31 FORRESTER ST - BUILDING INSPECTION (2) ' � 1
C I Y-OF�ALE --
PUBLIC PROPERTY
I�IT /
KI� DW
LLIERLEY SCOLL �
DEPARTME
MAYOR 120 WAMINGrON 5.MEEr•S.utiK AMACNM„M 01970
T'm-978-735-9595 4 FAX 97&740-98" �\
APPLICATION FOR THE REPAM RENOVATION. CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address: �?/ o fL2>"�l>"t2
Property is located in a:Conservation Area YIN IV Historic District Y/N 1L_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: V0 A
Address: 3 / F-t)d 4:ns S 7, r-ECL
L�wt
Telephone: 66-el
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING, BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New n
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to: I
r �
What is the current use of the Bui ding?
Material of Building? If dwelling, how many units? Z
Will the Building Conform to Law? Asbestos? A10
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone.�c 9 4 � _
Construction Supervisors License# DcP,�I5�6 HIC Registration#
Estimated Cost of Project$ O.Oc)cl Permit Fee Calculation
Permit Fee S 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 Pernik;tobull=esled
specifications. Signed under penalty of perjury X-
Date
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xar-EntEYn-"r M-1
WYoe 1M VA9@IG!rMSTMr a SAUM4 MABAOMWMOi97o
TRU M745-VM a PAX 9W4G,%%
Worhen' Compensation Insurance Affidavit: EWdeWContnetonmecbid&ew?hw bm
Applicant
Names g
Address:
CitylStatdZi : pho=#:_ S ?,- 2'
Are y a employer?Check the appropriate best
I. I am a employee with—_ 4. 0 I Am a g111010011 Cmtactw and I Type otpMent( .
employes(tat and/or part-time)-0 have hind the 8• ❑New cmstz=lm
2.[31 am a sole ptel rksm,or pettamo- listed an the aeaebod sheet t 7. Remodeling
ship and have no amployeea There nth Caaaactaea haw 8. 0 Demolitias
working for me in any capacity. workers'Camp.iaanaop,
[No workms•comp inauance S. 0 We ate a ompoation and its 9. [3 Building addition
required) offlcera haw asenised their 10.0 EWCUical repair or additiooa
3.0 I am a homeowner doing an work riSte of Memption permyasti[No workers'comp c. 132•;1(4 haavve m 11.0 Phembing repairs or addidona
rntussece required)t CmPWYea.[No workms' 12 0 Roof repairs
ctmp ieaamnce ) 13.0 Other
*Any�teat rhrrtw test et der Wo®ter ter areas twtar rhrWa�tr wolra'mmp�ssare pellay iebrssasa.
tcaeeaesaa eh"ftbba amsua& �YoddgdradrdsrWdMGDddrmeoredrmsro6ritanwaffi- dt wd-
adNdaaaiteeter rho lss Ian an*MPAVW ss nma w=abeateaanes d heir warkaa•=OIL d�aa
I wraraalewr ANbOrovldtwj workers'eoerOa mdow kmrwwesJor wry ea ytoyea. Belotr b abePolkj aa/Jeti rAtr
Insumnce Company Name:__
Policy M or Self-ins Lie.e: kOa .Z 31 S -3 Expiration Date• /48 G7
Job Site Address 3/ �aMazA City/Shts/I3p AGa �.
Attach a Copy of tha worker'Compensation Polley declaration pap(skewing tie Polley number and espirstioa date}
Failure to secure coverap as required under Section 25A of MOL C. 152 can lead to the
fine up to f 1.500.00 and/or one-year imprisonnoM as well u civil Of
STOP
of erimisai peoR an of a
of up to f230.00 a d• a ��in�form of a STOP WORK:ORDER and a fine
Y 8�the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA itumne Caverage verification.
