009A FILLMORE RD - BPA-07-624 PUB1LICVPROPERTY I
DEPARTMENT
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SM0{.XWAC 1,SL1 z0,970
1U_97&74S959S 6 PAZ 976-7404846
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION.OR CHANGE OF USE OR:OCQT%NCY,FORANY EXISTING:
STRUCTURE OR BUILDING j
1.0 SITE INFORMATION
_Location-Name: -P77wan _ _7 __-_- Building:_,_ -
Propart�Adares • Q mT ore --- - - -- -
Property Is located in a;Conservation Area YIN -Historic Distrkd Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: Ae_ o«�Son
Address: C'(� (I moth? 1 `
(ea,. A-
Telephone:
3.0 00MPLETE THIS SECTION FOR WORK IN IATiNn BUILDINGS-ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor(sf) `Renovated
construction or renovation
of existing building, New
Brief Description of Proposed Work:
Mail Permit to: JC b ,� —
D111�0
i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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MWAM0C NSlUW &cunt,l &UACMM rs01970
Tat.97W45.9595 .Fex:M74S9t1e6
Woriters9 Compensation Insurance AiNdavit: Bander/ContractorsMech{ciandphini y
ADDlicant Information bars Plea..Print
imply
Name cTlv.iae,vorpniaoadrnd;„�u,l: Construction Specialties
Address: '.0. Box 53
MM
City/Stawaip: phone lt -7 t—b 6r--44 I p
A
reaps u employer?Check the appropriate Ross
1. Isms employer with 2 _ a. 131 am a general c000�aOW and IJE
1«t(regdree.
employees(firll and/or part-time).* have hired the sub coneracwrsw caostrtrctioa
2.01 am a solo proprietor or partrter. listed on the attached cheat tmodeling
ship and have no employees These aub.m�acp�have molition
working for me in any capacity. workers'comp,issuance,
[No w0dws'comp,insurance 5. ❑ We ate a corporation and its ng additionrgtritea l officers have exercised their ctrical repairs ar addidorra3.❑ 1 am a homeowner doing all work right of exeption per MGL bing repairs or additionsmYself (insurancQYo worker'comp a 152,1l(4�and we have no tt1 employees.(No workers'comp.insurance required.)110mooroe wile ratadt m&Mde angf to ar th.mtl hlAoadoa lhdrwarkms'eonDaiey,eardwm
tcomacton 69 d *thin boa mum�.�i�a6.adr ad demw Wd.eaao.era.mat mbmk a new altidrrit iniiio W,g.ra.
+6oa(ei the am. abeoaeamaa and Meb naives'camp,porky reeamsae.
I sat all pnployer that&providing workers•cowpengrdon bsu►ence for nry,rarp/oyia Below b tke
Grforwallow / polky and fob sAw
Insurance Company Name: ( &—
Policy#or Sett-ins.Lis.#: W d 0 LO 6 ,�- b 6 o v
/� Expiration Date: O
Job Site Address:_ q /4 r L. L-A4 D/L '�—� � n
Attach a copy of the workers'wm compensation City/SftmMp- S Jf� F A"7
pe policy declaration page(showing the Policy number and expiradoa date)Failure to secure coverage as required under Section 23A of MGL o. 152 can lead to the imposition of criminal penalika of a
fine up to S 0.00a d and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$2S0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the OtBce of
Investigations of the DIA for insurance coverage verification
I do ksnbr cordJy under do pains and penalties ojPrr/ary that tke in
y— fmnwdon provided abo is dun and eorrecs
Signature: I'l/ �ti_ �� / o
Da w
Phone#: — 6 6 L( /v
F810arrd
on/x Do not write he this area,to be completed by city or fawn Offleial
n: PermlNLkease#
hority(circle one):
Health 2.Building Department 3.Clty/rown Clerk 4.Electrical Inspector S.Plumbing Inspector
Contact Person:
Phone#•
What is the current use of the Building?
Material of Building? "0 If !welling.,how many unrta?
Will the Building Conform to-law?
Asbestos?
Architect's Name.-_ ( ,
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC_Registration#
190
ed
a�,
Es
timated Cost of Proj $ Permit Fee Calculation
- Estimated Cost X$7/57000 Residential
Permit Fee$ -- - - - ---- _ -
-- ---- — — — I------- - Esttmated-Cost X Sfi14-1000- ma[----
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 aboye stated
specifications. Signed under penalty:of perjury
Date l-q-01
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