11 FREEMAN RD - BUILDING INSPECTION (3) f�
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensadon Insnrantit Atlidavit: BulIdea/ContnetorsMeepidan&j%esbera Apodcant Infolrmadon
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Address:
City/Sta omp: ,1i111 / Q�7 . Phone#: (P S7-
Are you au employer?Casek the appropriate boat
1.❑ 1 am a employer with 4. 131 am a peneal Contractor and Irs-
otprojeet(regalroo.
2. 1 am a Bole cooployces(!hB aoNar pact time).• have hired the wb wmrcton Ne7caueuctim
proprietor a parmeo- listed oo the Machad sheet,t g
ship and have no employees Theseworking for me in any capacity. workers' �w
Q workers,Comp.insurance 3. Q Weansden end io add�m3.�] I am a homeowner doing aB work right of ration ped their schical repairs a addidens
myself. per MOL 11.Q Phtmbing repair or additions
Y [No workers'comp, a 132,41(4),and we have no
insurance required,)t employees(No workers' 12.[3 Rw!ropsim13.❑Other
�inrmanoe ns"ired.]
t Hmror WIND svhma tide r now iald w andoodom a"ow aim its our due ssetlaa bdow showing their walls'rampomdpe try tstbrmalae
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one ae sarPloyer the#IsP providing workers'cowPsaaodlejo►watow Wureecs/o'r0 b`0e°s`ro01 sod ratans'•amP Pa1hy lnAamssaa
my earployrea Below 4 thsPo147 eelJol sMs
Insurance Company Name:
Policy N or Self-ins.Lie.N
Expiration Date
. Job Site Address:
Attach a copy of the workers'compensating Ciry/Stata/Zip:
Pa Policy deeof atlou pap(she the PONCY number and ea Failure to secure coverage sa required under Section 2SA of MGL a l32 can lead m the' t�doa fine up to f 1,500.00 and/or one-year imprisonment as well as civil imposition°f pO1�daa of a
of up to 5250.00 a d. a penalties in the form of a STOP WORK ORDER and a lice
Y Brost the violemr. Be advised that a copy of this statement may be forwarded m the OflfCe o!
Investigations of the DIA for insaraoce coverage verifcapoo
I do hereby cerdPV dsr As Pains and penaiiia o/Prrfury that the IQ o
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Phone
OJJklal use on Do no
t of write In thb sre4,to be eoapfstd by c/ty op town oQklaL
City or Town: Permit/Lieemt N
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cityt'rown Clerk 4.Electrical Inspector S. Plumbing Inspector
1 Other
Contact Person:
Phone N'
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
MAY ORhO111.
120 W.;it-nvG ONSCRHET •Saws+, Mnsi:u:luscI1S 0197:
Tn.:978-745-9595 ♦fax:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facthty)
(address of facility)
siguatuc of perm, ,pt ant
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PUBLIC PROPERTY
\ DEPART141E�1T
KINSM.Ev DIscwt
MAYOR 130 WwuN GTOPI 5MEEr
SAI-EK Srtis.�au;stI'rs 01970
Tm 97S.745•gS95•FNC 975.740.98"
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Narne: Building:
Progeny Address: — - - --------- -- - -
l ee�1 --- —
Property Is located in a;Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: co
_
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FYICTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (SO Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: r
�SUIlal bear dzc,1 16, X/i0 '9��
�c,.rtice,
Sl-u it s .
— - -- Mail Permit to: --
What is the current use of the Building?
Material of Building? If dwelling,how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone d S (vaj��yy sz vs
Mechanic's Name
Address and Phone
Construction Supervisors License# /) SS9 D /L_HIC Registration# l
Estimated Cost of Project S te'°' Permit Fee Cftlation
Permit Fee$ Estimated Cost X$v$1000 Residential
Estimated CostX$111$1000Commercial
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
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