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11 WILLIAMS ST - BUILDING INSPECTION ' CITY-0 -- PUBLIC PROPERTY DEPARTMENT AOMcn cv pu ^� t MAYOR / (�/ �� 120 W,�wlN=W!"ME&T�I_J(✓� �\Cl "MXK.MAAAcHtStTrs 01970 Tn.971-745-959S*PAX 976740.98" 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: LLt M { 91, Building: - Property-Address 11 W t LL-l 'A Kk -- Property Is located in a.Conservation Area Y/N Historic District YM Al 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: 'Slickrtnorn a.Y1d fAaK En �lf.cy Address: 1I W,111AMf Sf. SAL6AA MA Telephone: to/7� b' 5/- 23br8 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation �'f Number of Stories Renovated Change in Use c New Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building / New grief Description of Proposed Work: L e I/C n bct r cPr �9 ) *,0rk � ter' -ro&c P hoof ��Fj'� -501? t 1—aSCs �i 7 z�X z bi� ©o1 65�5 D l� n � c7 Q/� sD � I� f��/eS r�e S r i n ri D ✓1 Mail Permit to: What is the current use of the BuildingT e1�7 t Material of Building? If dwelling, how many units? Will the Building Conform to Law? Asbestos? IL Architect's Name Address and Phone Mechanies Name Address and Phone Construction Supervisors License# HIC Registration# Permit Fee Calculation Estimated Cost of Project S� Permit Fee$ Estimated Cost X$71$1000 Residential - - Estimated Cost X$41/51000 Commerc:a,' -- - ---- 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 above sta specifications. Signed under penalty of perjury /% Cute ct v ! 'j Vj p a a -- ---- --- _ _. - ` CPTY OF SALEM PUBLIC PROPRERTY DEPARTMENT xatutaaLattxsacau MAYoa IM VA9M4GT0NSTaUr a SALEK M%MACMmrM019y0 Tilt:9W43459S a PAM 9W40.9M Workers' Compemation Insnraace Affidavit: BWders/Contruto Anotleant Information Plc n Mat T meetly Name i dual) Q 4 4� Address: City/3tmemp.. I%C�l / Phone An you as employer?Cheek the appropriate bon 1.❑ I am a employer with 4. ❑ I Am a Small contractor and I �a ( ' employees ma and/or part-time).• have hired the mb•�tractars ❑Neer construction 2.0 I am a Sole proprietor a partner. listed an the attached,beet t 7. �Remodeling ship and have no employees These have s. ❑Damolidoe working Par me in any capacity. workers'comp,inemonc (No warltms'Camp,insurance S. ❑ We are a corporation and its 9' ❑Ong addition required.] o8tcers haw exercised their 10.❑Electrical repsin or additions 3.O I am a homeowner doing all work right of mcmtpdon per MOL 1 l.0 Plumbing repairs or addition. myself.(No workers'comp. c. 152,41(4),and we have no 12.0 Roof mysim insurance required.]t COPICYeea(No workmo 13.®Other ��i a¢r iYorC�COMP•bWWM u required.] 'may dr iris 6sa el mar arse®wr ro.,pb below reo.A tte�r - xameoware.dm adrn"sammit brdlaana mey.e dabs a weir d�.Mar melds ass a tl:oeaeemn sr�d ds box man rsobad an.dd aA sbut d ow4q Me Came of the rod erir '*Omp6pdW fidbewsiM& _ . l fermadow p tIs Pro s warbra'cowpentodow Graamwee f"my employees Bdlow Is db policy aad job do Insurance Company Name Policy 4 Or Self-ins.Lia N Expiration Date: Job Site Address: City/StatelLip: Attach a copy of the workers'compew&ln pedcy declaration pap(showing the policy number and expiration date)6 Failure to secure coverage as required under Section 23A of MOL a. 132 can lead to the imposition of criminal fine up m 31.500.00 and/or Gail-year imprisonment;as wall as civil Panama of a of u to$230.00 a penalties Form of a STOP WORK ORDER and a 8as Investigations of the Di "insurance v� Be advised that A copy of this statement may be forwarded to the Office of tCoverap veri k2dOL I do kdreby Berg& is and 1w/onwadow provldsd oboes 4 sae and earrdd / V r/ Phone M: bD 3 � 3� ���jt� F1080tuhager,rc sore oalJ► De soot wrlle tea!kb area,to be cosylefd by c/4 of mww o ek, Town: Permit/l.leense N Authority(Circle one): of Health L Building Department 3.Clty/fows Clerk 4. Electrical Inspector S.Plumbing Inspector Contact Person: Phone M: Information and tnsltruc,luu3 _Laws chapter I S2 MOM tn vide worker'comPe�on for