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190 FORT AVE - BUILDING INSPECTION EI`Y-OF SAL -- r' 1�OG'07 PUBLIC PROPERTY Q 6� DEPARTMENT KISWFR SY 13RLSCOLL �`":x 20 tJ MAYOR 120 WASIUNGMN NrREEr•S"LLW WAAACHLski-M 01970 'tft 97&74S-9595 0 FAx:978-740-9816 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: 5A,d1^+ t "'"ws "4r Caw Building: Property Address: p a Z t Pj W z. S/-L a.,� m Property is Located in a; conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2A Owner of Land LIL A,,- i PA4Z K e Name: e Y v- S N .a_w ait'l Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING? BUILDINGS ONLY Addition Existing Renovation (�,A "z r" Number of Stories Renovated ©mv- Change in Use !S,roft New Demolition Existing Approximate year of �P�`� Area per floor (sf) Renovated construction or renovation je 0 S New of existing building Brief Description of Proposed Work: R?Z- PAIL 7-kF2 SI�� Oe 'THE I sTvnY W06 'q 'F'2.4r-� CLIAs (Gault 6 -r4k- �i4� 1 � W1�LGLV7 yl4CltT C J p,/L T" fa a /L � le Te 1J� r'D0.2 CO,TLf CLLte, Mfcwt3-4r2S • - --- Mail Permit to: -e I-. U,a-11k5 1 X 1 i-,+1 2 0"A U W r 5-• i J At_mod^ N 04 e-l ? o — What is the current use of the Building? L U 3 R o U 5 Material of Building? Ij v v—0 If dwelling, how many units? _ Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone Mechanic's Name Address and Phone Construction Supervisors License# C S m7?f �HIC Registration# Estimated Cost of Project$T a Per ft Fee CalcuWbn Permit Fee$ Estimated Cost X$71$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 ate I d t b CD N ,R N Y «. a a Vo v CITY OF SALEM PUBLIC PROPERTY DEPARTMENT wa��osts�vu NAYOa 120 W SrWM•S,ur,K NAtSACiu:Sh'1'rs 01970 Construction Debris Disposal Affidavit (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code,780 CUR section 111.5 Debris,and the provisions of MQ,a 40.3 A Buildins Permit 0 is issued with the condition that the debris resulting ftm Na wort shall be disposed of in a ptvperly licensed waste disposal beility as dented by MQ.a 111.3 130A. The debris will be transported by: L U ('i Wgi .tA`'ice 2 ez S (samea[h""d The debris will be disposed of in: kv lz r-6F S t y9 L ` A ez-r /h(4 /I-(C (namt of facility) I Z S W a4 sn (T S C oTT�D (addrm of facility) F sitlnaturo o/permit app ' gait _ILIIf 3r/4;�100 C dais •.�trri..arr�e CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KAfaER1EY DRISCOLL MAYOR 120 WASH24GTON STREET a SAL EM.MASSACliUSEM 01970 Workers' Compensation Insurance Affidavit Builders/Contractors/E1ecp(cians/Plnmbers Applicant Informatio Please at Le Name (Business/OrganiEa60 dividual fL h x t~ //.tiI S At v bL Oq t-t Address: i,rL u :z C S d f 86 P 3 City/State/Zip: e-,7 Phone Fam ployer?Check the appropriate box; ployer with 4. ❑ I am a general contractor andITypeof project(required): es(full and/or part-time).• have hired the sub-contractors 6. ❑New construction le proprietor or partner- listed on the attached sheet t 7. ❑Remodeling have no employees These sub-contractors have for me in any capacity. workers'cot 8• El Demolition [No workers' comp. insurance 5. El We are a corporation insurance.ration and its 9• Building addition required.]3.[3 I am a homeowner doing all work officers have exercised their 10.❑Electrical right of exemption nP�or additions myself. xemp Per MGL 11.❑Plumbing repairs or additions [No workers comp. C. 152,§1(4),and we have no insurance required.]t employees. [No workers• 12.0 Roof repairs GIoRK To e C Jt uB comp. insurance required.) 13.f4 Other S t ,a A4 vz. ;Any applicant this ehecb tan et must abo fill om the aectlm below showieg their woken'compeaytmn Policy ' onOmM i that who submit this afAdevit mdiatina they an doing all work and thmm hue �f'ieforntstios Coxtraeron that cheep this box must attachod an additional sheet ehowin e11Wd0 Coo"'I'm m�submit a new at8devit nub.g the name of the sub coerraeron atd their workers'comp•policy wuma ims. i fo a a employes that Is providing workers'conrpensadan insurance jor my employees. Below is the polley and fob site injarmatlon. Insurance Company Name; Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form im STOP WORK al penalties e a tied a of of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and enalttes o jperfury that the information provided above it Si na true and correct Date; 161 f6 Phone $- Y - �e3 F6. cial use only. Do not writs in this area, to he complaed by city or town ofjTciai or Town' ng Authority(circle one): Permit/License# ard of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector heract Person: Phone#: information and instructions ter 152 requires all employers to provide workers' compensation for their employees is defined as"...every person in the service of another under any contract of hires: Massachusetts General Lava chap .. pursuant to this statute,an employee express or implied,oral or written.