7 WILLIAMS ST - BUILDING INSPECTION (3) 1
--
'"' PUBLIC PROPERTY
. DEPAR'TNIENT
KI%RBFJIIEY DRISCOLi.
MAYOR 120 WASHINGTON h rREEr S"LEK A%AACH YkTrs 01970
TEL-978-74S•959S 4 F=979-740-9846
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
rSITFINFORMATnION-'
ATION�B�I(�/ ti.,s S Building:
7d in a; Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: k✓rf c e-
Address:
_ LVoiliBannS
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FYISTINr. 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:
AIV-ul 0hb iv\Q-,fS
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Mail Permit to: 1p
What is the current use of the Building? 141C>
Material of Building? of If dwelling. how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name eS ^ llcfakee ! `2w *
Address and Phone 6 fi �� 1 � e r rl v r�tCS�
Construction Supervisors License# D7g, ! *4 HIC Registration�6 -2 $
Estimated Cos�Loff Pr $ Permit Fee Calculation
Permit Fee$ -mod='�� Estimated Cost X$7!$1000 Residential
Estimated Cost X$11/$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 X Date
Date V
of
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a
H o >
n.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
antaualaY txtncou.
NAYon 120 WA2aCrMSZseaT a SAtEst,MASSAQIUWM01970
TM-M745-9S93 a FAX 9M740.96%
Workers' Compensation Insurance AlBdavit: BulldaWContractors/Eleetriciansiph mbers
Anolicant Information Plea"Pri t LeRNT
Name(EkwoesUthganianowindividual): 1/Co re csr(k /hcz
Milt?Address: S Mi r
city/statemp: [jiZve1 I l5 Phone# '2 78 — 42-3— 1 l ,�3
An you an empbyer7 Check the appropriate boss
1.❑ I am a employer with 4. ❑ I am a general contractor attd I Type of project
(required):
pdployees(Atli and/or putt time).• have hired the sub-connacom 6. ❑New caoatruction
2. I am a sole proprietor or partner. listed on the attached sheet t 7. ❑E
odelingship and have no employees Then have S. ❑ olitionwo forme fn 'Rio workers'comp.k urasce 5. ❑ We are as corporation and its 9- ❑ �02 Widen
requited.] oA9cas have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL 11.13 Plumbing repairs at additione
myself.[No workers'comp. c. 152,41(4),and we have no
insurance required.]t employees.[No workers' 12.❑Roof repairs
comp.immance required) 13.0 Other
;A1Y WH9W do dwda ban e1 mint d"110 art the socdm Won dwwWS utaair warfare'
Haauowaea whe abok d&aAld is mdlatlea dwy N ddaa an wak ad gm tdm adds eaanaetao Wo Policy a oa af6drvtt dkmlvg
tcoaaeeewe tbn dwdt nab ban mar auwhW as adMdOed twat tbowma dw mms of d ab ownwan and dwtr MCI taa'sump,POHM mamaatlaa,
am an employes that is providing workers'eompeneadon hunronce for my employees. Below d the policy and Job seise
Informadow
Insurance Company Name:
Policy M or Self-ins,Lic.N Expiration Date:
Job site address: City/stafta*.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dab
Failure to secure coverage as required under Section 25A of MGL a. 152 can lead to the' a
fine up to f 1,500.00 and/or one-yew ire imposition°f criminal penalties of a
y priaonment,as well as civil penalties in the form of a STOP WORK ORDER and a Rm
of up to$230.00 a day against the violator. Be advised that a copy of this.statement may be forwarded to the 0 of Investigations of the DIA for imurance coverage verification
!do hereby cerdA under do
palus andseas/ olperJnq'that the Information provided above L aw and tarred
Da e
Phone p•
r
Id me on6% Do not wrlte in thb area,to be completedbycityoftownoQklaLor Town: PermitiLieenseg Authority(circle one):
ard of Health 1.Building Department 3.City/rows Clerk 4. Electrfrui Inspector S.Plumbing Iwpector
er
Contact Person: Phone p:
Information and Instructions
152 requites all employers to Provide workers' compensation for their emploYea.
