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1 WASHINGTON ST - BUILDING INSPECTION _-- PUBLIC PROPERTY DEPARTMENT AINGIOU"DRISCOM MAYOR MWASHINGTONSBFET &UkAkXA\UCHLSt-1-rs01970 141978-745-959S♦FAx:976-740-9846 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: ' h�rO, ST_ Building: Property Address: 1 w I}5 K� 5 Ales , tea- oc<j70 properly is located in a:Conservation Area YIN=Historic DIsMd YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner ofLandro " Gr e� ,.c�r��l � Name: LY\�,,.r C.� COAL T 5T- Address: Telephone: qr 8-,;)L18 4ovo X Y 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: 'bA�\nTr Sro re l ln oor {sr f Stir f1"d feR�S6er 6KT F ll�i r�r�heceC� • Cr P—te ireak To hoiS yvA?<c1A� 0r Tu foof'11 Mail Permit to: What is the current use of the Building? COo S Material of Building? if dwelling, how many units? ? Will the Building Conform to Law? \It�e S Asbestos? Architect's Name Address and Phone ( ) Mechanic's Name 4 •C- C A Sr/e C.C. 2. . Address and Phone 4 til Al k e R " pe<,600(V MA, O t Q G,o Construction Supervisors License# 05488a HIC Registration# o7o4(,, Estimated Cqq°f Project$ 0 0.0 a Permit Fee Calculation Permit Fee e� Q� 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 specifications. Signed under penalty of perjury X lam- laza ^✓ Date ti z5 0 L c. r ab+ 3 ate, �• y CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT snttOsatav mascot.?. MAtroa M W.amacrote Srassr a SAUK MwtL►CHIMM 01970 Th.971-745.9595 •Fix:WI-740.9m Workers' Compensation Insurance Affidavit: BandeWContraetora/Electridan9/Plambers Applicant Information Please Print Leidbin Name(BmimwO:ganiacodlndivi hw): A • C - c ,4 TIE C , 1 Address: 4/ 2Q . - City/State/Zip: P eab©c�9 , iM A o(q( Phone# 9 F�- 740— — C) J Are you An employer?Check the appropriate boss i. I am a employer with 4. 0 I am a general comurcme and IFC03D=oHd= required): employees(&H and/or part time). have hired the sub-constactors uction 2.❑ I am a sok proprietor are psrmer listed the amached sheet t g ship and have no employees These have working for me is any capacity. workers'comp,issuance.(No worker'comp.insurance 3. 0 We are a corporation and itsdition required] offices have exercised thea 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repair or additions myself.(No worker' comp. c. 152,41(4),and we have no 12.0 Roof repair insurance required]t employees.[No worker' COMP6 insurance requited j 13.EyOdw_5-r,,o/re roo F * conqWCUADAny wvtins sus concis boa rel mar.teo mm em dw recdon blow showing their.odn,a• Haaeowera who obdt We affAwt aftaft dey m doias as wad:cod dm Wn GoWts omomouintat whmu rCwmaemea deet cheek Ws boa mea ruched ae eddt wd cher showing du eme of do su&=ufteenn and dub wadm,comR I am an employer that If providing worker.'eoaprne9dow W"ance for my information employres Blow b NIM poHry and Job rim A Insurance Company Name: q� e I/SIS cera Policy N at Self-isle. Lic.N qL�63S ?6B7 09 O S Expiration Date i 3 O O QkArcq 5i . s Job Site Address: '.7 a S H i n 4 o N ST S a(e Ciry/State/Zip. wO , Mau () Ig7o Attach a copy of lir workers'comPeasadou policy declaration page(showing the policy number and esplradoe daft Failure m secure coverage as required under Section 25A of MGL c. 152 can lead to the ' a fine up to S 1,500.00 and/or one-year im sMPoaition of criminal penalties of• y prisonme vi a well as civil penalties in the form of a STOP WORK ORDER and a line of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for iruuraoce coverage verification f do kereby nerd&ander the pa�hm and pena/da of psdwy that the lnformadon provided above&&w and carred Sianaturc• � �Z>_ea�-���J Dae [l/24/O(p Phone N: P - ?40- j 14 U — O/Jleid rue on6% Do not write in this area,to be completed by cGy or tows oJj?claL City or Town: Permimees"M Issuing Authority(tack one): 1. Board of Health 2.Building Department 3.Clty/fown Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone N: Information and Instructions compensation for btassachuseng Ocnetal Laws chapter 152 requires all employers t provide the serviceworkers nodiec ands any ctheir a°nom of hire' Pursuant w this statute,an emPloyse is defined as ...every person express or implied.oral or wntten." '1 , as"an individual.partnership, o4 coition or other legal entity,or l Y two a mote An serPJoyp is defined ver of a deceased employer,or the of the foregoing engaged in a joint entap dae.and including the legal repraentati to ee& however the receiver,thefo a trustee of m individual,parmershtp6 association at other legal entity,emp10YU4 Yor the oeeup+st of the owner of a dwelling house ba'ni not more than to donanm construction cc �v�t no such dwelling ham dwelling bases of another who esspbri+P be deemed to be an tsnployer." or on the grounds or building appurtenant therein shall not because of such empktyment "every state O<{Deal tleeasiag agency fblg withhold the ifaua10te Of MGL chapter 157, 25C(6)also stave that erY V the commonwealth far any fee a business or to construct buildido ngs in covera�rtgttbned" reaneal of a tlsw or permit acceptable evWsw of eompazoee app leant who has not predated " nor any of its political subdivuwd shall Addationally,MGL chapter 152.125CM stats Neither the commonwe' evidence of compliance with the ineutance enter into MY contract for the performance of public work until acceptable teqtrWm=u of this chapter have been presented to the contracting awhoriry" Appgeaat5 Please 811 out the worker•comms affidavit eompleWY,by cbal°na the boxy that apply to Your tituatton and.d necessary.supply sol"ourractog(s)name(s),addre*es)and phone number(s)along with their employees)of than the insurance. Limited Liability Companies(LLC)or Limited Liability ParmeritiPance.(LLP) with mambas or partners,are not required to carry workers'con�°n insurance. en LLC or LLP does have employes,a policy is t He advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Alfa be sen to 51910 ane dot the MINIMAL The affidavit should be returned to the city or town that the application for the permit or litems is being requested,act the Department of Yon have any questions reg the law or if You am requited to obtain a workera' Industrial Aecideds Should call the Dept ir number listed below. Self-insured companies should ester the compensation policy.Shaul self-' aged license number on the City or Town Oloelab Please be sure that the affidavit is complete and printed legibly. The Department has provided ding a space h licantthe bottom Of the affidavit for you to 811 out in the event the Office of Investigations has to contact you regarthe app Please be sure m 811 in the permiVile="number which will be used es a reference number. In addition,an applicant lications in any given year.need only submit one affidavit indicating current that must submit multiple permiWce°se app applicant should writ"all locations is_—(city or policy information(if necessary)and under Job Site Addrese the app the l ri town maybe provided to the Of the affidavit that has been ofliciady stamped or marked by city town)."A cePY or licenses. A new afudrvit must be filled out each applicant as proof that a valid affidavit is on fiht f a license or permit not related to any business or commercial venture year.where a borne owner a cdtZM is obtaining u NOT requited to complete this affidavit (i.e.a dog license or Pamir to burn leaves etc.)said person would like to thank you in advance for your cooperation and should you have any questions. The Office of Investigations please do not hesitate to give to a call. The Depattmem's address,telephone and fax number. TherCOMMWWth of Mmachusetts Department of WoMal Accidents o®a of Investiptlaw 600 WuhM9M Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Rcviscd 5-26-05 w ym mm&ov/din CrrY OF SALau ' PUBUC PROPERTY DEPAILTMENT aura. INWAAMIM SCUM most* Construcdoa Debris Disposal Affidavit (reg"far an daawlidas and re"Va"woo _ 1 1s aaordaooa witb e6a ppovidow MGa d4 �i �C 7S0 CbQ axda�l ll.! 9 f -- is land w tts dw sondidos 60 dw ddula n wAdna foal this Work"be disposed Otis a popa b deenad weals diapoasl&dfitlt as dented by MOL a 111.�13QA. Thad will be UWLV oeted by: �q c_c✓j81 (e du�P "V (ams a[baelwt , The dabais will be disposed o[in: (=aofrm"» FaceST ST, P-ea6c&,/ sib of�ippliaat Lc)�, due