10 WILLIAMS ST - BUILDING INSPECTION CITY OF SALEM
. PUBLIC PROPERTY
DEPARTMENT \
f
F:I.\MERI.EY DRISCUIl. 1
MAYOR 120 WASHINGTON STREET ♦ SALLM,MASSACHLSL-1-S 01970 J
TEi 978.745-9595 ♦ FAx:978440-9a46
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: Q w, iva, S _ _ Building:
Property Address:
GU�//16Als 5
Property is located in a; Conservation Area Y/N !/ Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 6:2-7 e`'t`r� in �jS5 c
Address: f /
Telephone: s/
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 (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
P e---
/rliF, c /Poe /,
Mail Permit to:
s- 13 ) r-� tiec' V � (-� �`
What is the current use of the Building?
Material of Building? �/ If dwelling, how many units?
Will the Building Conform to Law? / Asbestos? l
Architect's Name
Address and Phone ( )
Mechanic's Name IL4,
Address and Phone -C,7 w o
Construction Supervisors License# 62/ C HIC Registration # Y'S-�
Estimated Cost of Project $ 9 Permit Fee Calculation
Permit Fee $ 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 st d
specifications. Signed under penalty of perjury X
Date
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N
GO
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` CITY OF SALEM
` PUBLIC PROPERTY
DEPARTMENT
KIABERI-EY DRISCO11
MAYOR 120 WASHINGTON SfRE.Sr ♦ SALEM,MASSACHusenS 01970
TEc 978-745-9595 • FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please Print Le ibl
Vatne(t3usinasslOrganizuior✓Individual): r Off, L
Address: lZ�,4
City/Statc/Zip: -5/1 Phone #:
Are you an employer? Check the Upropriate box: Type of project(required):
4. ❑ ) am a general contractor and 1 6 New construction
I. dm a employer with have hired hire sub-contractors ❑
employees(full and/or p rt-time). 7, Remodeling
2.El am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. g, ❑ Building addition
INo workers' comp, insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of per MGL I I.[] plumbing repairs or additions
3.❑ I am a homeowner doing all work gh exemption P p
Myself. (No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
-A,ty applicant that checks box it music also fill out the section W. showing their work=compensation policy information.
'1 iumu,amrs who submit this oftidavit indicating they arc doing all work and tarn hire outside contmuon matt submit a new afridavic indi"ing;such.
:Cuntmusrs thug chuck this box mutt attached an additional sheet showing the nonce of tha sub•contracton and their workers'comp.policy information.
l urn un employer that is providing workers'compensation frtsuranee for my employees. Below is the policy and fob site
informutiom t/
Insurance Company Name. l°�7 S
Policy k or Self-ins. Lie. fl: Q __ F�cpirution Date: SS
Job Site Address: d� - City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
III\otigatiuns ul'the DIA for insurance eovcragu verification.
I du hereby certify iturleA the pains art pr tics pe ury that the iuformuflon provided above is true and correct
Sien;uurc: D t
Phnnc:4,
Official use only. Do not write in this area,to be completed by city or town official
City or Tmrn: - Permit/License ----
Issuing Authority(circle one):
I. Board of Ileaith 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other —
Contact Pcrson: _— Phone ti: