3 HAWTHORNE BLVD - BUILDING INSPECTION (2) What is the current use of the Building? Ply Pti
Material of Building? If dwelling. how many units?
Win the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone 5 7�e e Gi +, Tw Cz ( I
Mechanic's Name n" t��a,
Address and Phone / l�"�HOUSi�7f',
isors License# HIC Registration#
6 3 9S _
Construction Supery 97
rt Estimated Cost of Project S 0o ao Permit Fee Cfttation
Permit Fee$—H-1-00 Estimated Cost X$7/57000 Residential
Estimated Cost X$t 1/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
I
Make sure that all fields are property 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
Date
II
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- CITY-oFgALEN -
PUBLIC PROPERTY
DEPARTMENT
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�(AxaR 130 W&UUNGUM hnFEr• '
5'�NnstaCHlsti'15 01970
TM-976.745-9595• FAX 97s.740.96K
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:
Property is located in a; Conservation..Ares Y/N H"Wic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: 3 7 LAB y i✓�><� S
N-7/-.;. 01,920
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXIRTtNC2 BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of ' Area per floor (st) Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
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------ ------- ----- -----
Mail Permit to: (Di-9GC,
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What is the current use of the Building?
Material of Building? If dwelling. how many units?
win the Building Conform to Law?
Asbestos?
Architects Name
Address and Phone s�? e C� " °'���( )
Mechanic's Name
Address and Phone l�vG"
Constnution Supervisors icense# CD-Z3 yz _HIC Registration#
Estimated Cost of Project i v. vo Permit Fee CalwWW
Permit Fee S '�� Estimated Cost X$7/$1000 Residential
Estimated Cost X 511151000 Commercial
An Additional 55.00 is added as an
Administrative charge.
Make sure that all fields are property 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
Date /- ;L-07
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9 r
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C6y 4
i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
W AM
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Tn.IW4649M•f.%*IW4600
Construction Debris Disposal' Af 1davit
(requinal far all danolition and munation wort)
to=anlattee with dw sixth eadan ddw Stste Huildins Cade,7SO C1612 section 111.5
oawi4 utd the provisions of NGL a aQ S 54
9wld1%Pamb 0 _ is lsswd with the eood[tioa dlat the debris resultkg ffM
ibis wat shall be disposed of in a property liceesed waste disposal tbcility as dented by WL a
t11.S15"
The debris will be transported by:
laaaw of Mato)
rhedcbds will be disposed of in :
Marne ui fx�tny)
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CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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LL\Yl>• in W&*v::%aW t S=M a fA
um 1geLwaytn's0tlTJ
Tw.97L74S."% a F.\x:9707e0.9ae6
Workers' Compo wadon Inurnaee AAWevita Bwkk s/Coa&actsraMleaddsasn%mben
aoalknot Informadon Mesa nine a eg`
�lametut.�aesrorw;:,t;avinJl.rh.p: ('t7h-,rr•, r�vC• S C• r9•�.�57`rlc7c.T�.�. I.�—L
AJdrm
City/StaZip: l�Eia (�o / w��n•J . oi9Gol�oae N_ 4�1T L,
Are yes as awplsywt Cheek the appropriate host
am a employer with 4. [31 ant a Seentai contracts and 1 *type orpro)eer(rM�
(roll Wnl/nr purwime).r have hired the Ad)-contractors tractors d' �CVOn
2.0 1 am a sole proprietor or partner- listed on the attached shoot t �. 0 Remodeling
ship and have no amployon These haw k Demolition
Working for ma in any capacity. w*Aws•comp,insurance. q, p Building adttitios(I�e waken'comp. imsusrnse J. 0 We am a corporation aryl its
required) otylcws haw exercised their 10.0 Electrical repairs or additiay
3.0 1 am a homeowner doing all wont right of exemption per hdGL 1 I.0 Plumbing repairs or additions
Myself(No workers'carp. a 132.f I(4).and via ban no 12.0 Ruotrepoics
insurance acquired.)t cmpleYeea(>\o workers•
comp inAtuance requirod.1 13.0 Other
'A,*+Ppkrt aAr eltocho beer at art atso lie as as faalaa 6abw Ogw•iq thin warhas•amgaradua pW�s inirarma
1 t W*wtiarae rho xiail this oAldarii a they ate doing dl wnt W tbo No aaetdo carcass am".rain"a new anteav t is kotina nib*
('oarutra tier chant this tea mar atnMui at additlmY.hen showing ns near of One ab.osoesaaon nod thumonsoon wckow'
w76poltry m4wounna
/oar saw ainployrr thaf b proWdlwg wrw•bn'coarprtatoNaw/nrwrotret/err wry enrp/ayeos, Bdow b the puHeY uwJJo�.slf!_�..