Laws chapter
Massachusetts General is defused as . every person in the service of another under any contract of
w hire.
Putant to this stamen,an ewpfeyss
express implied,oral or written."
as"an iodividtlel.Par[ne JuN assoeiarion.corportioa or otherlegal 'or any two or more
An swpfeYp is defined m*joint eotapris% ves of a deceased employer, the and including the b g✓al representet►
he
of the foregoing engaged aeaociatioa er other�y err dw occupant IOYeas, of the
receiver or trustee of an iadividual.pasmerahtP'
owner of a dwelling bourse having not matt than three sparunan s f another wbO employe persons to do memessumc@.coosonacti°n cc repast wale at such dweIImg home
dwelling bourse° at building appttrteoant thereon shall not because of such employment be deemed m be an employer."
0 on the 8�� sbar withhold the IN maw*
ar
MGL chapter 152.§25C(��O states that"�°�state nswoct uRdbW is the eommeaweaft four sty
to operate a business b
reaswat of a tleeaao et p produced acceptable evidence of eomptlaaeo wiry the{nsuranee coverage required
applltaoR wbe Was
MGL chaplet 152.§25Q7)am="Neither the commonwealth nos any of its political sub
entons
nsurance
er into an
of public wet until acceptable evidence of compliance with
the i
� y chapter ban p to the conuscmg authaity."
ICQ
App&Asts
Please fill out the worker' compensation
affidavit completely.by theclting tlse boxes that apply to Your situstian sad,if
necessary,supply subcoatraaer(a)nsma(s),address(ce)and Phone nnnber(s)along with their with no employe"
a)Of
other than the
insurance. Limited Liability Companies p.C)er Limited Liability Parmerh[ps(LLP)
not required to carry worker'compensanon na°reoc°' If an LLC er LLP dos have
n1°m�'°r '� Be advised that this affidavit maybe wbmitted w the Department of Industrial
l
C°�lOy"''a Pc�'s of insurance covergp. Abe be sure to sign and date the amdsvlL The affidavit should
Accidents for
confirmation application for the permit a license is being requested,not the Department of
be returned to the city o town that the the law or if you are required to obtain a worker'
Industrial��te, Should you have any questions tt at the munber Bated below. Self-insured companies should enter their
PleaseCompensation Policy.Please
call the Depertmaot lice
self-insurance Hcomm number an the
City or Town Of data space at the bottom
ted legibly. The Deparnneot has provided a
Please f sure that the affidavit is ntheevent
complete and grin ons has to contact you regarding the aWHcWM
of the affidavit for you to£ill out in the event the Office of Investigations be used
Please be roue to fill in the Permit/lieenee number which will be used a,n reference number. in a addition.i as applicant
applications in any given year.need only submit one affidavit indicating corral
that must submit m dtiPle P� OsO a�Job Site Address"the applicant should write"all locations in_—( S'or
information(if necessary)and under" the city a town may be provided to the
policy.A of the affidavit that has been officially stamped or marked by tY
town) COPY or licenses. A now afudrvu must be filled Out each
sera Haar
applicant er proof that a valid iffidavit is to file Pia gal vendee
ear.Where a home owner or eitiam is obtaining a license or ptamtt ant rotated to any business a commerc
y to burn leaves etc.)said person is NOT required to complete this affidavit
(i.e. a dog license or permit and should You have any questions.
The Office of investigations would like to thank you in advance for your cooperation
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The COt MMW"Ith Of Mosul usetts
DCpa uwm of bs&*W Aeeld rota
Offla d lava 1SittoUS
600 WasewgM Sheet
Eostoa MA 021 It
Tel. #617-n74900 CA 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26.05 WWW.II1 &&0V/tilt
CITY OF SALEm
' PUBLIC PROPERTY
DEPARTMENT
MOOR •SMJftNV ACNL3 M4IWM
Tme:0&7464M*rue OM746964
Consbwdon Debris Disposal AfWavit
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