29 WASHINGTON ST - BUILDING INSPECTION EITr0F _
PUBLIC PROPERTY
DEPARTMENT
K„aFALEV ouscwL
N"YO1 120 WASMNGT N S•rnmEar -
5UEK Nw%tAanst1-rs 01970
TM--976.71E-9S9S•PAM 978.740
APPLICATION FOR THE REPAM RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EMSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: :YAn Qzrtf u NUv-eo Building:
Property Address: a 9 IN a$�I nc� �7Jn S`f ree I
I Property Is located in a; Conservation Area Y Historic D Y
s
# 2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
S —
Name: J o 4 Aer'}raM }��ySL�
Address: of Cl W aS A"N3 -on 5 } rec 7
Salem, 0W 0'#970
Telephone: %7-F - ?y -- 1 0 0
3.0 COMPLETE THIS SECTION FOR WORK IN EXULTING BUILDINGS ONLY
F
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
8ref Description of Proposed Work:
InS}ct11 �1� D;eSel SQne,-N �Jr On con cpe4e pad -
-------- Mail Permit to:
GSSiS�ErA L1utn
What is the current use of the Building? units?�--s
Material of Building? } Rrrr K If dwelling,how many
y�5 Asbestos?
Will the Building Conform to Law?Architeas Name PA01 Z. e55W'd
�- �, I-��, �• � -cam �y�- oyna
Address and Phone
"t�
Mechanic's Name Lem lC�e SGv /n 9 '
Address and Phone a
Construction Supervisors License# 40 8ti l65 HIC Registration#
Estimated Cost Proi i ' 9 0 ' permit Fee Calculation
/vL'J\ Estimated Cost X$7/5
Permit Fee i000 Residential
Estimated Cost X Si1 US1000 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 uild to the above stated
specifications. Signed under penalty of perjury `
Date I n-
a � �
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a �
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Fgg •a � s � >
CITY OF SALEM
PUBLIC PROPRERTY
�-- DEPARTMENT
KIMBLU'PY DMSCOLL
MAYOR
120 WASNNGTON S7RrET a SAL EM,MASSACHUSEM 01970
Workers' Compensation Insurance Affidavit: Buflders/C ntractors/Electr[clans/Plambers
A licant Infor atio
//
Nam ga
e(Business/Ornintion/Individuai): /Ur1/Gf0/1 L'
Address: -Lu,Ac PC er f (gee --
City/State/Zip: AL-44rrp 11)A Phone#:Are you you an employer?Check the appropriate box:
1.�am a employer with_-E6_ 4. C] I am a general contractor and I Type of project(required):
2.C] employees(full and/or part-time).* have hired the sub-contractors 6• 0 New construction
I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling
ship and have no employees These sub-contractors have S. Demolition
working for me in any capacity. workers com
p. insurance.(No workers' comp. insurance 5. ElWe are a corporation and its 9, O Building addition
3.❑ required.] officers have exercised their I0.013lectrical
I am a homeowner do' nP or additions
mg all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp, C. 152, §1(4),and we have no
insurance required.]t employees.[No workers' 12.❑Roof repairs
comp. insurance required] 13.�other r9enErk { of,
IAny appgcant that clocks boa[01 mud 46o fill out the section below showing their workers'
Haneownen who submit this 11 idavlt indicating they are doingaV wodc CO°a�oOp polo�mmatlod
Connucton the check thin box mud attached nn additional ahm showingan then of
�contractors must submit a new&Mdavit'
ndicating name of the sub-coatncWrs and their warkma' guch•
I am an employer that is providing workers'compensation
infrmadan inraronce for my emp/oyeet Below it ekepopcy andJ
++ 1
Insurance Company Name: r h er' � 4 t ,) 01 U C,
t.Policy#or Self-ins. Lic.#:_ IlJ C- I I C - 5 �*j(oq t� F-j
Expiration Date:
Job Site Addresa: C+,S{,nS �Bi1 ��y<<�/
., City/State/Zip: �P/h /�•$ O/97a
Attach a copy oEthe workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,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 violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby ce - nder ale and penalties of perjury that the information provided above it doe and correct
�Sign ��
� �� - 39/ - a7a7 /D a dd
=Other
only. Do noe write in this area,to be completed by city or town OB&IaL
n
• Permit/Licenae#
ority(circle one):
ealth 2.Building Department 3.City/7•own Clerk 4. Electrical Inspector S. Plumbing Inspector
son:
Phone#:
Information and instructions
tier General Laws chapter 152 requires all employers to provide workers compensation for their employees,
as employee is defined as"...every person in the service of another under any contract of hire,
Massachtise
Pursuant to this statute. P
express or implied,oral or written." two or more
individual.partnership,sSSOCiaao4 corporation
or other legal entity cor slog employer'
or the
An employer is defined as"an indi and including gal representatives of a deceased mp Y
the le However the
Of the foregoing engaged in a joint enterprise, employing employees.