their employees . Pear•to this st ft^an e�yeg is de�as aY pin 1s�"r of another under any cones of Kira. express or imPhA oral or Wn tea.' or any two a morn assoeiainoto.oorporadon at°��legal fin'' An*avow �fi°Od""sn individual.parmnd inc the leye► vas of a deceased emPlnyer•or the of the foregoing engaged in aloins msetpr+sR and i>sthsdmg smPloyea. However the,. assoeistim at other�entity.empl°y1IIs rec et trustee of an individual.parmash,p. sad who resides thm'em.or the occupant of d» owner of a dwelling boom hwinf nos more has 11 "do maiotensnet.ccn t a work on such dwWft hell" dwelling house snnther who empbY+ Shill net because of SOCK employment be deemed to be an or on the Pounds or building RVAtsuans Slat wkhloid the hues a"es MOL chapter 152.$2SC(6)al"Wtea than-e very shh O<local Hesitates at{e v tb eevmeawsalth aq far remand of a memo or per"to Op",a basins"e<h teYw btsildlat0 acceptable"W ce of esspliaaee YA*the In WMAMpoh � sPpUeset wtte tt"not predoeed etas""Neilla,the�nwealth nor any q�the"shall wminanany.MOL chapter far t e $23C(71 of public work until acceptable evidence of compliance remrntra�me�ofwm ��� to the contracting wshorW rW Applicants e6ecicng the boxes that apply to yaw sig"dae and.d affidavit es"pletelY.by PneeeassrY. workers tur(s s).addresKed)and phone numbers)along with their ceuRCate(s)of•hall the necessary. insu sup. Limited ,htYLtab :mWeates(LLQ a Limited Liability partnerships(LLI)wnh no°p don have bYea �e a Partners,are not required to carry woticeo'compensationbe insurance-dIf as epa MX at at Induanial empiays".a Policy is Be advised that this affidavit may be edra"d to the Department Accidents for conArmatian of ina me ooversgs. A�be ante h sip and date the sffidavn, The affidavit shrub be nmtaed to the city or sown that the application for the pandtof la of i�wn+ you have seY 4tte�ims t ccsify is�� not the Mpamcid d required s0 obtain a ;d�idents. should below. sett all the mundw listed granted compsnias shaub enter their compensation Policy,pinta,tell the Ifi Self-ins asoCs license numbs nn City or Town Ofadats a space at the harm be sure that the affidavit is complete and printed legibly . The Depactn,mt has�� of tha affidavit for you m fill our in the event the office of ill be red"s has m torte"you regarding the applicant, ' m fill in the perroWlicense number which will be used a a reference number. In addition.n applicant Please be sure in any given year,need only submit one affidavit indicating currant multiple P�s"ecatiou write"all locsdons is__Jc,rY s moat submitapplicant should policy i Houton(if necessary)and under"Job Site stautp the ear a marked by the city of town may be provided m the town)"A copy of the affidavit that hae been otficislly stamped panda or licenses. A now ai`udrvu must be filled out each applicant as Proof that a valid affidavit is on file f a lieu"a<permit not related m any basins"a commercial vanave year.Where s home owner or citizen is obtaining to leer this affidavit, (i.e. a dog license or Permit to bum leaves eta.)said WSW is NOT req*W comp esti as woub like tothank you in advance for your coopsradoo and should you have any guatiom, The Office of htv gran please do not hesitate In give us a call The pepsrtment'a address.telephone and fax somber: The COtllMMWegth of Massachusetts peputment of b&* d Accidents Ofika of Iavesdpttoos 600 W11SWO&S Strad Bastm MA 021I It Tel. N 617-727-4900 Wd 406 or 1-877-MASSA E Fax Al 617-727-7749 Revised 5-26-05 www.ZpmVv/dig c CrrY OF SALEM PUBLIC PROPERTY DEPARTMENT mats Consbvedom Debrb Dbposai AM&vit be"Ird ow in ANON=and mwvdon ww" 1a mudn wl&dw AK&ddon ddw Stft Bo WWG CW%7W C M3t sodke 1113 - OdWN6 d du povlalar dUM o 401 S 5% gundles ft 10 i.bud Tft Or aondld=Out dw daI moddog dmas Lhb wak sbdl bo disoowd din a paopr�r 1( d wareo dlsDoaal Or qt so da0ad by 1iO.o T7»debris will be ban*0 0ed b!►t � q~ t' _5e f� �17 (saes afbrrlwl ro ddbrio wid be disposed of in: (mmao(AailiM7C�/' .Sf9tf(�✓j r>,wrm offtea » Qaas