74A WHARF ST - BUILDING INSPECTION It
EI`Y-OFSALEC
PUBLIC PROPERTY
DEPARTMENTS
91%9I JLLEY DRISCULL
MAYOR L0 WASKINGTON b.rREEr*Ste:,A%A* ACHLSLra 01970
'hi 978-745-9595* FAIL 978-740-98"
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:1 iCher+ 1VI'Uuf & orni niuv \s Building:
Property Address: '14 A W�A,L p 4,
Sale M, MA 0IG1-0
Property is located in a; Conservation Area WN 11V Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: M
Address: 'KA WhOP 8fi
60.611,, MA 01cl o
Telephone: gH)Sg14'oro+
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:
o/l
t ; xcel,/�� /mil �X�dT7�/�l G�zni� , ✓ice
C ',
0
--_ -- Mail Permit to:
What is the current use of the Building? r-,cq O
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name �D
Address and Phone cl / "L4
Construction Supervisors License# O7�'� HIC Registration#-�
Estimated Cost of Project$ L Permit Fee Calculation
Permit Fee$� /0�o✓o Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
5 An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury In 6r '
Date o2-r /-&>-0D
of
N
y a
1 4
O O > S
n.
•' CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xmtaeataYfxuscou
MAYat IM WA4�v000NSTREBY•SAtEse,MAfatACriUs$T3501970
Tea:VS-745.%% a FAX 978.740.9846
Workers' Compeusadon Insurance Affidavit: Bullders/ContractorgMectr(cians/Mmbm
Applicant Information Please r Print
Name(Buniaeas/Orpniafianrtndividual):
Address:—J.,L ce / d,
l/
City/Statemp:�iG� e c;; . O�4 Phone
An you an employer?Check the appropriate bom Type of pn]eet(regptred):
1.0 I am a employer with_� 4. 0 I am a general contractor and d
e�aptoy«a(fun and/or part-time).• have hired the sub�conaactaa 6• ❑New construction
2. I am a soh proprietor or partner. listed on the attached sheet. t 7. 0 E
odeling
ship and have no employees Thep sub conteactora have 8. ❑ olitionworking for me in any capacity. workers'comp.insurance. g ❑ �g addition[No workers' comp.insurance S. 0 We are s corporation and in
required.] officas have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exanption per MGL 11.®Plumbing repairs or additions
myself.[No workers'comp• a 152,$1(4).and we have no
insurance required.]t employees.[No workers' 12 0 Roof repairs
comp.insurance required.] 13.0 Other
*AoY APPlk.er thw aherb ben e1 mow doo fen at the seedm blow dhows tbdr varkwe'mmpmeetloe PdoY toArrmeusa Hanwwme who wbmh rho d&lw*=Wcmftg they m dooa d oak ad then hum amide mormatae mow stdtmk a ors dIIdmk iedfeet6ra and
tCmeeebre dot cheek No ben oust snub"m addWmg Am dwo ku the ante of the aodaootraetae and��t�=hwor a n ateµ n* inktmetlas.
1 am an earployar that Is provld/nd workers'compenaodos/nsaraecrjor my
injormadow employes Below tothr pa!&y andJob all
Insurance Company Name: ///", pay
Policy N or Self-ins.Lie.N 0��0 �p v Expiration Dater `O�7
Job Site Addrew 7 5 City/Statcmp:
Attach a copy of the workers'compenption policy declaration Pali?(showing the policy number and e:
Failure to secure covers as expiration date}
lie required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as wen as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 3250.00 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
Ida hereby cents under du palm and pen Ales ojper/aty that the injormadon provided about 4 trrtr and correct
mature:Phone
/17I'.d /�'�j,✓J,/ 1
0,0k1d au only, Do no:iAllsk :tobe:compkkt#dby,,efty Jlelal
City or Town:Issuing Authority(circl1. Board of Health 2.Bcal Inspector S.Plumbing Inspector
6.OtherContact Person
Information and Instructions
ir employaL
Massachusetts General Laws chapter 152 requires all employes to Provide workers'n in the Service Of Mother underundernon for any oonntact of hnm.
Pursuant to this s��an empby"is defined as ...every Pao
express or implied,oat or written"
as"an individual.Partnership-association.corporation or other legal entity.or any two tt more
o f he foregoing
is defined and including the legal rives of a deceased employer,or the
of the fomgoing engaged in a joint astespriam6 association a other legal entity,employing employees. However the
receiver or trustee of an individue4 Pap+ who ,err the ooeuVast of the
owner of a dwelling boom having not more than thou aparbeemb ...d..,'.t�..or repair work an such dwelling hours
dwelling house of smother who employs pions to do maintenaam+ such ctimempl �deemed to be an employer
or on the gromnds
a building appurtenant dmct*shall not because of
that"every stnto or Beal dressing agency shag withhold tM lassies"or
MGL chapta Wall g23C(6)also states a business or to construct buildings is tM cOmmoswea"for aq
csWaabM*"ties of compaases with Me issuranee coverage regmleed."
natswat of a deemsa or permit to operate
applkant who has produced Neither the commonwealth not any of its political subdivisions shall
Additionally.MGL chapter 152,$23C(7)ny couiriese for the performance of public
until acceptable evidence of compliance with the insurance
Teter ts of this chapter b� presented to the connecting authaitY
requirements
p►PPdeasb
affidavit completely.by checking the boxes that apply to Your situation and,if
Please fill out the workers co ten addrees(es)and phone number(s)along with their certificate(s)of
necessary.supply sub-coneactor(s)name( ). with no employees other than the
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships iLLP)
to carry workea•compmmtiom mavranco- If an LLC or LLP does have
memo or
i are nee required to
that this affidavit may be submitted to the Department of affidavit
employees.a policy is and data the affidavit. The affidavit should
Accidents for confirmation of insurance coverage Also be score b sign not&a Department
of
be returned to the city or town that the application for the permit or license is being requested to obtain a
Industrial Accidents. Should You have any gmmms regarding the law or if you are required
st the number listed below. Self-insured companies should enter their
compensation policy,phase call the Department risto line
self Weentence Heenan member on the
City or Town Onidads
Please be tore that the affidavit is complete and printed legibly. The Department has provided s space at the bottom
egarding the applicauL
of the affidavit for you to full out can number which will be used as ahe event the Office of Investigations ceference numbe to contact you r addition.an applicant
Please be sun m fill in the permslicadons in any given year,need only submit one affidavit indicatingrrent
m cu
that must submit multiple permiMk w Job Site Address"the applicant should write"all locations in__(city or
policy information(S°°ceasary) or marked by the city or town may be provided to the
town)."A copy of the affidavit that has been officially stamped b or licenses A new af,_U6vit must be filled out each
applicant as proof that a valid affidavit is on file for future perms
Yea.Where a home owner or citizen is obtaining a license or patron no related to any business or commercial vesture
to burn leaves etc.)said person is NOT required to complete this affidavit.
(i.e. a dog license or Permit
thank you in advance for your cooperation and should you have any questions.
The Office of Investigations would like to
please do not hesitate to give us a call.
The Depanmene's address.telephone and fax number:
The Commonwealth of Massachusetts
Department of lndoMW Accident
Oft*of InvadPdons
600 wtis111119"strut
Boston%MA 02111
Tel. Al 617-727-4900 W 406 or 1-977-MASSAFE
Fax N 617-727-7749
Revised 3-26A3 www.um%&pv/dia
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Crry OF SALEm
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