4A HALSEY WAY - BUILDING INSPECTION e E � ..
f PUBLIC PROPERTY
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UM
APPLICATION FOR THE.REFAiR. RENOYATI'` N C,ONSTRLICTION ,
D£MOLITION.:OR CAANC�E O l�1SIto
R OCCUPANCY,;FOR AN=Y ) STING;
U `STRU�TYJRE'OR-Bi1ILDIN`G
l.ocatlon tVamr: 0./1 C Building
- any
Address-
Omp Ie boated-In a:ConservatlomArea Y/N: Hlltaric:Dt trkt YM
].0 GWNERSHIP'INFORtaA/1TION
?�a Owner=of LanO
Address 41�
x1+, , I'}'1 t) ►R T o
Telephoner
3 0 CCMPLETB THI$ SECTION FOR'1fVORKAN jp(g T ura BUIIDINGB:ONLY
Addition Ez(ating
Renovation Number of`"Stollee ` Renovated
Change In Uss New
DernoliNon y Existing
Approximate-year of Area:per floor (4n Renovated
Constructiomor"renovation
Of existing building. New
9del Desption oFPr sed Work: oV� .tom
('&c + c-vKase
Cvl�� Cc�Se. �s'1A�'
b"
A
ub
Mail Permit to
what is the current use opf th�e•Bu}ding?
Materlai,of Building? 1
�10PI If dwelling,how many units?
Wo the Building°conf&m,to Law?
Asbestae?-
Architect's Name
Address4nd'-Phone ( )
Mechanic-s Name
Address and%Phone
to ���w.on� mP��rt�Str 1l�147
Gonshuction Supervisors Liventte'# - 3� HIC.Regisfration# I
Estimated;Cost of Prajed S
Perml Fee.Cah%aWtibn
Estimated Cost X S7/S1:tX10 Redidential
An Additional oo"OO isadded'=a$tth
Administrative gharge
Make sure=that ali flelds.are properly and'•legibly.wd ten to avoid delays;In processing:
The-undersigned does hereby apply f(*a,Building�P/ermft'to build to the above stated
speciflcaflons. Signed under penally ofperjury
D'ate'' b
of
ee N
3 syC V
•VL '�
CITY OF S.1LEM, ANSSACHUSETTS
BUI DING DEPART%(EINT
120 WASHINGTON STREET, Yo FLOOR
TFL (978) 745-9595
FAX(978) 740-98U
KI%IBEP- EY DRISCOLL
MAYOR THoitw ST.PlIEM
DmECTOt OF PUBLIC PROPERTY/BUILDING COSMISSIONEIt
Workers' Compensation Insurance Alfldavit: Builders/Contractors/Electricfans/Plumbers
Antillcant Information . Please Print Leeibly
NalnciBusimvOrpniruiomInarv,d")!
Address:
City/State/Zip: o MA- _ o21Z Phone 0:
tr ou an employer?Check a appropriate box: - Type of project(required):
1.XI am a cmployar witb 4. ❑ 1 am a general contractor and
employees(full and/or part-time)." have hired the subcontractors6. ❑New construction
2.0 1 am a sole proprietor ar partner. listed on the attached sheet : 7• ❑ Remodeling
ship and have no employees These subcontractors have s. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.) otree:rs have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[Na workers'comp. c. 152, §1(4),and we have no 12.❑ Roof re irs�
insurance required.)t employees. LNo workers' 13.®Other O O
comp. insurance required.)
-Any applicant thin eitRb boa Of MUM also fill out the lectim below showing their work='compensarhm Pulse r inrurmadim.
'I h,meawrwrs who submit this aRldnvit indicting they»doing all work and then hire outside coming xs MUM submit a time,anidavil indieaunt;such.
:r,momu on that check this box mud attached an additional slur showing the some of rile sabNnrrins,"and their workers,ramp.Policy inl rmaaon.
l am as employer that Is prwviding•workers'rompentadon lnsaranee for my emplayeer, Below is rile policy and Jab site
information.
Al
Insurance Company Name: ' -1 Cp ^J pT �
Policy N or Self-ins. Lie.
Expiration Date: g 0 (�'
Job Site Address: ETC k�� f City/StarNZip:� a\A—(—
.mach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to secure coverage as required under Scction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. lie advised that a copy of this statement maybe forwarded to the Office of
Invcsltgatiunx ahhe nIA for insurance coverage verification.
l do hereby cern#murder the ins and penalOes of per/any that the information provided ove is true and carrect
�ienuure: t f/ �` r I)atet
Phone ti:
Official use anly, no :of write in this area, to be cunmpleted by city or town a/ftciati
i
City or ruwn: PermM.lccmeq__
Issuing.%ulhorily (circle one)-
I. Ituard of Ileallh 2. Building Department 3.City/Town Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
Camtact Person: .. _—. __ Phone c
' CITY OF SALEM
PUBLIC PROPRERTY
�-� DEPAR"I'MENT
III •r'.v.-r:.-I:.,: � I \c s'v v_ "u •
Construction Debris Disposal .affidavit
(required l'ur all demolition :old rcnuvmion \voi k)
In accurnlance \\idl the sixth edition of the State Building Code, 750 CMR section 11 1.5
Debris, and the provisions of%IGL c 40, S 54;
Budding Permit H is issued with the condition that the debris resulting from
this work shall he disposed of in it pruperly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
I name of hauler)
I lie debris will be disposed of'in I-I
(name ul laer fly)
H'r
LIJJrc<. ur IJcililVl
.ICIIa InIc of pinnit al+plic ant
b ( 01
.lale
e
.L.' �I;astcluisctt. -
� Department ill*Public Safety
Beard n1'Buildin" RcInlaliuns :tnd St:tn(laros
Construction Supervisor License
License: CS W97
Restricted to: OO
TIMOTHY J FINN
8 VALDORA DR/PO BOX 53
STONEHAM. MA 02180 �
Expiration: $/y2011
unrer._._ . 1540O