28 BARSTOW ST - BPA-2008-244 ROOFING CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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V AYon 12C VA!i %G(0KSntesr a SAtEst,b(ASA :l IUVA-11.0197Z
Tel:97111-743.9595 is FAX:978-74t19946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electr]cians/Plumben
Aanllcant Information /' ' // /� / r Please Print Leeibly
Name ltluai,tsslOrgattizatiotulnd,vultutll:zott l f4"1 :ir a 4 71 _ 1 to
t• /_. ' S4-
.AJdrea .t� l/P(�eng
City/Stale/Zip: 3 D Phone /t: 7el
VI♦re y u an employer?Check the appropriate box: 'Type of project(required):
I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees(rull and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
(No workers-comp. insurance 5. ❑ We are a corporation and its 10.[1 Electrical repairs or additions
n quircd.] officers have exercis cl their
3.❑ I am a homeowner doing all worn right of exemption per MGL 11.0 Plumbing repairs or additions
myself(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. (No workers' 13.❑
comp. insurance required.]
Other—
.An)apylicam the chaos box e1 mltu also rill out the semat below dtowiaa Iheir wwhm'ewnpfnsmion pulicy inti,m a,kw
'llumwtwnan who submit this aMtdsvir indicating stay ate doioa all work and that hits maside camractiss mwt submit a new attldavit indiedina such.
:famracuws that c►uck this box mow aitacMd an a tchimtsl Jsmt showGy the name of the subeontraaron and their wurkom'cony.ptlicy in6tmtatim.
li l am an employer that&providing workers'compensadon htsaranee for my employees. Below is the pu/ky and job.sill
information.
insurance Company Name:
Policy+4 or Self-ins.Lic.N: Z _72 f- d/2 `a' :pirauon Date:J '�
Job Sirc .address:enX Ae7 f-3101A) z4v'If CityiStawZip el G...Sf
Attack a copy of the workers'compensation )licy declaration page(showing the policy number and expirativa date).
Failure to secure coverage as requited under Sccl ion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
rinc up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day uguinsl the violator. lie advised that a copy of this statement may be forwarded to the Office of
Im•csngauuns u' he DIA for insurance covcragw vcrifrcatton.
/du hereby ce i y under the pains and penuldes of perjury that the informullon provided above iit at�eand correct
tii•Nature: __ "/ U }
ate- O/�.�/ "
Ptunle 7: 791—SYY y�s/
Official use only. Do not wriu la this area,to be cumpleted by city or lawn ofjlei"
City or Ttwn: __. Permil/Lieense
Issuing Authority (circle one):
1. lluard of Wallis 2. Building Department J.Cityffown Clerk J. Electrical Inspector 5. Plumbing Inspector
6.Other _. _
C'ultlact Person: -- . - _ ---- Phone q:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTM. ENT
.�.\I::III aft `F�I:�•I L
\LIuNt t1C w.%gd JM5 KEIT•Ut,M,%L%aL 1. LL*XIS:0.
Tn. #nj45.-)M •F.M-97 406A
Construction Debris Disposat AMdavit
(required for all demolition and renovation work)
In accordance w ith the sixth edition of the State Building Code, 780 CNIR section 1 t l.S
Debris.and the provisions of M- GL c 40.S A
Building Permit N _ . I_ is issued with the condition that the debris resulting ftom
this wort shall be disposed of in a property licensed waste disposal facility as defined by.IGL e
W
The debris will be transported by:
�J-A
I Iuma of haul")
fhe debris will be disposed of in :
(namr ur' a.ILty)
_ \�.L:rei� of faciLty) .
�rj...IbiC.)r •:cfll.11 .I7�. 1J[ - -�-
_� 6
— EITy-OF-
PUBLIC P'Q ROPERTY
DEPAR'I1bIENT
KINGWALEY o.ISCOU
MAYM 130whum=whnFbT•1MkK cSkI-M01970
M L-976.745-9S95 1 FAx 9767404W
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OMAN
CVq FOR ANY EXISTING,
STRUCTURE+' OR BUILDING
1.0 SITE INFORMATION
Location Nams: W Building:
-- -- - ---- -- — _ -----
Property Address:----- -- -- - --— -
Properly Is located in a;Conservation Ares Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: I 'PtC
Address:
Telephone: 9r7 —
3.0 COMPLETE THIS SECTION FOR WORK IN E7pSIlNi2 BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Boef Description of Proposed Work:
Oaf
— Mail Permit to:�l�
What is the current use of the Building?
Material of Building? If dwelling,how many units?-4____—
Ww the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone 1 l
Mechanic's Name + , 1 T o�tQn'/ S12
Address and Phone'%S Ofgart y
Construction Supervisors License# HIC Registration
Estimated C044 of Fr0j, 7Q��0 Permit Fee Calculation
permit Fes i Estimated Cost X$7/$1000 Residential
-. Estimated Cost X$11/$1000 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 Perm o buil¢to the above stated
specifications. Signed under penalty of perjury r
Date �5 0
vl
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YU
F 3 a� G7 > y 3