permit aeeeptahM evidesee of eompgaaea
appikasmt whoe has not predaeed Neither the commonwealth not any of its political aubdiviaione shall
Additionally,MGL chapter 132,$25C(�states" k evidence of compliance with the uwunws
entecontract for the pmfotmanee of public work until acceptab
requ m of this ehaptw have been!resented to the contracting suthority."
req
Applkana chadtin the boxes that apply to your situation and,if
Compensation affidavit s(es)and p by a their ems)of
Plea�o�� ns)nsme(s).add t Limit and Phone numberships along with with no employees other then the
insurance. Limited Liability Cotopaniee(ice m Limited Liabiliry )�or LLP does have
members at partners,are not required to carry workers coven
employees,a policy is requited, Be advised that this affidavit may be submitted m the Department of Industrial
of lormanee coverage. Abe ba sorer m stgit and date the affidavit. The affidavit shmd
Accidents for confirmation application fen the permgt m license is being requested,not the Department
be returned m the City or town that the the law or if you are required m obtain a workers'
Lidneatr Accidents. Should Accide Should You have any questions regarding should enter their
compensation Policy.Pie Call the De mpu od lati this
number listed below. Self-i anies
nsured comp
self-inaIIance licertse number on
the a
City or Town Omalab
Please be sure that the affidavit is compl
ete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you m fill out is the evert the Office of loveatigatione has m contact you regarding the apphcaat
Please be sure m fill in the permitniecose number which will be used as a reference number. In addition,an applicant
ltcamons in any given year,need only submit one affidavit indicating eurteat
that must submit multiple permidiueme app Job Site Address"the applicant should write"all locations in_--citY°i
policy information(if necessary)and under" provided m the
or marked by the city m min may p
town)."A copy of the affidsvit_that has been ofAf rfio stamped ordicenses. A now af"-&vu must be filled out each
applicant as proof that a valid affidavit is on file Pm fiuture"Pewim
year.Wlere a home owner Ofcitizen is obtaining a license or Permit not rotated to any business err commercial venture
(i.e. a dog license of Permit to bur leaves eon.)said Person is NOT required to complete this affidavit.
ou in advance for your cooperation and should you have any questions.
The Office of gnvestigations would like to►hank Y
please do not hesitate to give us a call
The Depatmnenes address.telephone and fax number.
The COMmnvMtilth of Mgsuhusetts
Department of lnti>lsUW Accidents
Offte of lavadgRdOns
600 washing"Street
Bags 4 MA 02111
TeL #617-7274900 eat 406 to 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 WWWA MgOv/dig