157 WASHINGTON ST - BUILDING INSPECTION (3) What is the current use of the Building?
Material of Building? � 'd if dwelling.how many units? _
Will the Building Conform to Law?�r Asbestos? A/ J
Architect's Name
Address and Phone t )
Mechanic's Name dd
Address and Phone
ConsWuction Supervisors License#n? Z HIC Registration#
Estimated Cost Pr ' i Permit Fee Calculation
Permit Fee i Estimated Cost X$7/$1000 Residential
Eedmated CostX S41/S1000 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 t e.above stated.
specifications. Signed under penalty of perjury
Date / L S A
� N
CN
s �
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x Z w
1
EI"rOF
PUBLIC PROPERTY
DEPARTMENT4120,,6?
KMONS"13RMCLIL
NAV'Ol 120 WAMUNGWW SMEEr 'iu,ca4 S(nssaon;scl-rs 01970
TrL-911-745-9S"•FAx:M740."46
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: 57 tA)4,fkl 7-0 Building:
Prop"Addresx---- -.--- ----- —_ __ —
Property Is located In a:Conservatlon Area Y/N o Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land G 6' C0�f�m�G si7b
Name:
Address:
Telephone: 70 7YO 0 Q
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of stories Renovated
Change in Use Nov
Demolition Existing
Approximate year of Area per floor (sf) Renovated 700
construction or renovation
of existing building New
Bdef Description of Proposed Work: oo sT 7�[oviz
Snia1e"f- S rz t of SPA-tF, APO bW'#1� 1 .N lam/
i4DD CXICIZ 4n1D 64r2 A-R-(4 FrvZ -7ZP-01 Ct On3 /
--- -----Mail Permit to: 1 t r - - -
CITY of SALEM
PUBLIC PROPRERTY
DEPARTMENT
;.lusruetr rv..w,...
>l vats ix sfarea%+atilosrtlemr a JA t1ta1,Mastery".wnsolvo
T".mf snsys a F.,,x:97144Cs *
Workws' Compemadou Insu►asee A8ldavir BWldanlCostraeton/Elecridsnst/phmbees
Aatllteaat Information y Castro Mail
a ottws..
Name Iuuvoe.,tO.p.;,,tiolVllwl.re.l1: 9i+it L d cz:/b c
Oily/SL1[CJZIp: k-�O/ 7 -5 9 C/-'
Art as emPbyer?Cbsek the appropriate boas
[[C3
rat a employer with � 4. Q 1 ant a scoor l eoottaewr and I Type ofProJ�lrM�
atPl.tyctxl(Cull yw!/or p fn.ume).• havo hired the sub ewxextoea 6 ❑�'ow,construction
am a sole propriever or partner• listed on dis attached shaft t 7. Q Remodeling
ip and Mrs no ampbyces Theo, haw IR ❑Aemolition
orking for an in any capacity. Amtorws'�inauano�
corporation NW its 9'
o tllafketa'comp insurance J. a an s Builttiat addition
quited I otTloera have exerciaal dwir 10.Q Elacaieal repair or additionsp
m s homeowner doing all work right of exemption par MGL I I.Q Plumbing repairs or additions
self.(KO workers'clmtp. c. 152,#1(4),and we have no 12.Q Roormpi
int
urance requited.)t :mployera(1•o workers'
¢amp ittwuattus rcgttimtL] 13.❑Other
'
'A10+ppk.d dip etlaess eaa el nap or Weirs
s"x ail ar Wow shmiq dear wpa-a'a1spIW1(as PaM'iariastalisa
tl WW,4rewa wae.ubw"dWwk Witku is flay ae dows a wad rta 6=WN anrNe eauraom asps.emit a saw
'C.aar"M 111 W thak tais bw safe aoatseee r add d oW AM 4 0wip o f nee ever A&48wranala sae*W water.• 'm't"a YWlpaiax Wes.
°ps►•A'nk7 iethrareaa
/are an ainpbyrr that 6 prov/dfnR work",compensation Insurance jar my ernp/oytua Be%w IS the pole ant/ r
uyrw.....i .
Insurance Company Vanw b _
Policy 0orSclf--ins. Lie. 0- Pjue &g3t 4 /� .7-k�> E.epiratlonDate:_ 3
Jab Site .Address: E� City/Strw2ip:
\ttacb a copy of the workers'compensation policy doelaratloa page(showing the policy number and esp(ntloa date}
Fai lira w x:cute coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa
ri nc up to SI.500.00 arul/or ons-year i1nprimn1n
en1.4s well as civil penakitst(a the form of a STOP WORK ORDER and a few
.if up to S250.00 a Jay against Ili violator. lie advised that a copy of this stateaxnt may be turwardcd ko the a UDice ut'
I�1�':�Ih:111OIr l 111a DIA °Of ltlluncee aivera3l; verificrtiun.
/Ja hereby cerri/j uaJti rbt poi an/ n s a n/oraayon provided above
pro Irtrt iW cor�rct
Ci•:crti�r.:•
O/W&1 art an/jt Ae naV Irdrg/n ni/r arra,/o ba ronpJr11d a c/Ypoy revert o0$/aL
City or Taw": Permit/Lkeats
A,u(ng Autbority (circle one): _-
1. 114pard of llcalth 2. Building Department 3.Cite•/row"Clerk 4.Electrical Inspector S. Plumbing Inspector
G. Other
Gnitact Persou:�_ Phone 0:
Information and Instructions
fit.,-.".husetts General Laws chapttr 132 requires aft employers to provide workers' canpensatioe for their empbYrsaa.
Pursuaru to this,-.turd,an#mVhW"is defined aa'...eweY person is the novice of another unda any coarser of bin.
e.press.x imphod.oral a written"
aeasaatiaa.easpowaas a odor isWl satiny,er any two se mote
As ea"sispar-s,Atitd istlwwmL pas�sa enterprise.� ►including k�a ves of a deice- W e mpl nova de
at the
of the foe t truss aaaaa ties et odtat laPI wage.amployias emplayom
oacdiver er tstesrms of f �v •per ' d wIM easidas dmmm.are the ooapttt of de
owner of a dwsl O0t errant that�M spat"-aOta cusslrut uuos or repair work oa such dwelling houst
dweUina house of another who etnploya p� .��ploYttteae bs datatod t°be an empmya..
or an the a er bttu'Id{>><aPpwummo
sjGL chapter 152.f2SC(6)ale°stem doer_@My am"err bed 8sessbg aPney AM"'wb*U(he Msm m Or
a apostate a baabeess dr b Cousbrad bnlw.p In tke e•.Uenwe.w tar wW
resewd of a assert or tat�adcsPabia evids"s"elf eoespossa with tha isse"Nee eeverap r*%Gk shad
eppdeast y teas r pswd the commosrreahh am UW of its podded wbdldslane
Additional
nto a . OCA c�fisr the p rf�drmaa ere ofp�pu'Neither until acceptable evuisaee of compliance with the iruureset
MW oft chapter have bias pnatauod to the reused V autb ft
Appdeants to our situado0 and"(
ts MIut
Plea me
the weriteet' �cdaasam sffLlavis eomplemly.by checking de boxes that apply Y
necessary.supply atb•oottteaetor(s)nane(s).addnae(as)and adore number(s)fs),tons with their emilkae(s)Of
lft Companies(LLC7 or Limhad Liability Pattiershlps(LLP)with no employees other than de
u-sunnaL Limited art required es carry w�A. -yucsnea If an LLC or LLP does have
members. Policy uiedd. so advised dust this affidavit Trey be submitted to the Depart ent of Industrial
employees.•Policy tad, L Abe be sure lo sip sad date the stfidaviL The affidavit should
Accidents for cosf -met art of inerurnce er licerin is being requested, sot the Deparnae as of
be returned to de city a town that the applicat[as for the�law a if you an required to obtain a worker'
Industrial tion policy.
Spy you call theva and RMNWN AM td nu Us"below. Self-inard companies abadd enter eheir
cmnpatusatlm policy.
self.insurance license number on the
City or Town OfOetab
�,. ...__ . .. -. 4 -b The Depattrnetu hse provided a spur tut de hotrod,-..
Please be sure that the affidavit is complete and pivited `g' 19; the Ifu-tt
of the affidavit for you to flli out in the event the Office of Investigations has to contact you regending
- purmitllicense number which will be used as a reference number.
re n affidavit addition,indicatinganrant
prase be sera to fill in the tions submit
ew
that must submit multiple psrmitilicense applica A any given year,need only
Site Address the applicant should wrier"all localities _o-in _(sib of
policy information(if naessary)and under"Job
townl."A copy*(the affidavit that has boar-officially stamped or marked by the city a town may be provided m the
each
applicant se proof that a valid affidavit is on fib far
liiuture ccense"p nit ts or Iicensee. A now na Anted to any busineit ss or om nercialbe filled lvenm+ro
year. where a hams owner r ciuu"Cri'a 0leaves wd ptsrsos it NOT required to complete this affidavit.
(i.e.i dog license or peRdt 10 bum
Chu Otiicc of tnvesriptions would like to thank you in advance for your cooperation and should you have any questions,
i,lcaae ju rwt hesitate to give us a call.
The Par
M. merit's address. telephone and fax numbed
TM Cortuaonwealth otMassachtuetts
DepatUUM of lIMhLSM d Accidents
Olga,of Invoodgede fs
600 washinom Shiest
aawwk MA 02111
Tel. 0 617-7274900 US 406 of 1-277-MASSAFE
Fax N 617-727-7749
t.viacd 5-26-05 www.num.gov/dia
CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
aL�+.s t!C�.�eaa::ossi 7rR•i�t:�ftavt.�t:w.a�1r::9
t11t:'p►1aY19'IM�f.�C47iJ�6lW
Coastrucdom Debris Disposal Affidavit
(requiml Rx all.laanolitinm and renovation work)
In uxonlams with the sixth edition oldw State Building Codas.7W CNIR section 111.5
Debr*and dw provisions of vtGL c iQ S S .
Suild8eS Ponit* _ is issued with dw condition that the debris resulting bom
chic wont shall be disposed of in a property licensed wasa disposal facility as dented by r!GL a
t11,S1S"
rho debris will be transported by:
lumae alr t+outM
rho&--bris W i It be disposed Orin
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