207 WASHINGTON ST - BUILDING INSPECTION (4) What is the current use of the Building? r—o�
Material of Building? It dwelling,how many units?
Will to Building Conform to Law? --
Asbestos? -
Architect's Name
Address and Phone
Mechanic's Name ✓"�o n ��d e a
Address and Phone
Construcdm Supervisors License 0 HIC Registration tr
Estimated Cost Of Project4-= Permit Fee Cakulatlon
Permit Fes i O 7 Estimated Cost X$7/$1000 Residential
Estimated Cost $11 V$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 5 0
� of
PR
s F r N
y ` �
a a
F
3 g
s O St
x
I
CrMQF-
PUBLIC PROPERTY
DEPARTMENT
V:I%QW "D■ISC(" 7 16
�rwYolt 130W&%uaw-ocwhnLm• x Asti s019,M
TM-976743-95"*FNC 971-740.""
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING=
STRUCTURE OR BUII.DIIN
1.0 SITE INFORMATION
Location Name: AA,n , , —V*,1t)&fipl 8uildtng: K y6 ffo/jW
Property Addres
----
1iS!!l
Property is located in a;Conservation Area YIN Historic Distrk:t /N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name: h G GG
Address: l 7 . (ft1;- -(A "li, �� Oaly3
Telephone: 617 6 d 31 S
3.0 COMPLETE THIS SECTION FOR WORK IN EX=M BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing a��U
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
FaijPJvlw
Description of Proposed Work:
g&aw, ail/ C61 f�iJ� n1 Lti
— - ---Mail Permit to: -- - -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
%L%it-R 1 Vr.�1Ni::JK 1EtT S\tiM.AM&W.-a*11s%94.
Tn:9WO-l9S E.%X-OMAC-96*
p�
Construction Debris Disposat affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,7SO CALR section l I t.S
Debris,and the provisions of vtGL c 40.S 5*.
suildinS Permit N _ . _ is issued with the condition that the debris resulting ftm
this work shall be disposed of in a property licensed waste disposal facility as defined by%IGL e
t 11.S 130A.
The debris will be transported by:
f
c
tr/OctS� f�LG� CC((
Uume oC fouler)
c
rho dcbris will be disposed of in :
(came of�a:�lity)
I
Pao
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
slstnr atEr ustuxlu
M.vvtsa 12r WAIlu.Na7oN SWEET•SA EM.WASSAU n.V 1 1s 0197.^.
T&L.97L7e5.9595 o FAX:97111-740Q9as6
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrielans/Plumbers
Analieant Information Please Print Leeibly
%lame(HuvncssfOrgaoizatioNlndiv,dduuul_)'/� 'I /✓1 °Q r�-
Addreac: e�Evee�S
City/sweiZip: Y��� G�/l"vu �l Phone#A71 ) —40 6e
Are you an employer?Cheek the appropriate boa: 'type of project(required):
1.❑ I am a employer with 4. ❑ I am a general coutractor and 1 6. ❑ New construction
employeea(full and/or part-time).• have hired the sub-contractors
2 am a sole proprietor or partner- listed on the attached sheet : 7. ❑ Remodeling
ship and have no employees- Them at+bcoaasctors have 8.,,�Detnolition
working for me in any capacity. workers' comp.insurance. 9. 0 8uildins addition
iNo workers'comp. insurance S. ❑ We are a corporation and its
required] officers have exercised their
10.❑ Electrical repairs or additions
3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. (No workers'comp. c. 152,¢1(4).and we have no 12•0 Rtwfrcpairs
insurance required.] t employees. (No workers' 13.❑ Other
comp. insurance required.]
•A„y;q,plicao1 tlat cNVks boa et mug also lilt out see section below Ylowina Chair woha t,cumpoination poll y infi,reatiwr,
t I lumw,wnae who subatil this affidavit indicatin`Ihey am doing as w m work and a him onside emrraasa own suhnii a new amdavil Wimtina arch.
�Canttxt'ns that Awk this treat must man aid an additional dreal dmwina ate ttalao of do sub-contractors add their workers'aanp.policy inrotmatioe.
Man
I am an employer that Is providing workers'compensaton Insurance for my employers. Below is the policy and job.rile
information.
Insurance Company Name:
Policy a or Self-ins.Lie. 0: _ .. .. .._._ Expiration Date:
Job Site Address: CitylslatuZip:
attach a copy of the workers'compensation policy dadaration page(showing the policy number and expiration date).
Failure to wcurc coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
fine up 14>S1.500.(N)and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a Jay agaimst the violarar. Ile advised that a copy of this slatement maybe forwarded to the Office of
Ira c�ngauorts ol'dic DIA for insurance covcra4c verification.
i de hereby certify under cite pains and penalties of perjury that the information provided above is true end correct
tiiLaawrc' __ Date•
Phone T
jopieial use way. no not write is this area,to be completed by city or lawn offleh L
City or'rown: _. Permit/I.1cense N
Issuing Authority (circle one): --I. Iloard of Health 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: __ Phone p
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant to this statute,an employee is defined as"...every person in the service of another under any context of him
espress or implied.oral or written."
An"player is deflacd as"an ietdividusk parbteesbip.association-corporation or other legal entity,of any two a more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
mmver or trustee of an individual,parmeri*association or other legal entity,employing employees. However the
owner of a dwelling house having not more than tbeee aparbttents and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance.construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shalt not because of such employment be deemed to be an employer."
MGL chapter 152.$25C(6)also states that"every state or Intel licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
appucaN wise has ant produced accept"evidence of compliance witb the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with time insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavitcompletnly.by checking the boxes that apply.to yoursituation sort,if
necessary, upply sub-contractor(s)narne(s),addresses)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
s
members or pruners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. at advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the•affidavit, ilia affidavit should
be returned to the city or town that the application for the permit or tlense 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 appropriate line.
City or Town Offleials
Please be sure that the affidavit is complete and printed legibly. The Department has provided•a space at the bottom.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant_
Please be sure to till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information of necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A now affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is?NOT required to complete this affidavit.
The Office of I11vtsn1'ation5 would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Depanment's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
ONee of Isvestipdoaa
600 Washington Street
Boston, MA 02111
Tel. #617-7274900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 ,w,ww.man.gov/dia
x- it--Aml ,�
Demo l ere I-lndieeted "i"n` Reds '
k a r
m
I
X _
i
1 nK
}
.:r. ...
qA' A Z.�K SOARD�OE BU 0 REGULAM
40
''"`r`,Ntuny.•CS, 088774
0X
t pr p a cl Q jnp c,
YY18i irtY,4iJ,a. VF y 'i
y eyi 47t12008 tr no:a 887b7
.: . TIMOTHY S
820BOSTQp1 S -
LYNN, 1 1905'
i ` Qdmm9tbnN• r,.
i