65 WILLSON ST - BUILDING INSPECTION EIT� OP*�AL 1
PUBLIC PROPERTY
DEPARThiF.'�IT
I:I.%WERI.EYDRISCOLL 51 /'/
nYoa 6 (/ to WAsmdc7ca+5[aFEpr 1 'SUM,,\rtiUQfl:ihl'IS 01970
T a--978-745-959S*Fnx:978.740.98"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1 A SITE INFORMATION
Location Name: QP 7,e� " Building:
— -Property Address.----
Property Is located in a; Conservation Area Y/N iv6 Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land -f-
Name:
Address:
Gs �
Telephone:
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:
e
Mail Permit to:
L
What is the current use of the Building?
Material of Building? If dweliing,.how many units?
Will the Building Conform to Law? Asbestos? �^L
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# G 2 v eG HIC Registration# /oG /G 7
Estimated Cost of Project$ k v u u. oy Permit Fee Calculation
Permit Fee$-6/�2d Estimated Cost X$7/$1000 Residential
— -_ -- — - Estimated-Cost-)F$11/$1 Goo 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
Date
r
0
a w
v .yo+
u
4— -- ------ -- --- --.._. _.__. -. ..---- - - --
_-aw _ 4 a. — --
CITY OF SALEM
PUBLIC PROPRERTY
i DEPARTMENT
MAYoa 12o VA4 Sesser a&UXK MAOACtn3sM 01970
M&97L745-959S a PAX 9W09W
Workers' Compensation Insurance Amdawe Bundera/ContraetorsMecb clanw7lum
Au to oticaut Inrmadlom bers
MIAd r.sibly
here
Names - v 13CA ,, PRE
Address: 16 V r sTli- A o e S4 / r=
City/Statemp: d t 9 76 Phone#: 4 7 -2 y s — 5' sk Z
Are you an employer?Cheek the appropriate boss
I.[] I am a employer with 4 131 em a;m:do ]
eacoor and I Ty�°f�el�( :
employees(Na anNar part-time).* have hindcoonactara ❑Now camsmuetiaa
2.01 am a sole peoptisor at parmeo- listed an thed sheaf,t 7. 0 Remodeling
ship and have no employees Theset haw L 0Damolitfon
working for me in am capacity. works='csnanq.(IJo worker'eoemp inmtraap 3. ❑ We so a eom and its 9. ❑> i addition
requited) off cers halaed these 10•010acmicai fepaea or additions
3.0 I am a homeowner doing aB work riilitofex par MGL 1 l.[]Phtmbing repain ar additions
myself(No works='comp, 0 132,41( e haw no 12.[]Roof repaint
insurance requited.]t employees. rks=' 13.[306w� �r
OAOY a Ucw dm chmb has et mar abo ti0 out tb soedm i6w dmk� )
tiamwwmmrhtalmitWtadwwkbdhadgdrymedde=dlwmbadsumNo mfde maitaobmY awe almrvit lCammxm dtdt tide loot meat Wwhad a•add(daad dime dbu6�Wa same of gm sad 0 M washes.kason sal ie eks B L
l sae an eA1t>loye►nraf bProvldbj tvorl en'eowoewrodow lwjorawasfoda beerewei for dry asdployas Belay b a1v0oBey awdJol rltr Insurance Company Name: rAd
Policy 4 ar Sel&ins.Lis N t v C # ar 9 S- 3 r — 3 / Etpintiom /��/p 7
Job Site Address G r' ^� Ciry/Shta/Irp `')?0 , O/ 9 76
Attach a copy of the workan'compemtudou policy deelandou page(skowbag the pulley number and a:piratlou I
Failure to securecoverage as requite under Section 23A of MGL a. 132 can lead to the imposition of crimimsl pseuthiss of a
fine up i I .00a and/or ova-year iof up to mpri
3sonment,as well as civil penalties im the farm of a STOP WORK ORDER and a fine
Invests 23000 a day against the viotamr. Be advised that a copy*(this statemem may be forwarded to the Office of
gations of the DIA for smuramce coverep verification.
fie banby cadb/r�under rho pews andpanablp ofPedruy rbat rbe lw/onwoalow pr0W4d above b lone and comers
Signature• 11 Cu, Date• /a- �16��G G
Phone# 97�— �tFS- SSB2
offleid sore on/Jt Dona wrka lw!lob area ro ba coarO/tted by city or M-vo offluaL
City or Town: Permit/Lites"p
Issuing Authority(cbrcb one):
I. Board of Health 2.Building Department 3.Ctry?own Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone Mr
Information and Instruc"wu3
for their employ«'•
Maseschuseonad Laws chapter 152 requites all employers to Provide of bite,
to defined es"...every person is the service of aeothertion Y contcad
m Gonad
to this statute,an ea+PbYse i ..
express.or imp"oral or wfiuoa»
asfoeiatio4 cotPoratioa of other lead�.at any two ere more
An es rl"is defused es"as.individual.pattand including
nc the 1.0
of a deceased employer��a the
the
of the focegomg C6>P�is aloes estarP�, or other lO m ty.emploirmg amPleYOOs
receives cc truxtell at So
owner of a dwelling house having no< dm personsdata And to do maoftnu&M who etioa or repair`xO�on such da�Mbwaw
dwallog bouss of building appurtenant thwoms shan not bse�of each employment be deemed to be an employ»
of on the gtouods hauaaea err
the
that"taratry stab O<taeal tletmiaa agsery rice w� fse aV
MCd.chapter a 1e2.4��oleo states a buslaw or b eeari>r ed bditltaP V the eoassawp ro
fsaerfal of Seen"as ptudt td sP'r'b wttb tie hasuramu average ram° '»
ant sew eaa set prod 52. scow"s le��et a common its political subdivisions shall
� ,MGL chapter or e p ftassTi s moss o f tiblic wodL until acceptable commonwealth nor ofcompliancts with the inmrsoe9
enter jao any
ofthis
ebspter bonbignpresented to the coog+emng authority••
rtq
APpftsab affidavit eomplamly.by cheeping the boxes that apply to Your Situation"if
P out 'comps) mtiets s( .ad&u s)a dL�Pa �Pa�l-)��s)Of
other than the
liceenonineaanee. Limited Liability Comp! insurance, If an LLC or LLP does have
mamma of p are net required
e as a ro catty arotkw °0�06 of industrial
a le liy advised that this atIIdatrit may bs Submitted to ihs Department
employees. Po covecap Abe bs Sore b sip and dam&a affidsviL The atlldavit�al
Accidents far of insurance for the p it err He="is being requested.°��a rvorlcera'
be returned to the city es town that the applieatioa the law of if you ere required
aria►Aeeidenm. Mould yen have sty questionsae�liamd below. Self-wand �d enter their
comPesesdO°p°ibY•P call tint Daptatnnaoa lies.
felt-itetaaes]icantse numbs O°the
City our Two Of cisd a�at the bottom
Please be rote that the aHYdsvit is complete and printed legibly. The Des has t c �� din the aPPlicant•
of the a@idevit for you to till out in the event the Oftie s of investigations Gas to wend Y regarding
Please be sun m till in the pomdvlkcnss numbs which will be used as n reference tombs. In addition. is apog coo
that moat submit multiple P anse applications m any tomes Year.need only sub»nt one affidavit Indic-- (city o
Policy. suntation(it yaepsafY)and under"Job Site Address"the appileatt should write-all locations le�1ctY or
» that has been of ciallY stomped or malted by the city cc town may be provided m the
town). A copy of the affidavit or license'. A new afuduvu must be filled our each
applicant as proof that a valid atRdavit is on file far findne Paroun not masted to any business or commercial vwmte
Ye Whore a home owner ofcitizen is obtaining a lions or pmmtt
m bum leaves cm.)said person is NOT required m complete this affidevit.
(i.e. a dog license or parrot and should you have any gnroStioN.
The Office of invcWgaaona would like to thank you in advance for your cooperation
please do not hesitate m give us a call.
The;:;=a address.mlePhoao and fora number.
The Commonw"A Of Mal"Wimsetta
N"Mam of TadtiMd A=dentg
O®a of Iivadvi t u
600 waehi09"Stoat
Boom MA 02111
TeL #617-n7-4900 Wd 406 or 1-877-MASSAFE
Fax 11617-n27-7749
ltcviscd 5-26-05 Www•mitq.Vv/die
CrrY OF SALE,m
:' PUBLIC PROPERTY
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