51 AURORA LN - BUILDING INSPECTION 4•
Jr _C� PUBLIC PROPERTY
DEPARTMENT p '
Ki%mF.u.EvouscwU.
MAYOR f
120 WAvuNcmN Sr1eEr#SA MASLU3iLSL1'rs 01970
TIM;978-745-9593#FAX W&740.9"6 1
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION --_J
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXIQja
STING
STRUCTURE OR BUILDIN
1.0 SITE INFORMATION "
Location Name: Building:
Property Address:_
5 1 1 Lev V-4 Cie
Property Is located in a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: I ✓M �i
Address:
Telephone: `717511 927-.S'- iZyS
3.0 COMPLETE THIS SECTION FOR WORK IN EYiQTiNic� BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building, New
Baef Description of Proposed Work:
Mail Permit to: w• b w n��- __- -- - - - -
J
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Asbestos?
Will the Building Conform to Law?
Architect's Name
Address and Phone s 5��r {,�
«r �
Mechank's Name � Z ti:
Address and Phone `r 5- f r
Construction Supervisors License#
HIC Registration# � ��
6� 1. Permit Fee Calculation
Estimated Cost of Project$�'"O Estimated Cost X$7/$1000 Residential
Permit Fee$�_ Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
erl and legibly written to avoid delays' rocessing.
Make sure that all fields are prop Y
The undersigned does hereby apply for a Building P it to build to t ove sta
specifications. Signed under penalty of perjury 6
Date G/
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CrrY OF SAL.EM
' PUBLIC PROPERTY
DEPARTMENT
wVCS INVAemw,onasmr.sw xt�aa�ssats7a
Construction Debris Di Imal AMdsvit
(required hr an demolidoa sod m wvadas work)
To aeoordsna with the adidw ddw Stets Buildtns CWk 780 CMI section 111.5
Debris,and&s povisiaw of MGL a 40.s St
SuOdba Vendt• is isand with dw=adtd=that dw debris mm Wes aaat
tlds watt"be disposed*fin a poparly!teamed wsass disposd&ditty as defined by MCIL a
1 u,s tltll►.
Mw debris will be transportod byt
The debris wiU be disposed of in:
A
ia>�at mow»
(aedroo of MOW)
of pomis apptiead
eat.
'.tri.r7.ys
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
(am, Fel 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers" Compensation Insurance Affidavit: Builders/Contractors/Electiicians/Plumbers
Applicant Information ' Please Print Le! bly
Name Business/ore2*rizationlndividual): Fe /k
arxd D(:)or-s
Address: 7 S Foe, 4� t l
City/'State/Zip: Uew--4 t 4:2S32 Phone #: 979--2 65-72 65
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a empiover%with Z S 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or Part-time).* have hired the sub-contractors
2. ❑ I am a sole Proprietor or partner- listed on the attached sheet = ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in anv capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work right of exemption per MGL 1 L❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.l f employees. (No workers' 13.0 Other
comp. insurance required.]
','inv atrolicanr that checks oox. I trust also fill out the section below showing their workers' compensation policy information:
T Homeov.ncn,ho su'omir this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
=Contractors that cheer This box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an emplQver that is providin.- workers'compensation insurance for my employees. Below is the policy and job site
information. l�
Insurance Company Name: �KS ur-aytC 'L 60 Ga^�(
PoiiCr or Self-ins. Lic. =: OBhJ GIVL57'42— Expiration Date: Dt O
Job Site Address: 57 4L,�M City/State/Zip: Scs
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverase as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.'00.00 and/or one-year imprisonment, as well as civil penalties in the fount 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
Isrestigadons of the insur, overage verification.
I do here' cetrifi' and t e pains a penalties ofperjury that the information provided above t 'true and correct
Siesta Date:
Phone - Z65 - 7255
Official rue only. Do riot write in this area.to be completed by cin'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
Contact Person: Phone#:
' Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR _
g'� Registration: 129774
Expiration: 11/212007
Type: DBA
PELLA WINDOWS AND DOORS
SCOTT HOUSE
45 FONDI RD.
HAVERHILL,MA 01832 Administrator -
...
,8, '�Y ✓/ie -Pio»rnrwou�ealC� o�'✓�omoc�ineetla
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
* _
Numtier. CS 089839
Birthdate: 06/19/1972
r -*• Expires: 06/19/2008 Tr. no: 89839
Restricted: .00 .,.
SCOTT P HOUSE -
854 RROADWAY#1 _
HAVERHILL, MA 01832 Commissi--�
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