77 WEBB ST - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KwarrE MDittticotl.
MAYM
TAtttaet.MN S MT a IMM4 MASACf1p' M 01970
Talc M745-9M a FAX 97i709M
Warners' Compensation Insurance Affidavit: BpildeyContraetOnMetbidanaPlmdwn
Applicant Information �! ��r �
Natnet ): o U r �4Ccr(q't
Address: _ 6 w aAl a/ k i
Cityista emp:_t ak," &. Phone# 97� 77/-!e ZOO
Are you as employer?Cheek the appropriate east —
1.0 I am a employer with 4. 131 am A gmwd contractor and 1FRemodaffng
Type ( '
employees(11tU andler part-time).• have hired the truetim
2.,R I am a sob proprietor or partaeN listed m the attached shoot,t gship and have no employees Theo sub•omhaciam have nworking for me in any capecity. worker'atop inmtranes(No workers'comp innuance 3. 0 We are a corporstion end its ddition
required) officers have o teeeised their 10.0 Electrical repairs or additions
3.[1 1 am a homeowner doing all work right of cmmptim per MOL 11.0 Phtmbing repairs or addidom;
myself.No workers'comp• C. 132,i1(4),and we bavo no
rnmranee required.]r employees.(No workers' 12.0 Roof repairs
romp.insurance required) 13.0 Other S
t-Any
�•bo a�air box as drwit An ae the swdos Wow Aoeiq dtehwois a'ae"Undo I volley Wnum a.
tCoaaeemrs der cbeek tole lox mm aftAW a as ddWandd r6a�w ad�ast�m ab ahWam o�aaeMra mot skit a aw afEdrrh(edpdag rock,
sh"dm ne of the a red dmir asrkmr'camp per febrowdea
Ian an ewsPloya that bProvtd/ng•workers'compeamrlow lwswrowei or
lwjonradow. I mJ'emp/oyeex Below ie thePoBey ead job step
Insurance Company Name: / Lr Q Ln r�,re,tC C cd
Policy M or Self-ins.Lie.
Equation
Job Site Address: 71 �eill,
City/S4WZip �o/cM 4
Attach a copy of the workers'eompenutbs gooey declaration pages(showingthe Policy
Failure to secure covers as a imp number and esperagon date
ge required imprisonment
sections w of M civil a I s2 can lead to the imporitim of criminal penalties of a
fine up to S 0.S00a d and/or one-year imprisonment, a aril as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S2s0.00 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
I do hereby cardA andp the palsy and penaldw o/pstfwry that des Iwjorotadow provided above 4 trwt and correct
<-Z65�:
EAuthority
only, Do not write in this area,to be completed by c4 or lows o,0feld
n:
Permit/1leense N
ority(circle one):Health 2.Building Department 3.Cifylfown Clerk 4. Electrical Inspector S. Plumbing Iwpettor
son:
Phone p:
EIT�QF
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PUBLIC PROPERTY
DEPARTbIF,�iT o
",LLK SrAssntHUt»5 0070
TM,97M74S.9S".FNC 976.740.9"6
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR WnDING
1.0 SITE INFORMATION
Location Name: L (As cT Building:
Property Addres.—
Property is located in a;Conservation Area YIN-,�/QL—Historic OWWa Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 2 �esf�y
Address:
Telephone: G , -2 4 Z 6 4
3.000MPLETE 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: Tn
Mail Permit to:
�Nhat is the current use of the Bu'ding?
Material of Building? c� 66
If dwelling.how many units?-2 _
Will the Building Conform to Law? ul Asbestos? //
Architect's Name
Address and Phone
Mechanic's Name co /cc
Address and Phone / Sc/o a r ,�'t�1
Construction Supervisors License#.7�9 T HIC Registration#
Estimated Cost floject S/Sad Permit Fee Calculation
Permit Fee
Estimated Cost X$7/51000 Residential
- --- - - Estimated CosYX$11/$1000 Commercial
AnAdditional$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 pedury X
Date
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