18 FREEMAN RD - BUILDING INSPECTION EI`ECPR
PUDTMENT
KI.%(gEN.EY DRISCOLL
MAYOR 120 WwfING170N SrnEEr•SAIEW MANSACHLSka-IS 01970
TM--978-74S-959S*FAIL 978-740-98,66
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION eeib
Location Name: Building: �• ,
Props f Address:
property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: hi 4�L5 i R7ta(_
Address: .
Telephone: - g 3 3 �t7t
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING 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: 1 (
�lel� �hSl�ti:T\G� MCA vl�✓'• ✓--
00M e
Mail Permit to:
What is the current use of the Building?
Material of Building? !o c'-, if dwelling, how many units?
Will the Building Conform to Law? Asbestos? 1'LO
Architect's Name
Address and Phon .2 i"c e ST ( )
Mechanic's Name «
Address and Phone
Construction Supervisors Licensee# HIC Registration#
Estimated Cost Pr ' $,Ans J G Permit Fee Calculation
Permit Fe Estimated Cost X$7/51000 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 rocessing.
The undersigned does hereby apply for a #Pe * the tat
specifications. Signed under penalty of pe -
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it
ass I
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xnraratE,t oasscou
a AYM VA9C1arMSraW s SAlr34.MwseaanrsgM01970
Tttr.:WI-745S9595 a Fex:978-740.1
Woriten' Compensation Insurance Affidavit Builders/Contraeta"Mee)z'(eian a/platit
A information
ben
Please Print
Name(Busine:ti
Address:
City/State/Zip: � :(4, VG y S Phone
An You o employer?Check the appropriate bossType/
1.0 I am a 911 general contractor and I of ect(required):
employer with 4. am a
employees(1111 and/or part-time).• have hired the sub.coneraaosa 6' COO OII
2.F6ri am a Sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These subcontractors have I. 0 Demolition
working for me in any capacity. workers'comp,insurance.[Qow r en'comp.imurance 3. 0 We are a corporation and its 9. 0 Ong addition
otltcan have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of conniption per MOL 11.0 Plumbing repairs or addidonu
myself.(No workers'comp. c. 152,¢Ρ1(4),and we have no
insurance required.]t employees.[No workers' 12.0 Roof repair
C00p inalrsaro 13.0 Other
;Any aPptkam do dweb bes et moil des aI am dw&I blow tmwin ark watts'ampo"do I DekY tasamaba
r ttaorowaam wie submit uis sMdava kdkaing dwy m doing aI wadi sad em ties omids omasesas most mbma•ear dRdwa ties,
C et oatnom dm ehaet this box mat awebad an sddtdeaal ibis dmdag tie aims otdo subssmaetam and ark warbts'oomR Ply iel6�msaoa -
!n m ax ems er that it providhq workers'comps atedon inserowe%r nay employsea Below b the policy andJob mm
lsiar
Insurance Company Name:
Policy N or Self-ins.Lis tY Expiration Date:
Job Site Address: City/StatNZip:
Attach a copy of the workers'compensation policy declaration page(showing the
poBry number and explratlota date}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the
fine up to S 1.500.00 and/or one-year imprisonment, imposition W criminal penalties of a
y prisonment,as well es civil penalties in the form of a STOP WO ORDER and a tine
of up to 5250-W a day against the violator. Be advised that a copy of this statement may be forwarded to�OtAce of
Investigations of the DIA for insurance coverage verification.
I do hereby card antler and n /pe th t 1 fib?Telexprovided above/s bIw and correct,Ix' Darew — GG
Phone 3 3v2(�q
U,Q?clal are only. Do not write G th4 area,to he completed by elq or tows o letal
City or Town: PermltlLkeass iY
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cilyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone 1t:
Information and Instructions
Massachusetts General Laws�chapter 152 requites all employers to�ovide workers' compensation for the service of another under ir=PIQY*eL
any ontract of Lice.
Pursuant to this statute.an emp&/--is defined as"...every person
express
Or implied.sal of wriVAIL,
association,won or°�legal�'or any two a more
An sspfoyer is defined as"an individual.part as R till le, moves of a deceased employer.or the
of the foregoing engaged in a joint entapris� ssie c udin or other legal entity,employing�ploy�' However the
receiver or trustee of an indtvtdual,partnership, and who etity.c P10 *n.or t 0 otxupaut of the
owner of a dwelling honsa employs persons m do ro memsoce, On or�wodr on such dwelling beats
dwelling bouse of mother thereto shall not because of such tkSymem be deemed to be an employer'
or on the grounds or building appus�
Or
MGL chapter 132.$ZSC(6)�o stance that"ate state or{Deal lkensirrg �sW withhold fa thin eom s ��ow
to operate a business or to eons co'
required,"
sppaeantf&ikesse or permit who has not produced acceptable evidence of eompgaace with the insurance shaft
Addidooally.MGL chapter 152.$ZSC(n stela"Neither the commonwealth nor sale of its Pow subdivisions the mauance
contract for the of public work until acceptable evidence of comp
ent of this chapter have beonl to the contracting authority:'
requirements
Appile>ute the boxes that apply to your situation and.if
Plesss fill out the wodcers'cOmpmsem affidavit completely,by ��
address(es)and phone number(s)along with their cestifieatda)of
necessary.supply y�eon(}aeton(s)nsme(s),
(LLB or Limited Liability Partnerships(L1-P)with o employees other than the
insurance. Limited Liability Companies members partnam,are not required to carry workers,compensation insrrance. an LLC or I I P doe have
es.a policy is required that this affidavit may be submitted to the Department of industrial
empbw. He advised
Accidents for confirmation of insurance coverage Alps M son to alga and date the aestrA L The affidavit net the DeputMCW of
be returned to the city or town that the application for the piths la Of w e s if yis at�are required
�� Should you have serY goons regarding to obtain a workers'
comps industrial lase call the Depmrtn►mt at
d number listed below. Sell innued companies should eater their
compensation policy.p
Self-invxana license fiber on the
City or Town OPlidad e at the bottoms
please be sure that the affidav it is complete and printed legibly. The Department has provided s spat
of tie affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the appHcanL
Please be sure m fill in the permitllicenne number which will be used as a refacnee number. In addition,an applicant
lications in any given year,need only submit one affidavit indicating current
that must submit multiple permiMicanse app
)and under"Job Site Address"the applicant should write"all locations in c or
policy information(if necessary
or marked by the city or town may provided
town)."A copy of the affidavit-that has been officially stamped or licenses. A now afudrvit must be filled out each
applicant as proof that a valid affidavit is on file for fiuure permute tat related to any business at commercial ventureyear.Where a home owner a citizen is obtaining a license or Permit
(i.e. a dog license or Permit to burn laves eta.)said person is NOT required to complete this affidaviL
as would like to thank you in advance for your cooperation and should you have any questions.
The Office of Investigaao please do not hesitate to give us a call.
no Department's address.telephone and fax number.
The Commonwalt6 of Massubusetts
DV ttineM of lnfiunW Accidents
Owes of 1avgNgafloas
600 washing Street
Bantus,MA 02111
Tel. #617-727-4900 Wd 406 or "77-MASSAFE
Fax N 617-727-7749
Revised 5-26A5 wwwaws gov/dia
• ,O � ��N�.ti J
MAR Lk Lo T Z? `c
CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION
CERTIFICATE OF OCCUPANCY /
LOCATION: f�«1!/ qC� DATE
APPLICANT:
ASSESSORS I�c-/C.��L
FRANK KULIK DATE: �(�)�-' C7(o
(93 Washington Street)
CITY CLERK / j -�6
CHERYL LAPOINTE DATE: �D
(93 Washington Street)
PUBLICS SERVICES
BRUCE THIBODEA - DATE:
(120 Washington Street)4 o0
WATER
DOTTIE THIBODEAU DATE: 7/ �J
(120 Washington Street)46 Fl r
CROSS CONNECT SUPERVISOR !�
-BRIAN-FHBAHEAU "DATE:
(5 Jefferson Avenue)
PLANNING
DATE:
(120 Washington Street) 3n0 Floor
CONSERVATION COMMIS4ION
j -C"*f DATE:
(120 Washington Street)s-P16or
ELECTRICAL
JOHN GIARD[ DATE: / 6
(48 Lafayette Street
FIRE PREVE d
ERIN GRIFFIN `y[/C>t_ _. ✓Cc_--� DATE: IG �7 6G
(29 Fort Avenue)
HEALTH
`,c ANNE SCOTT ` . DATE:
(i20 Washington Str t)4'Floor
BUILDING Q
p THOMAS ST.PIERRE DATE:
(120 Washington Street)Yd Floor
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