of an individual.partnership,association or other legal entity, or the occupant of the
receiver or trustee hav�g not more than three apartments and who resides therein work on such dwelling house
owner of a dwelling house who employs persons to do maintenance-construction or repair to yet"
dwelling house of another thereto shall not because of such employment be deemed to be an emp
or on the Founds or building appurtenant
MGL chapter 152,§25C(6)also states that"every state Dtsfidings is the commonwealth for any or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct
applicant who has not produced acceptable evidence of compliance with the insuranceor any of itscoverage political subdivisions shall
Additionally,MGL chapter 152,§25CM states"Neither the common dense of compliance with the insurance
enter into any contract for the performance of public work until acceptable
resented to the contracting authority"
requirements of this chapter have been p
Applicants 1 to our situation and,if
Please fill out the workers' compensation affidavit completely+by checking the boxes that apply y
supply subntractor(s)name(s)+address(es)and phone number(s)along with their certificate(s)of
necessary. im Y
Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
insurance Limited Liability mP ed to carry workers' compensation insurance. If an LLC or LLP does have
members or parmers.are not required d that this affidavit may be submitted to the Department of Industrial
employees,a policy is required' Be advise
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit- The affidavit shout
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,Please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the a rim line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has Provided a space at the bottom
the a licant.
permit/license number which will be used as'a reference number. In addition,am applicant
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding PP
Please be sure w fill in the applications in any given Year,need only submit one affidavit indicating currant
that must submit multiple permit/license app "the a hcant should write"all locations in (city or
policy information(if Necessary)and under"Job Site Address PP be provided to the
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may
applicant as proof that a valid affidavit is on file Tdr future pezadts or licenses• A new a business
must m filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
yea a dog license home
a Permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank Y
ou in advance for your cooperation and should you have any gVestion%
please do not hesitate to give us a can.
The Department's address,telephone and fax number.
The Commonwealth of 1ylsssachltsetts
Department of Industrial Accidents
office of famdgattons
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 wwwjnasa.gov/dia
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIUW GY asuodt
corn, t3D w Sys•swot N�ss.�oa:sarts Ot9T0
T9L-gnus-9sss•eN¢m740-MU
Construction Debris Disposal Affidavit
(required for all demolition and renovation worst)
In accordance with the Ahlb edition of the Staos Building Code,M CNM section 111.5
Debris,and the provisions of MGL a 40.8 St
Building permit d is issued with the condition that the debris resulting Soya
this worst sball be disposed of in a propsly liemsed waste disposal deility as defined by MCX a
1 t 1.S 150A.
Ilia//debris will be transported by:
✓-kfn,, s .96 6 in d(1
(same albsals�
i
The debris will be disposed of in:
�i/uoc4 4 CGS le- 6� XdS 4-1
(a�ma of 13eiliry)
(adds m of hoaity)
sigaamro of pumit applicant
to- �� � 0 6
date