/do hereby cast ala+rlwl ulwt rho lnjoraraaww "Y'Ad p above is aw and eorroes
Phone At r7 5� 2 �- z/' /`]/
r"onarrd
af art-oaiyt De am wrke la aibt arra,la be Campka d by cltr at/oww o,QTe4d
r Town: Permit/1 leease it
Issuing Authority(Ci role one):
I. of Health 2.Building Department 3.City Clerk 4. Eleetrleai Inspector 3.Plumbing Impeetor
e
Contact Person: Phone S•
information and tt<strucuuu3
�assachusem Genaral Laws chapter I S2 requires all s:mploYM to provide workers' compe�OO fa their emploYtss
pursuant to this Stan^an a"pbj'p
le defined as"..Avay person in the service of another under any Macrect of kite.
express or ismPUA oral at writsm
assoeiaria4 Car" or other legsl eOi'er l Y two r more
Aa ewpfeYp le dOftn°d "an individual,pseao�dP incheding the� �of a dew�°���doe
er the
of the fmregomg a m�v,"pernordelp. n or aher tent e»btY.Ca Pleymgdse of the
roeeiver or trusty hones baviei sot Mora then eleee and who resides therein.
wodt m aa� hOum
o othouae amths who empbys P m do no becsou. °o°err m be sa emPIOY�"
cc oa the irotnWs er building appurtenant thtsxte shall mot because�stacb employment be demoed
the
Instance
MGL chapter 152.12=6)also states that"tee state ss local gteasti[apaeyte W�r �MW
reaewal of a meson or Perm&to Operate a budras or to eoafh'"d balldla0
saaptaw oviasaa of eospgaaee wide the howas" shaLL
aP 'M� Pnot� 1 42SCf nsum"1tQ1 do COO°woes e�of compliance with do invau ee
eater into any contract for the pnfamsau otP�c worktil'die conuacUng J
requkemgma otthis chapter httw b"aaa prermted
chwidog the boxes that apply toyour'wsdca nerd.it
planes fill out the wodrars'compensation affidavit eomPo filly s with that u:ti8eate(a)of
necessary.„may�.conOw r(a)�as(I L Q Looked LiaMlity Partnerships W.P)wide no empkycn other dun the
mambata eror parosas,ace not mTAmd itY m�wceseposent �IIanoe It a ep u LM don have
Of Industrial
e enebo ei•s INUIOn s as advised doer this affidavit aaaY be sebmitted b the Deparsmeat
Policywarp AIM be seem to alp and dab the sfAdavlf. The affidavit s6�d
,accidents far 000&matico of k a once ��P�a license is being requested,eat the Departo�
be returned to the city err town that dhe apPHOaeion the law a if you are required to obtain•workers'
Industrial, Accidents Shotdd you have any gtrook regadias
compaoestioa policy.plea"eaII the Dapnsmaat at the number Hesed below. Self-unused companies should enter choir
self imaeaaea license nttmba tits the
Hue+
aq or Town Offaeiab has provided s e d the botsom
please be sure dent the affidavit is wruplete and punted!eg<bh'' ThuOnt
of the affidavit for you to till out in the event the Office of Investigations has to contra you regarding the a applicant
number which will be used tee s refeseace number. In addition.an applicant
please be sure to fill in the pamitAiceme applications
in any given yen,need only submit one affidavit indicating cutrent
that must submit multiple PamtNicenso slap toe applicant should write"ell locations in-�—�OitY a
policy intacrostioa(if necessary)and under"Jab Site Address"the
marked by the city or taw may be provided to des
town) -A copy of the affidavit that has been otIIciaHy stamped err licensee Anew AM&vu maul be filled out erOk
applicant so proof that a valid affidavit is on file for Amen pub , stet related to any business of commercial venomar.Wheb a house a e owner or citizen is obtaining a license Pew
(i.e. s dog license or Permit to bum leaves ate.)said parson is NOT reqcitsd to complete this affidavit
The Office of investigations would like Indunk you in advance for your cooperation and should You have any gttesao04
Please do no hesitate b give us a call.
Then D �s address.telephone and fax umber
The COMMMWealth dMatisst hIMft
otb&Sl W ACCidentl
Off1a of tbvadgedod
600 WIAM91M Sked
Bad^MA 02111
Tel. #617-727-4900 Old 406 at 1-877-MASSAFB
Fax 617-727-7749
Revised 5-26A5 wwwjm&s Vv/dl&
CrtY OF SAtam
PUBLIC PROPERTY
DEPARTMENT
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