0035 COLUMBUS AVENUE - BPA-08-627 + �c u
What is the current use of the Building?
Material of Building? o 14- if dwelling.how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanie's Name :S-C I c.,Address and Phor►w 1� I�a�r� Z 8 13 I - I (fig
Construction Supervisors License a i S o IR 4 L-I 17 HIC Registration g
Estimated Cost Proied,i_a5-OO-DCD PermI Fee Calculation
Permit Fee$ � Estimated Cost X$7/$1000 Residential
Estimated Cost i11/$1000 Commercial-------- ----- - -
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
N
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PUBLIC PROPERTY
DEPARTMENT
u.�mFdsr u■,s-,w, ?7 /
130 WAS UNGWO SMM•SMW4%LM&AaLgi-M01970
Tw--M745-9S"•FA=m7J0.96N
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR WELDING
1.0 SITE INFORMATION
Location Name: auiwkv
----- Property Address:—��—_ -
:50j 1/Iti
Property Is located in a;Conswvatlon Arse YIN Historic D Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land C-0
Name: -00v;
Address: S S co (U"OD Ve .
Telephone: 9`j g Z 4f L - 1 `{ S
3.0 COMPLETE THIS SECTION FOR WORK IN EXISXLUG BUILDINGS ONLY
Addition Existing
Renovation �/ Number of Stories Renovated
Change in Use Z New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation (Q
of existing building New
Brief Description of Proposed Work: d eL
o e ex- wre o-- q4%-e- .e_,�,4 1 s +,Y, LC ,+c.( f,w
Two v�e_uo w a. 1ls LIL) any door
044-d- s t� k
---- ----Mail Permit to:
CITY OF SALEM
_PUBLIC PROPRERTY _
- DEPARTMENT
%L%14• 12Cttr.%AM7.O6$DER03A4klkMA'A 92A+t�1s::�
Tb:IW4§,,ytN11/•f nr I W404M
Construction Debris Disposat A1'lldavit
(required dac an dcnalidan and tonoration wort)
ta.=a lanes with the sixth edition at the State Building Coder,7So CA1R ratios 111.s
04b"sad the provisions of M. OL a 406 S 54
gwlm"S Pwmit N _ is issued widt the condi m that the debris readtbtS hom
this wort shall be disposed of in a properly licemed wssse disposal &dUty as dented by WIL a
!d t,s l sow.The debris will be transported by:
oo iA .
t,tonK.fr IIOYIQI
rho ckbririss Wilt b�e�disposed ofin :
t n.cne uE fx,tay)
.aLt
CM OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
' iw14N'ataY UaW++�
x�""a 12e�s...,anottsnsr.L tt:a�s1>,ar+waytiisolsrl
TALL:VW4i%% .Fsx:v7Net?9iN
Workers' Compeasatfoa lasursom Atlldavir. IWI&rWCoatnctuWElectridanLg%mbers
Annifenot Informadem
Pilot L*tibtg
Name r Z�
,add
c cry/stat�z�p: //1/(�-✓b(�e Yd f4— i'booe : 3 I -I L10
Art YOU as taaPleyer?Check the aPPMPrlaq bosi
1.0 1 am a employer with 4. 01 m a g�+al coubacler and 1 i
PwJ (rMtdrtdl
(fall"raYor pAtWiroe).• have hired the wb.cuturactom ew cotasruetios
2. 1 am a Solt propricsor or partner. listed on the attached shaft t atooda►*8
ship and bave no ontpleyoes Thant haw �itiw
working for nu in any capacity. workers'comp,insurance
(tb wotkets'ccerip insu snot S. 0 We am a aorponnim turd its aadty addition
required.) ofl(ears have exercised their lectrical repairs or additions
3.0 1 am a hatteowner doing all work dgkt orwwmpdon per MGL lumbing repairs or es"tions
myself.(No workcra'camp, d~ 132.¢1(4X and we(taw no of repairs
inau sisca rego�d 1 r empbyexs.(A'o workers•
comp ittsdtrsnoa required)] ther.
.,v,'+PP Yt tea etk"st"ba"tl n"p a4o as as tti areuo"brow rowing ttan wren'ataryewrtw DWi"a'I luaeariarea""a wanit tan anldevii wand"diw an doing ON watt"ed Am Isla ew4f/"easadr"ttw"wet auaaa s e amdava inikoi
i".nttnktars err da"aa eti"bat mat 3oadw m addhfmY awn.bowing tb"a"""f air mb.'si e'sers ied ta"n wtttw' M k r L
et"tttp.Dan)!r'iaa"rnaana
I am an ampilepw that b p�rov/dla;wonFirs'comptxitadow Irurtronce joi sty en"p/oyers Below/a the paNa2 ru►dloi.s/lg.__..
Insurance Company Vane:
Policy a or Sair--ins. Lie.1l: Eapirrrton Data:
Job Site .Adtkcsa: City,$lateizip.
Attack a copy of the workers'compensation pulley declaralloa page(showing the Polley number and expiration data).
I-'ailurc w xxum covcragt as required under Section 23A of.MGL c. 132 can lead to rite imposition of criminal penelties ors
('nU up to SI.Jtt0a J y Worigai ant-year imprisonment,err well as civil penallieat(n the form ofs STOP WORK ORDER and a rive
-If up to i230.00 a Jay against kI'd violator. lie advised that a wpy urthis slart:tnr a tnay be wrwarJcd to the OI)iee of
Lie„hg;.nutu ul'dic DIA for insurance:overaad: serif'tcatiun.
hereby Cellii&under i ins ern/ nubs t cry Chet rib/n trmallon proru/trl claw it I/W end coma
rFa inc,,,
Fd)ffkAm1,vj;r&&4&oeljt of Maw o,Q4%L
n.. Pcrmivi lressehority (circle one):
IlraltbIluild allD:partutettt 2. City/fona Clark4. Electrical ►tdspeetor S. Plumbing Inspector
son: Phone p
Information and Instructions
ticneral[awe chapter 132 requires all employers m provide workaw' compensation fat t pwa&
�tassach on u�({ nr"...svary person to the service of another under Y
contract Otbuv-
Pursuant m this'tatute.an eaa ho -
tWe"of impl;od,oral or writtae.'
.Corporation of other legal modty.a troy two at tents
.�A AA
jaw is defload g aaPtt°dra ;sdtvidsal.p �tb�kgel repraaanosives of a deceased et Howc �
receiver se«ttetee of s todiv.dsal.ParoassbW at other legal cuuW-amPkyu*anPWYoM otter
hmn bavia�trot more tber these spartmeate red who teeidsa annio.or dw owupsnt
ownw ors dwaft ns m do maintessoca.cunstrucnntt at reptur work on soar"dvasnllirg lour
dwelling troves of another who e1+tPloYe perso,ea shad net beasttoe of ant►employ be downed 1D be an„mployar.-"
at on the grounds at building apptnteoson _
dud
ths bases"
�tGL chapter 152.;2SC(6)aim oep thu"eve dusbass er rr eoettreet bu1WInP�eemeasswed* K
renewal ere Oman er prrlt b opera"a Widows of eomoser wuh the Wourases eaversp rNuWaL"
applies"who her net prandsrad eaePhbM not any of is politicalaabdidaeos dull .
pddinisteslly.M(A chspts 152.;2SC(y)+ mentstwe
Is ev�ona ofcompliance with the insarmea
enter into any contract for the parfaeuwaca of pt eamraetiug attdtority"
requirements of this draper haw him presentedO
theAppOesns
Please jilt out the wwkaa• merrtpensatien stf dievit completely.by checking the boxes that apply rt your(s)Of
and.if
naeesw y.supply tea)n'�s)'address(es)and phone aumbs(y along with that amtploye(s)da
inaurenoa Limited Liability Companies(LLC)of Limited Liability Parsaetshtpe(LLP)with no ampbyer other that the
n ant nequlnd m retry wstnW compound=tttsuraocs, if an LLC or LLP does have
mambas of partners,i uired. Be advised that this aHWevit my be submitted to the Dapacmtalt of Industrial
e lm 's Colley of insurance eoveraga. 'Van be sure m alp mad date the aftWsvfl. The of idavit should
Accidents for cooAmtstion that t�application for the peewit a licents is being requested.sot the Depstumm of
be rctumad to the city or Own the law or i4 You an required O obtain a worker'
lnJustrial Acs;irlms. Should you have any quasdoae a number
y ies should enter their
cmnpsuatioo Policy pleat tall the Dapsttmnt numbs listed below. Self-isaured sampan
sclf-insuraaa licanse numbs on the
City et Town Officials
l ib The Depsmunt has Provided a specs at the.botto4_.
please be sure that the 3011 is eomplieta and theprinted f l9` to the liesnt
of the affidavit for you O fall rour
in cthe
event
whi�chawill be used as s vestigations�terertce numbers[n rddidon,an applicant
please be sure to till in the pu dons in any given year.need only submit one affidavit indicating current
that must submit multiple p"wivijecoss apphe applicant should write"all lowlear io__(city or
polity information I if necessary)and under"lob Site Adampe" or marked ry
town).-A copy of the affidavit that has been offieiaDy stamped
the city or town may be provided m the
led out cub
applicant as proof that a valid affidavit;a on file for future premiere be it not related m any business mustnses. A now affidavit be
n lercist venture
yea. Where a hams owner or c;aaen is obtaining s license at pan
i.e.s dog license ar permit m burn leaves so.)said prxsoa is?(O•f required m complete this affidavit.
t '
t'h,:Ofti,x of AtvestiPt'ons would rue to than*you in advance for your cooperarion and should you have any questions.
i,lcaae do rwt hesitate to give us a call.
The pcpartnent's address. telephone and fax number.
The Commonwealth Of Massachusetts
Depaftutaent of lndtlstrial Accidents
ofte of ls"sdp-1 M
6W WASINDSM Street
Boston,MA 02111
Tel. 0 617-727-4900 CU 406 Of 1-977-MASSAFE
Fax 0 617-727-7749
;Icvi>cd 1-26-05 www.mass.gov/dill
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