„ two or more is defined as"an individual,partnership,association,corporation or other legal entity,or any Xn ed in a joint entapriso,and including the legal representatives of a deceased employer,or the employerto employees. However the of the foregoing engaged a Partnership,association or other legal entity.employing receiver or trustee of an individua4 than three apartments and who resides therein,a the occupant of the house owner of a dwelling house having to ee mainte°ance,construction or repair work on such dwelling dwelling house of another who employs personsof such employment be deemed to be an employer.„ or on the gro unds or building appurtenant thereto shall not because en shall withhold the Wtnnee or states that"every state or loyal trust buildings g ag cY mmoswes"for say MGL chapter ice a or p)also Operate a business or to eoostract heis the co „ renewal of a license or permit to arc produced acceptable evidence of compliance with the iasof°�coverage subdivisions shall applicant who has not p with the insurance Additionally,MGL chapter 152,§25C(7)states"Neither the com t evidence of compliance enter into any contract for the performance of public work until acceptable resented to tha conaacting authority.. requirements of this chapter have been p Applicants cking the boxes that apply to your situation and,if Please fill out the workers' compensation affidavit completely,by chees and phone numbers)along with their certificates)of 1 sub-contractors)name(s),address(. ) s LLP)with no employees other than the accessary.supply Companies(LLC)or Limited Liability Partnership insurance. Limited Liability mi . to carry workers' compensation insurance. If an LLC or I does have members or partners,are not Irequired Be��d that this affidavit may be submitted to the Departm e'Mtrial employees,a policy is required be sure to sign and date the affidavit- The affidavit should Accidents for conformation of insurance coverage• Also be returned to the city or town that the application for the permit or license w or f being requested,ou are requreedto btaaiin a workers'ent Of Industrial Accidents. Should you have any questions regarding below.ySalf tasured eompumes should enter their compensation policy,please call the Department at the number listed self-insurance license number on the a City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has Provided a space at the bottom the a licant. to fill in the permidlicense number which will be used as a reference number. In addition,an applicant of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding PP Please be sore application'c any given year,need only submit one affidavit indicating current that must submit multiple permivlicense „the applicant should write all locations in (city or policy information(if necessary)and under"lob Site Address PP the city or town may be provided to the m):` A copy of the affidavit that has been officially stamped or marked by tY applicant as proof that a valid affidavit is on file for future permits or liccnese A new at7,drvit must be filled out each related to a year.Where a home owner or titian is obtaining a license or permit not any business or commercial venture (i.e. a dog license or Permit to burn leaves etc.)said person is NOT required to complete this affidavit ou in advance for your cooperation and should you have any questions, The Office of Investigations would like to thank y please do not hesitate to give es a call. The Department's address,telephone and fax number Thor Commonwealth of MassachusettS Department of Industrial Accidents Offlee of Investigation 600 Wasbington street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-2"5 www,mm.gov/dia