19 HARBOR ST - BUILDING INSPECTION tITY-OFS-A E --
PUBLIC PROPERTY
DEPARTMENT --2fe-o
KIMBEJLLEY ORMCOLL
MAYO& 120 WASHINGLON N REEr•SALES,MASSACHl5 I-M 01970
TEL"978-74S-959S 0 FAx:97&740-9846
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: Building:
Property Address: I G /)A"O f— s 7
Property is located in a;Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: '39 7 1
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 (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
-- Mail Permit to: '� Gf�UR��f G � Inn • _-
What is the current use of the Building? CONDO S
Material of Building? /34kAe— If dwelling. how many units?_ _
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone l )
Mechanic's Name �I/BUiAbr /rlla` /�/�
Address and Phone %Y G q V g-ck S T 64W )0/ll M14- QzO 21
Construction Supervisors License# HIC Registration# S 3 29
Estimated Cost of Project$ 2 +o0 6•00 Permit Fee Calculation
Permit Fee$ J G �O 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 Permit to build to the above stated
specifications. Signed under penalty of perjury x� �
Date 2 2�
on
\ N
r
—_.---
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KntaEat.s,r,)a6coLL
MAYOR 120 VA204GMN STUU•SAt Est,MwtsAc}st WM 01970
TEL 97L745-9595 •FAX-V8.740-9sm
Workers' Compensation Insurance AfffdaviC BnIIders/Contractorsmeetridana/Phunbers
Applicant Information
please R^ln*a egibty
Name lBuaineaetorganvatiadlndividualy A1&W A&E A%4-t O'/1/AV
Address:- �e( G gV/-.GIV ST
city/State/Zip: l 4wYvAl M ff 7 9—fr s`/2�7�/ - 7 e, �l�
Are or an employer?Check the appropriate box:
1. I am a employer with 1 _ 4. Q 6. ❑I am a Smug coatsactor and 1 Type��J�(required):
l New constructionion
employees(&U and/or pamume).• have hired the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet,t 7. ❑Remodeling
ship and have no employees These subcontractors have a. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
(No workers'comp.insurance 5. 0 We am a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or ad"ona
3.0 1 am a homeowner doing all work right of exemption per MO L 11.0 Plumbing repairs at additions
myself.(No workers' comp. c. 152,§1(41 and we have no
insurance required.)t employees.(No workers' 12.❑Roof repairs
t sump. insurance required.) 13.�
'may applicant dot docks boa NI mat.reo eu as k6a andos below Anw�dab wakow.eampmmda s Policy m
Homeowans who stash dds atadevb mdl—W day m doing as west and din him outride em6e00110 an"udkmb a am afildork indicating tuof<tConuamas dat check dds boa mad atuehod an addidoml than dlowmg as am"of des and drtrwarlose.camp PORGY fidwouma
1 an an employer that Is providing workers'compensadon insurenee joy my employees Below Is the poUey and Job site
injormadioa
Insurance Company Name: D M L'N 170S .
Policy#or Self-ins.Lie.M: / x 3 2-1 / Expiration w Date. 1 / /
Job Site Address: l it t A- � City/Statcaip: 4A-t V" M4—
Attach a copy of the workers'compensation policy declaration pane(showing the policy number and expindon dab).
Failure to secure coverage as required under Section 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 3250.00 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 voerification
f do hereby cerdA under the pains and n l&s F PuY that the injormadon provided above is&w and correct
Z O
Phone#: 6l7
Qafeial use onIA Do not write in this area,to be completed by city of Iowa ofyld4L
City or Town: Permlt/License M
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.CityfTown Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone*
information and;instructions .
compensation for t
IOYCOL
us General Laws chapter I S2 requires all employers to Provide workers' their
hue.
pursuant to this sutum an emPfoY"is defined as"...every person in the service of another under any
express or implied,and or wnttan." ny_Or_
an individual.Partnership-anneal'corpOrsm04 a orbs legal entity.a 10 ar,a the
o f herptoyw is defined as and incltuding the Iegsl representatives of a deceased employees.
emP Y
of the foregoing engaged in v joint euuap�+ association a other I entity.emP �Y w the
receiver,at trustee of partnership.then�� I resides of the house
owner of a dwellingmetaratiancei.coosemenne a repair wodt m such dwelling
dwelling borate of smother whe employe Persons
� shall not because of such employment be deemed to be an em1110Yar."
or on the grounda a building appurtenant
MGL chapter 152.12SQ6)also states that every state or leed Heeaaing agsacy abet wlthkold the Wntma or
too a business or to eonstrua buildings is the emnmoawesltk for say
reaswal of•Reese or permit Mee pteP�y avl&=*of eomptlsaes with the Wennee coverage required.
appocant wire hu°Ot p<eudneeui stares"Neither the commonwealth nor any of its political subdividow shall
Additionally.MGL chapter 152,$25C(n �, y,he work until acceptable evidence of eomplisnca with the imunnce
enter into anyfthis contract forapt the performance public the conaacnng audiontY•"
requiretnmb of this chapter have been �
Applkaab
affidavit completely,by checlmag the boxes that apply w year situation and,if
please fill out the r(sco won s), (es)and phone number(s)along with their catiRcatt(a)of
necemary.supply
Abcorim Liability Companies(LLC)or Limited Liability Partnerships(LLP)if an�or LLP does hav employees e
than the
insurancemembers or partners,are not required to carry workers compensation inauranc°•
a policy is required, Be advised that this affidavit may be submitted to the Department of Industrial
employees. of insurance coverage. Abe be sum to alga and date the afWsvtL The affidavit should
Accidents for confirmation application for the permit a license is being requested,net the Dep�e of
be rettuned to the city or town that the app ' regarding due law a if you are required to obtain a worker'
dustrial Accidents. Should you have any qua
ompennstion policy.P can
the Depart�number listed below. Self-insured companies should enter their
self-hmsmamx Nemec number on the
City or Town O81daM
Please be we that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
to contact you regarding the applicant.
of thus affidavit for you to fill out��number whichhe event the �of
be used as altt aence number additio an applicant
Plesse be sure m fill in the petmi in any given year,need only submit one affidavit indicating current
that must submit multiple pernn*vhcense�applications Job Site Addrsnt"the applicant should write"all locations in_—Jcrry or
policy information(if necessary) or marked by the city a town may be provided to the
town)."A copy of the affidavit that has been officially stamped r filture permits a licenses. A new of idt vil must be filled out each
applicant as proof that a valid affidsvm is on file for
license permit na related to any business a commercial vennme
year.Where a home owner a citizen is obtaining complete this affidavit
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to
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 us a call
The Depacmnent's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
O®ea of InvadEadons
600 WashinQtou Street
Boston,MA 02111
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 wwwA=mSov/dia