56 BELLEVIEW - BUILDING INSPECTION What is the current use of the Building?
Material of Building? n /1 If dwelling,how many units?
Wtlt the Building Conform to Law?
Asbestos?
Architect's Name
Address and Phone ( ?
r
Mechanie's Nams Y Ae s
Address and Phone 2
Construction Supervisors License# 0sqanz-,V HIC Registration# /lS Z-&—
Estimated Cost ofJ�Pryycl�e-ct-�i\T —��U PertnR Fee Calailatbn
Permit Fee Sd LL4J Estimated Cost X$71$1000 Residential
Estimated Cost $111S1000 Commerc►at-------- -- - - - -—
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury —
Date S
N
YOi
W
Q
CrrY of SALEm
PUBLIC PROP-RERTY
DEPARTMENT
n.vst•1 at}•"AMa4L
atw.s Ill r.�N::Jt+3?(1T AtF t1.>uvty iu a 11 a�;9
Construcdon Debris Disposst Affidavit
(reyuimi tot all deawlidom and tenovadon wa t)
to aeconlanm with the sixth edition o[dw State Building Coder,730 CNIR Salton 111.s
Debris6 and dw provisions of NGL c 40,S Sk
Suildim Penwit per_- _ is issued with dw condition dwt the dcbris mRdtkg hoar
this wak shall be disposed of in a property licensed wash disposal &dlity as defined by%iGL a
t11.2is"
The debris will be transported by:
lname M
rho debris will be disposed of in :
WAM of fxdhty) 1 /
y!
• 4
CITY OF SALEM-
PUBLIC PROPRERTY
DEPARTMENT
;.wet nttr umrt:atu
StLtrae 12C'Ia4a,W:rOatg9RW a SA UK i7x019M
Tel_V&143.9595 a F.vx:97L74Q9see
Workers'Compensation Insurance Affidavit: Builders/Coatracton/EleeWdanA%mben
AtIMIC at information
Varne tNusitnas/tkynizatioNltabvtdttol):
Addrea: 6 �• / �,
City/swrizip: -Al - t;YZ 1•hooe a: e2
Are y n emplaytrr?Check the appropriate boat
Fv. �
tproject(rMaalnd$
1.01 ata a empbyer With 4.4. ❑ 1 am a general contractor sad 1 �^, ce•rnarucuou
empluytxt (full and/or part-time).• have hired the sub-contractor
2.❑ I am a sob propritwor or partner- listed on the attached sheet t tins
ship and have no employees Theca have Demolition
working for me in any capacity. workers'comp, insurance, Budding additiam(NO workers'comp. insurance S. ❑ Wo ant a corpomdan and its ! . Electrical
required] or7feere have examined then ❑ repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself(No workers,comp. c. 152,¢1(4),and we have no 12.0 Roofrepaira
insurance required.) ► cmpbyces.LH'o workers' 13.Q Other
comp inutrance tt:quinxL j
nip applicmd tier tdttadts boa al map also all tau On wit"Iaiw Aowitte their wwhns'vanpo ilk,Police ie�is,
Itua w was who subW Mrs afltdsrti iadimmS dwy ate&v%ae wok sad tkm NM ettulda eoarncwn stet submit a taw ant vk iarfarins t ,L
r'.fptaaara that r4sh ski bar atom atteelett an addition+fatal thowity eke ntlale dais sad tAwe wurk",map•Polley m6 a radon,
/oar Mn omp/oyer that A providing worriers'comperaradon Luarancefor my employees Selow is the puHa and ob site „_
...__,,..:»_.ty�wrwrJala..,,�:�., ,w.�,..�.u.,�,,........�..ti..��,.._,d....�..,.,...q-..�...:....... .,..��.,.�..�._.�.__�.n,....m>.. _ ..,�:_....._
Imurance Company Name: -
Policy s or Self-ins. Lie. 0- Espirruon Date:
lob Site Address: C14yrSutter2ip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and esplratlos date).
