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City of Salem Sign Permit Application Worksheet
21-Feb-18
O St. John Ukrainian Church
122 Bridge Street
Zoning (res/non-res) 131
Entrance Corridor(Y/N) Y
Lot frontage 15 feet
92 total 55.on
Building or tenant frontage sign side feet
#of businesses on site 1
Bldng dist from street center 30 feet
Multiplier 1
BuildN and Blade Signs j
maximum area permitted 55.00 sq ft
total proposed sign area 19.50 sq ft
sign 1 19.50
length 78.00 inches
height 36.00 inches
Freestanding Signs
maximum area permitted 0.00 sq ft(per side)
maximum#of signs permitted 0 signs
maximum height permitted 0.00 ft tall
sign 1
proposed sign area 0.00 sq ft
length 0.00 inches
height 0.00 inches
proposed sign height 0.00 ft
sign 2
proposed sign area 0.00 sq ft
length 0.00 inches
height 0.00 inches
roposed sign height ft
Application meets guidelines set
forth in the Salem Sign Ordinance yes
Recommend approval yes
The existing 48"x 51"surface sign will be removed. The application is for a
sign in the same location as the existing sign. It is a high density
polyeurethane, non-illuminated sign with a blue background and carved
letters gold letters. Dimensions comply.
NOTE.BUULDING PERNMT MUST BE OBTAINED BEFORE SIGN IS ERECTED
Location.Ownership and Detail Must Be Correct,Complete,and Legible
s
Salem,Massachusetts
Date
To the Building hopectOr
The unbar ggned heraby app#es for a limit to c Erect, I(Alter, u Repeir a sign on the following described buildings:
Street Address Zcpiing
o Cuban Renewal Area trance Corndvr
-2- a Historic District
Telephone ` 73'
ilaor
float
Address floor
Telephone 4 floor
E-mail U WI How many businesses are in the building?
ff a caMware body,�nja��rm
of mWonave omc C
!-p
linear feet
Conshi ion S•s L i No - ,� ant's Spada(it mufti-tenant) linear feet
Address '• P�rY -t 5dQ
linear feet
Telephow '
E-mail o Sign Owner)(Sign Erecter o Other
Sign i Sion 2 Sign s
'Surface a Surface a Surface
o ightAngle to Building a Right Angle to Building o Right Angle to Building
o Free Standing a Free Standing n Free Standing
a Awning a Awning o Awning
a Portable WFrame) a Portable(A-Frame) o Portable(A-Frame►
a Other(specify) a Other(specify) a Other(specify)
Sign Materials.— Sign Materials T Sign Materials
i - N.��
S n D'�nikns "' --� Sign Dimensions - Sign Dimensions
S Area Sign Area Sign Area
E r itsq Sign
ft
Sign Heigh (ff standinng) Sign Height(if free standing) Sign Height(if free standing)
Estimated Cost of Work
i s
Existing Signs
Type Sign Area To Be Removed? S-
xSurfece sq ft )(yes a no
ri Right Angle to Building sq ft o yes ❑no S r s Attttro' ftepresen
tt o yes o no
o Awning &ng sq ft a yes a no
a Other(specify) sq ft o yes a no P
Va
�r r
Planning Co unity Development Department Historical Commission
Approval
J �
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Building Inspe or
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+ Print Form
The Commonwealth of Massachuset s
�p,
Department of lndustrkd Accidents
Office of lnvestigWions
1 Congress Street,Suite 100
q
� Boston,MA 02114-2017
www mass govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/organizatiowlndividual): C
Address: T�1�►'�
City/State/Zip:, ' ' 46v ?( J S Phone#: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 1 6. Q New construction
, employees(full and/or part-time)-* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. Q Remodeling
ship and have no employees These sub-contractors have g, Q Demolition
working for me in any capacity. employees and have workers' 9. Q Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.Q 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' i3.[P Other t
comp.insurance required.] l
Any applicant that checks box#1 must also till out the sectim below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
iContractors that check this box must attached an additional shed showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-cantractors have employees,they moat provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and}ob site
information.
Insurance Company Name: l 3 —
Policy#or Self-ins.Lic.#: �r Expiration Date:,S- C>i
- 3I.g
Job Site Address:���. "l �- 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 MGL 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 hereb ce . un the pains and males of perjurythat the in ormation provided alcove is true and correct
Si nature: -
Phone#: G
Of,j3ciai 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 _-----__. .!__...___._._..__...............___--