11 CHURCH ST - BUILDING INSPECTION (6) J
EITY-OF-�XLEl�
\ l
PUBLIC PROPERTY
DEPARTMEINT
KIM5FRLEY MSCOLL
MAYO{ 120 WASHINGCON SmExr•9"LaK MAssAoiLStxrs 01970 \
M*978-745-9S95 9 FAx:978-740-9846 �
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: G{ Buildin
Property Address:
Property is located in a; Conservation Area Y/N ddZ _Historic District YM
0" OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: Ko — — — ®—
3.0 COMPLETE THIS SECTION FOR WORK IN FYtCT,NrS 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 Propo ed Work:
/nl,�:r
err7o�r� d �'i r�� 700
'el ez J 09101
Mail Permit to:
ff �
What is the current use of the Building? e�j (-
Material of Building? f1/iC - If dwelling. how many units?
Will the Building Conform to Law? � � Asbestos?
Architect's Name
Address and Phone
Mechanic's Name o
Address and Phone. 12aZj6441�, hZjai /J A7Q., iJ ZYL5��— �
Construction Supervisors License# O7cP��� HIC Registration# >? ?z<�
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee$ 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.
i t
The undersigned does hereby apply for a Building Permit to build to he above stated
specifications. Signed under penalty of perjury
Date 102
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CrrY OP SALEM
PUBLIC PROPERTY
DEPARTMENT
mums" t�vl�aetor�.sua�xwwasanetrte
Constmdom Debtrb Dbposd ANdsvit
16t all detnel"ma teeevadaw woe4
to acmdmee with the �e,4,3N 2mi Coder 790 CUR secdom 111.1
13UB a u l•tatt d with the eon"m dkd the ddmb mad 0oe�
Bttildbtd M�0
tide wads dud be dap m"of bt a t+ Ovwb lteeoe"wra digmd Adft an&dhW by ISM e
The debris wilt be tranV* ted by:
r i. ta�r.
(ame afbseMrl
The debris will be disposed of In:
(„t6.0 d ISeiut»
�iW�of pasut�p0ticso�
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
aaaatmtav DRnC=
MM.9W4S9M •FAX 9W40-9W
Worlcen' Compensadon Insnraace AfQdavW BWdeWContMto
Aoollcant Informaden llud Aent Legibly
Name
Addrem:
City/StateRip: D ' Phone#�21�77��y-(>-,"2 _
Are you as employer?Check the appropriate best
1.❑ I am a employer with 4. [31 am a Yeoarsl coaa=coa and 1 a of Preis"(ngdred):
�PbYesa(!hB asd/oe pse4eme).• have hired the sttb000asdoq ❑Now c ettstima
2.❑�am a eok proprietor a permeo- lined as the asaehed cheat t 7. ®�temodsling
ship and haw to employees These mb-omtea0000 have 8. Q Demolition
necking for rust le nay rapacity. workers'comR innaanee.
[No workers,comp.insurance S. ❑ We ors a emperstiep and rot 9' ❑BtildiOg addition
R9�] officers law as ecised their 10.Q Eieetricul repairs or addidaos
3.❑ I am a homeowner doing all work right of exsaptioa per MGL 11.Q Plumbing repairs a addidone
mys"[No works='comp, �15Z 11(41 and we have m1O"'� )t �[No works=' 12 p Rootrepairs
insurance .) 13.p other
-Any rapier do ch.rb boa ei mmt der tie eta the mcdoa below d oeler their teshe•
1lemeowamewes coma me.elenr thq in dohs a eadr ad then hie comb ea t oah.h a nw'dearvh baco s,o�..
rCoeseamn thm she#tW bra mitt tetttrhed ea eddbtaeei them rhwles the nee dub enbeewseeom and their wabm•camp.nasar&abtmeeaL -
an an empipyar
jorwatbra rAat hr provldritj workers*eowpewroalon Gtsareaee ja my setfflAJ'ee+ Below isde po&7 me/%i sks
Insurance Company Name. L� /r4,1 �f'/9i7 ��,
Policy 4 or Self-ins.Lie.M: /L l 00�p ` Q
/ Expiration Date;
Job Site Addtts 4/z- CiryJStaterLtp p
Attach a copy of the workers'compeusatlon policy,declaration Paps(showing the pogey cumber and e:ptradon date}
Failure to secure es CcWh d under Section 2JA of MGL c. 152 can lead to the imposidw of criminei penalties of a
fine up to 31.500.00 andia ons year imprisonment as wall as civil penalties in the Pam of a STOP WORK ORDER and a Rae
lA cs m MOnd o a day against the ante or. ra advised thatatio a copy of this satement may be forwarded to the Office of
Investigatiota of the DU for insurance eoversge veriRcation.