Failure re wears coverage as required trader Scuion 25A uf.IGL c. 152 can lead to the imposition of criminal penalties of a
tin. up to S I.S110.00 and/or one-year imprisonment,as well as civil pcnallitat in the form of a STOP WORK ORDER and a fuse
a(up m S250.00 a day agaiam file violator. Ile advised that a copy urthis stateu om may be rurwarded to the 011ice u(
Im.•,ngauata ul'the DIA for imwarce cov.raV verification.
i do hereby certify Mndei the pains and penMit4 1perjum r ar the irtjonsat/on provided above is true Mild Correct
1i•t:uuro� _ - Dare,
PMn:e a
F11004% /lb Mot write in this array to bscompklad by city or town oA-11 Ln:hurily (Circle one):Ilcallh 2. 0uilding Department 3.City/forts Clerk 4. Electrical Inspector S. Plumbing Inspector
C"ntlact Persou: _ Phone q:
Information- and Instructions - -
,%las"chusetts General Laws chapter 132 requites all employees to provide workers' compensation for their enipiay teen
putsuartt to this statute,aft ew/NJree is defined as'...away person in the service of another under any contract of hire•
express or implidd•oral or written."
AA erred is,�r..r iadFiWu 4 p�isip.asaodadM cmptuapos err other legal eased many two at man
of the -ooegomg engaged in a Joint enterprise'aid including this legal represenntives of a deceased employer,lj w v the
aseociation of odow ktgd eeidty,employing
employees. However the
cocaiver or nutter of as as ha dud,one
mare lint sail who rcsWo dwrai%air the occupant of the
owner of a dwdtisg hours having sot meta tons tondo mainsapart rods or r work oo such dwelling house
dwelling house of another who employs persons o do nag because
a famcuabb ctiwt repair work
deemed to be an employer.»
or on the grounds or building appurtenant
thetep soap not btteaue of etch aagdoytoaot
stGL chapter 152.f2SC(6)edao states that"evtrY scats or bed licensing agency shag withheld the issues"or
reeirwse o o a basbtatse err to Construct buildings o the co iseeteweripk for any
appigi d et•license er Des uced acceptable avldsw of co�pllann wkh the insures"coverage regdrsd"
spplieaat tyre has sots prod of its tics'subdMe'eas shall
enter ionelly, cMGLorn chapter 152,rforman wren public
w r the until
.sec acceptable
evidence of compliaoee with the insurance
coat imo any cantina for tits performance of public work until aeeeptab
requirements of this chapter have bean presented o the convecting audtetity.-
Applleanb
Please fill out the workers'compensation affidavit completely.by checking the boxes that apply o your situation sad if
necessary,supply aideativs t(s)nan*s),addm*es)and Phone numben(s)along with char cortiticeat(s)of
insurance. opined Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employees other than the
membea or partners,arse not required to carry workers compensation if an LLC or ent does have
employees.a policy is required. Be advised that this affidavit may be submitted o the Department of Industrial
Accidents for confirmation oP insurance covarego. Abe be sure o sign and date the affidavit. The affidavit should
be returned o the city or own that the application for the permit or license is being requested,not the Department of
industrial Accideau. Should you have any questioas regarding the law or if you are required in obtain a workers'
comperwtion policy.Please call the Depattment at the number listed below. Self-insured companies should eater their
self-insurance license number on the VI
City or Town Olfklats
..- - ...a. . ent has provided aspeed at did batons.._._.. , -
please he sure that the affidavit is complete atthe off ed"of Investigations
The Department h an
of the affidavit for you o fill out in the event the Office of Investigations here to contact you regarding the applicant.
I'leaso be sure o till in the permitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilitems applications in any given year,need only submit one affidavit indicating current
Site Address"the applicant should white"all locations in_( tY
or
policy information(if necessary)anal under"Job
town)•"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to clu,
applicant as proof that a valid affidavit is on rile for future permits or licenses. A now affidavit trout be filled out each
year. Where a home owner r ciu=n is 0 sitting s license is NOT required o complete this business
it. inertial venture
i i.e.a dug license or permit to burn leaves cu.)
fhc Oi rice of Investigations would at to thank you in adv nce for your cooperation and should you have any questions,
please du not hesitate to give us•a call.
The Department's address, telephone and fax number
The Commonwealth of Massachusetts
Department of liklustrial Accidents
000 of levedivadetaa
600 WashioSton Street
Bost^MA 02111
Tel. p 617-7274900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Zcviscd 5-26-05 www.mm.gov/dis
ErrY-orSAr ti —
PUBLIC PROPERTY
DEPARTMENT
AI\pFJL6Y DlISCl71J.
Nwvot 130 WAMQNG CW,rRWr•SALWk M %ACKL5krM 01970
Ta-975-74S-9"S•FAx:97s•710 9d10
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: VI'n'WX — Building:
Property Address:----
-----
Properly is located Ina;Conservation Area YIN d Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: �
�1
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXMT= 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
Brief Description of Proposed Wo9`
------- ---Mail Permit to: G_ U --- - --- '�
J