SIGN APPLICATION FOR FRESH• Permit Number
APPLICATION FOR jpERMIT TO ERECT A SIGN
NOTE: BUILDING PERMIT MUST BE OBTAINED BEFORE SIGN Is ERECTED
Location, Ownership and Detail Must Be Correct, Complete, and Legible
Salem, Massachusetts
To the Building Inspector:
Date
The undersigned hereby applies for a permit to Erect, o�4r, Repair a sign on the following described buildings:
Street Address
....2oning District
e ❑ Urban Renewal Area o Entrance Corridor
o Historic District o None
Property • ` Use of Building
Telephone - y 3 1S1 floor
Sign • c N 2nd floor
r
Address D,,rbA3'd floor
Telephone 41 floor
E-mail 7 -S, MQ0101S. C ct-t How many businesses are in the building?
If a corporate body, name Frontage
of responsible officer
• C C�� Building Jr X linear feet
Construction Sup's License No C&IApplicant's Space (if multi-tenant) ,Mar feet
Address I� = ��y� Property S a x - linear feet
Telephone C� '_00D Mail Sign Permit to
E-mail �� —.1 ( A 1_-'CV-v\ Vor ign Owner ❑Sign Erector ❑ Other:
Proposed Signs(If more than three signs are proposed, attach additional sheets)
Si n 1 Si n 2 Sign 3
❑Surface ❑Surface ❑Surface
9 Right Angle to Building ❑ Right Angle to Building ❑ Right Angle to Building
❑ Free Standing ❑ Free Standing ❑ Free Standing
❑Awning Nb �qc ❑Awning ❑Awning
❑Portable(A-Frame) ❑ Portable(A-Frame) ❑ Portable(A-Frame)
❑Other(specify) ❑Other(specify) ❑ Other(specify)
Sign Materjals l vi ly e Sign Materials Sign Materials
pvls M r
Sign
Di ensigns Sign Dimensions Sign Dimensions
Sign Area 15
Sign Area Sign Area
s ft s ft ft
Sign Height(if free standing) f o l Sign Height(if free standing) Sign Height(if free standing)
Estimated Cost of Net Work
$ Poo S1 oorjkAoyJ I 0. Wo w C s w+}'Lt x
Existing Signs Signatures
Type 3/
Sign Area To Be Removed? Sign Owner
❑Surface sq ft ❑yes ❑ no
❑Right Angle to Building sq ft ❑yes ❑ no
❑Free Standing sq ft ❑yes ❑ no Si Authorized R ntative
❑Awning sq ft ❑yes ❑ no
❑Other(specify) sq ft ❑yes ❑ no
e Owner
Internal Review
Planning&Community Development Department Historical Commission
Approval
Building Inspector
08/24/10 rev
I � The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of III vestigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): C ot��,���
Address:
City/State/Zip AA, nkii I c) Phone #: 167
Are you an employer? Check the appropriate box:
Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6 ❑ New construction
2., I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• ❑ Demolition
workingfor me in an capacity. employees and have workers'
y p n'• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing ail work a:id then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy Aeclaration page(showing the policy number and a iration date).
Failure to secure coverage as required under Section 25A of M=.1L c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 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.
I do hereby cent'y er theins and enalti of perjury that the information provided above is true and correct.
<'l
S1 ature: ( Date: f
Phone #: / 7P'7 �r C
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/ToWn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other