[do hereby card&under tAt peha end ojper/ary thm tAe injoreeoa&as provide!oboes Is aw eu/eonrd
Sie_nature� / /172/��/�--r��/ /J/✓� Date• �✓ � d6JO�
Phone#:
QVIrld urn onip Do not write in this ere4 to be rorp/eted by chp or town ojkW
City or Tows: Permit/Gceme I
Issuing Authority(circle one):
1. Board of Health L Building Department 3.Cilyfrown Clark 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone N:
Information and instruclluua
provide workers'cotnpmsamm far their CM&YmalmokcO
hmens Genaai Laws chapter 132 requite•all amploYea ODia the service of another under any conaad of biter. i .
pursuant to this Sterns.an is defined as"...evert petaoa
express at implied.oral or wrimea'
aswtiatiee.ootpotati•n or other legal euwh,or am two a mow
An earpWW is d,&" "as individual.pa a"p cbWft the 190 �•of a deeeaaad����w t�
of the foregoing engaged in• tea asoaaaoa err afar�entity,empl ft.It am&yO0"
receiva at owmr of a dwddOg bouts Wmng sutOOt��thm���who resides therei4w�at on m. dwelliot faun
dweftg haw of a G&W who empi•Y• dur�eto� be deemed to be an mpbYa•"
or on the gretmas at budding appu1m•w
MGL ch par 1S2.12=6)•bO stater that""rWY s1W W local deed•fls�•y mat um fw any
raaewal of a tl ba sa err panned et eO♦�� tasaof im. �v;dom shad
•PP�iee"aO r••'Ot ptednead m=-Neobw the oommmweahh oer any itt,politkal
Addiaooally,Mt3L chapter 152.$25C(n want anal aeceptabli Cvideucs of compliance with do insuaoea
enter of this��biespressn"to the eoat<adht{a Acft•"
APPde••b cognpiewleheeltini the boxers that apply tu'Y'�sNaaen and..
please till art the wodme seo lsupply dd<e+K ph�m with that cmtiseatd�then the
s ps and numbers)alone
a of
necessary, L ca(LI,C)or Limited Liability Psemerabipa(lam wtC r LP does•
bmRwmkm have
�s or palm 16 as not mpitad to curt woskw'CO O°ins rance- If m LLC or LLl'�d
Industrial
employee•.•policy is H"sd"i that this affidavit mar be submitted to the Deparemeat
Abe M stare to sip sad dab the.eddavie. The affidavitshould
Accidents for of insurance covanps Accid-M is not the Deputneet of
be mourned m the city or town that the application for the pa"of license
�Y�t n required ww o •aorkas
ln t6>aui•i Should you have any 4u• om
eompemaaon policy,pit s•Gerd the DOW—st the Humbert listed below. Sa�inaaed ampanies should enter than
self- •U0O••mmbar`oa the
ItaL
City m Town Omcfgde s space at the bottom
Please be sure that the affidavit is compute and printed legibly. The Department ;tOw�
of the affidavit for Yes►to fill out is the cutest the Office of levewQaaons.has to contact you regarding MIS�&a#•
nunsber which will be a a mf mce m mber- in additun,an appi
e �
Please be sure to till in the permiNieesa•applications in any gives YEs:.nced only stb�one affidavit indicating Comes
that must submit tnnldple pgmwucm s"a�
(if meessary)and under Job Site Addrese the applicant should writs,"all locations m_�(c►tY err
policy infmmadon(i or marked by the city err town may be provided to the
town)."A copy of the affidavit that has been oflutalty stamped at licensee. A now afudrvit must be filled out each
applicant as proof that a valid of ldsvit is on flu far tau"p�'t• net rented to any business err a be BW vautw
year.wbae a home owner of citizen is obtaining a license at pest
(i.e.a dog Ilona or pa'trek to bun leaves cso.)said person is NOT required to complero this afgdav'L
would like to drank You in advance for your cooperation and should you have any qea um%
The Offies of invesafiaaon•please do not besitam to give va•cad.
The D�acZ;e s address.telephom and fix number.
The Commonwtm d MLWWIMSGU
Dapamuat Ot b&s1 nd Atxidants
Offte elf laved fine
600 was6illOm Shvd
Boston,MA 02111
TeL #617-727-4900 t.Rt 406 at 1477-MASS/ FE
Fax 0 617-727-7749
Revised 5-26.05 www.IIiagg.SOv/dia