0023 BEACH AVE U1 - BPA-08-289 What is the current use of the Building? y?€ '
Material of Building? L±�2 Y- if dwelling,how meny unitaT
c
Will the Building Confomn to Law?�� Asbestos? "�b
Architect's Name v
Address and Phone )
Mechanic's Name
Address and Phone �" w----�---
Construction Supervisors License S >'6 7 HIC Registration# /� Z
Estimated Cost of Projed S r Permit Fee Caleulation
Permit Fee S S OO Estimated Cost X 117/51000 Residential
Estimated Cost XS11/51000Commercia4---------- - -An Additional $5.00 is added as an
Administrative charge.
Make sure that all fleids are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build e a sta
specifications. Signed under penalty of perjury
Date � d7
1
� L
a
-
PUBLIC PROPERTY
DEPARTMENT
KMOSEubr o.SSC•v
Mwrat 120 Wwswew- ON SsW,T•SALAAk NAttAQ/LShTiS 01970
14s197674-95"•FAX M740.98e
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING,
STRUCTURE OR BUH.DINC
1.0 SITE INFORMATION
Location Name: 023 BEA(fV -Sl-, CcsN(b 4Z5C.SuildlnT 3 61411Ts
Property -
'SA[.i5uH LAAA
Property fs located in a:Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: / -F700 — 71 S-- %736
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
adef Description of Proposed Work:
S'Truc*urok Pitp4'r.S l67AC RErXR 2�fcK5-
.) ,VeW pzxr,-r
biQyprua.0 �,2.4c'irlgi NCw oE'.oifi�S
Mail Permit to: ,9 S 7i11T�E2!/�OGF
i
l
CITY OF SALEM
PUBLIC PROPRERTY
'` DEPARTMENT
ri1URF Rtfy Wten:tx..L
M.%yos 12t:WAstuw'ravSntrPr 4 SAtEM.WA$At:ln.'i T1%0197^
TILL-97f745.9595 4 FAX:9M740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ani licant Information `�� �^ /� Please Print Leeiblr
dame tauuncss/OrganiratioNindivuluuit: 1 �E� STRO � GOV. CO/t/7/ •
Address: C,:;)-9
City/smteJZip: c>i Z6'MM Phone a:
Are u an employer'Check the appropriate boa: 'type of project(required):
1. 1 tan a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full atul/ur part-time).* have hired the sub-contractors
ode
❑ I am a sole proprietor or partner- listed on the attached short : 7• lKJ Runling
ship and have noamployces Them suh-contractors have g. ❑ Demolition-
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
f No workers'comp. insurance S. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.El am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
I myself.(No workers'comp. c. 152.§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' 13.❑Other
comp. insurance required.]
I -Any,ppliwd tIW chocks boa el mug 260 fill out the wat"taluw dwwiaa IAoir wurkru'cumpaawtiva policy infutmwiwt.
'I( n Iwnelt who submit this affidavit indikatina fty are Juina all watt and then hire outride eawracom mutt oubma a a amdavu wiattina rich.
:C'•mttxwKs that c1spck this box must anaehad un adtatiaW.hat ahowine the sumo ordw rub oraeton aM their wotkm'comp.policy infotmatim.
j 1 um an maployer that is providing workers'compensadon Luuranee for dry employees Below is the pis/icy andlob site
informadoiL
Insurance Company Name: � /- ..... (/V( ICTGAL—
Policy N or Self-ins. L-�ic.0: ((/�llG �_— 3/�^ �6.26�- O/ Expirruon Date:
lob Site.Address: 2 �S E-Ae-41 ;S—rr, CitylstatUZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratiou date).
Failure to secure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
rine 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 riot
of up tm 5250.00 a day against the violator. Ile advised that a copy of this statcmunt may be forwarded to the Office of
Invesngatiuns ul'thc DIA for insurance covcragc verification.
do hereby certify an to pains es of r' ry that the information provided above is true and correct.
Si,•:ruurc' 1114 t : $ 7
Pht,ne;; ?yam
OJJ&ial uu only. Do Nor wrire is t/dr area,to be completed by city or town o/J1riaL
Cityor'rown: _ Permit/LicenseN
Issuing Aulborily (circle one): -- _
I. hoard of itcaith 2. Building Department 3.City/fours Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Other _
Contact Person: _ Phone N: