178 FEDERAL ST - BUILDING INSPECTION (2) i
t .•
What is the current use of the Building? 4eS lxhT/A
Material of Building? If dwelling, how many units? 1
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanl's Name A"-(6If-i?CfT`, rnKJ-t2AcTOeS
Address and Phone WAt./U Ot 3T. 44baloy Vkl a 41Q bD
Construction Supervisors Ygense# HIC Registration# 1 fah-n Y
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.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date 3 a7
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CITY-OF SALE,
PUBLIC PROPERTY
DEPARTMENT / r)
t:u�lF21.EY DR15l:U J. d�
MA'S« I20 W,LwiNarr S'r%Eur•"=y,\LL1sAIXLsk rn;01970
TEL 97. -74S-MS•FAX 975-740.95"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION%
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
r
TE INFORMATION
on Name:rty Address:
perly is boated in a:Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: T 13
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIING BUILDINGS ONLY
Addition Existing G2
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 Work: T p Srr1101 15r1 / , Lrn�klllv&eSj &P(4KL
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' CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation Insurance APAdavit: Builders/tiontractor MetWdanxplmbers ADDHeant In-formatlon
"'It Ledbly
Name(Butincw ): :::aA.I AIM C fT`/ ('nxtrrarri,os
Address:— Lt)ACA (- T ST .I
City/Statemp:— b 0
An u employer?Check the appropriate bon
1.L� I am a employer with _3 4. Q I am a Co�actor and I ����01°� jcdm
employes(I1111 andlar pact-time).• have hired the sub-cones d t
st
2. I am a sole proprietor a partner. Based an the attached:beet t 7.ship and hworking �ve T�+e haw8.r me in my Con
spacity, workers'comp.inaut:ace.4 Comp.insurance 3. ❑ W��a motion and its 9. ad3.❑ I am a bomeownar doing all work right of ex"haw are per,their10 ditiansmyself [No workers'Co 1>m MOL11.0 pb�b�fditioorsop C. 132.J1(4),and we have no12,0 Raof repair
insurance regtttred j f employees[No workers•
gyp•insurance required.] 13.�Other
f Hameowmv bo�dds aw ckvkt IMM•bo a am dew raetlon eraw des fassad tnlr&aa.at..•om�pe..de.yona�,ieto�metie..
tCamaaaa shoe cheek dm boa amok enacbe n Ad AM i°•at sad now
search emtraetem mmm R"k a ova,alRd"�swL
ems dr Dame GUM addaetr a'atms•camp pellar letbemeeoe.
ow an employer rhea b provldlns workers'cowpenradon lnsuranei or
lwjorwadon. // f my e+spl eyeex Below b the po&7 and/ob she
Insurance Company Name: f,Iiwry /V1 f you
Policy M or Self-ins.Lie. v.- (,0(,-L -315 — 3 33 Ste/ 3 7
/ Expiration Date: 4LAZ-6$
Job Site Address _ At S /yl �
rs s�
Attach ,I.
City/StatrJZip; G1�i7G
Of compeauadoa policy declarad a page(sko the
Failure to secure coven ns wag t7O�Y number add eapirsdon data).
8° required under Section 23A of MOL n. 132 can lead to the imposition of crimiaa(penalties of a
fine up to S 0. 00a d y d/oraping
one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to 5230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Otlice of
Investigations of the DIA for insurance Coverage verification
l do hereby ce %j.under&a andpenalder ofper/ury that the ln/ertaedon provided above Is trse and correct
a a
Oplelaf usi on/lt Do not write L thb ores,to be completed by clty or/own q(JlciaL
City or Town: Permlbtkenu N
Issuing Authority(circle tine):
I. Board of Health 1.Building Department 3. CltYtTOws Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person:
Phone tt•
Information and Instructions
to rovida worker' CompCnsatioa for their emphoyeC�
ytassachusetn General Laws Chaptadefined
�� ovll a the service of anceW under any COD° of
Pursuant to this stack^an#Nets
yge express or impliC4 oral or wtitttte•"
am
An erployar is�Oed es-as>dvtdtral.pattnecabil t1 I�representatives latleft.corporation at other legal eased.or IOYW-a the
and of a deceased step However the
of the faragoing engaged is a joint mtuVmg! aaaeiatiCs a other legal salty.employing atoPleY�'
receiver or trustee o[m tndtvtdtaal,partoaaht0.m than thm qmmsnts and who resides theei0.s the oceuWtti of the
o�bma of ams wbo�Pusms db mwuomm O' a�deamwealt e be via dwelling htwse
or building aPputtleace thaeeeo shall not because of such emplCymeat
Cc on the gtouoda wlt6b tb leaaases or
MGL chapter 152.42SQ6)alto 0a that"°°°�' s kcal aeesaing agetney ales
.."at of a Banes or Persil to opwoo•b�nest eospllsaes with the Wurases ~�for agshaLL
coverage Kq°�
aP sDawcalds am any of im political
ny,MGL chapter rroduj��k �Nekhmtha otpublic we* aoeepnbk coof evidence of compliance suith the lee
eater oContract loir*A f this chapter bmnpresented to the contracting audm*-'
raq
APPHCante Chad=$the boxes that apply to your situation sad.tl
Pleue fill out the wodme Compensation a� a vit may'one by numbers)along with their Ca Ltcs*§)of
necessary.MW*sub.CO°tiaets(s)aame(a( �°d L.�ted LLiabilitY
Liability
Partnerships(LLP)with no cWPky�other thus the
1°�- Irmnedare lot tequirCd or isuuratum If an LLC a LLF does baw
u�tirtd, Be advised workers O° tted to the Department of lndoaaial
at partner. be sitbnti
c members a pommy, that �` to slg.sad date the amdavil, The d&jwh sh the Dopwulcd ould
Accidents far emg am tthat fee cov�a� Alsefor the permit or license is being requCste4 mot
be returned to the city that the spp r��dw law a if you are required to obtain a dents
Industrial ACcWWAL Should you have any questions�attiobac listed below. Self mmur ed companies should dsis
compensation Policy.Plew Call the Depot lice
self insttttmce UC=w nums b an the
City or Town 0mclab has provided a space at the bottom
Please be sure that the affidavit isCompkn and printed legibly. The Department
of the affidevil for you to fill out in the event the Offkc of invesdgasons has to contact you regarding the applicant
permit&Cnse number which will be used as a refsenee number.
Please be sure to fill is the In addition.an applicant
appliCatiooa in any given year.need only submit one affidavit indicating current
that must submit multiple Perini °and .Jab Site Addraa•'tbC applicant should write"111 locations is —(city or
policy information(if necessary) or marked by the city or town may be provided to the
town). A Copy of the affidavit that has beast fileoffo for stamped of licences A new afudrvu moat be filled ewe eagle
applicant as proof that a valid affidavit is on file f i license palms not related to any busiaeaa or Commercial vennne
err
year.Where a home owns or citizen is es obtaining g u NOT required m complete this affidavit
(i.e. a dog licence or Permit to burn Leaves etc.)said person
and should you have any questions,
ns would like to thank you in advance for your cooperation
The Office of Invessgstio ve us a
please do nett hesitate to to
Call-
The per em•a address,telephone TM with of Mm uhusetu
Dep"Un At of ILtillaid A► I&nta
OtIIa ttf lavadpdota
600 Washington Serest
Boston,MA 02111
TeL g 617-727-4900 W 406 of "77-MASSAFB
Fan 0 617-727-7749
Itevised 5-26.05 wwwmiuss gov/dia