it�r��•—
Irnsuranct Company roar. �7c,
Policy a at Self-ins. Lie.M_ (ll C I (o o•l//Go2 Espirataon Date:_
Juke Site AJthss: CitylstuwZip.S •9e-ls -
\ttueb a copy of Cho workers'compensation policy declaration page(showing the policy number and aspiration date}
I+ailure w xxun coverage as required under Section 2JA of MGL c. 132 can lead ro the imposition of criminal penalties are
fine up sat S1.500.00 and/or one-year impriaanlncrnt.L well is civil pcnolliur is the form of a STOP WORK ORDER and a lute
,�rup to S250.00•Jay uguittad the violaror. Ile advised thut s cuPy of this stamunm may be forwarded to the o1 icst sat
Lnvsng;tunm ul'ahe DIA Per iu,urarcc covcn�t:vcrificrtiun.
/Jo hers by rarri/j uuJar the point un/pewu/t&s u dury that Me Gt/wwe&MjsMvided wyow is true and correct
11!:Lltllid• /
U/Jatrirl wx owfjt /.b waV wdie/w nib errs,to br romp/rteersy d/yor pawn offh-f d
City of 'f1) ' Peroit/Lkcua p
Issuing.talburity (circle oat):
I. Board of liralth 2. Building I)upartnncut 3. City/fotva Clerk 4. Electrical Inspector J. Plumbing Inspector
(r Other
Cntlacl Parson: _ Phone p:
Information and Instructions
Of 152 r
�isssachuseas General Laws chapter equiem all employees to Provide is has service of'' canothar uttder any fat their autpbye _
contract hire.
pudmtang to this sutute.as dayhyde is defined ana "am
eapreae at a orsl at wnttes'
aasseiaoae.aorPotaaaa a other IeW)entity,of two f t ttsolo
AA join despe di as iadlvidurp Pates►fig tkWtead repnKnn°ves of a deceased emp the
of the raceSant asaaaed m• seeoeiaaos or other legal matt.empMYing eau
receiver or uartae of as individad.p h and whr raider t- - id or the ooerrPana of tbo
owns of a dwelltag law laavisg oat recto tlusa ea do apangunisu to si cusisar ucaon at repair work on such dwelling bosun
dwelling bases of naodnr was a nploYa Peru=ea do mo beconce. be dated n be no"W"i r
set or bailaw app s°'g ant beeattaa drf sable atepisYlaaK
0e an the s�
SIGL chapter 152.42SQ6)ale°stow dtet"suety aka or Meal 1Mtrasfag oresty shag s'tlabb"as b atuaee or
a dpetaa•btssMas er to m"W"boud w M tM eosamnawultY he say
reaawsd at a aaa w at pt =k evidence of==planes wYh the Msttraaa ewerap rsgides`d.
dppllesat wM W sat Pradaeee aet�abla nor any of ile political mbdlvidow shall
oddiaKmnalb.MGL chapter 192.ii2X(y)a M wSleitha ttlic week� M evidence of complirote with the insurance
acceptab
COW into my eoemati hr the performance of pu tot contracting arhorW
require, , w of ibis cbapta have bra PM§90"
AppgeaaM to our siluaaon and,if
please fill out the wwkees' coaga0"tion a��O0°g�ati'by checking the boxy that apply Y
s)aa> (a),a &V*es)and pbotr owuiter(a)along with tsar certilkateU)of
necessary.supply sub 4o" C r( lea(LLC)or United Liability parmnrsltpa lLLP)with so empl4yeaa our thus the
insurenm teens LWdFAd Liability teq�nponWrod m Carey workers' c°mpe�a°a�aOCa If sa LLC or LLP does have
or
Cmployese.a policy is raluirwL Be advised that this affidavit may be submitted to the Deparm ms of
Industrial
Accidents for connfmarlerr of irtsuesuea COV.." ' Abe bosun to sip and date the sawavfl. The aHldavit should
be returned to the city ar town that t application for the permit or license is being requested.not the Department of
the law or if you are required to obtain a workers'
compensation
Industrial do ideate PimaShould�have an�p���td��below. Saif-inatred companies should cuter their
compeeuatioa policy.p�
self-'in—.— liernso tttnttabet on t
City WTswo OQfelsb
pica.se bu wre that the affidavit is complete ind printed risibly: The DepmerA hes provided a speed at t beltoslt -.
of the affidavit for you to fill out in the event the Office of Investigations has to contact
you regarding t appr. In addition,an pplic
t,leaso be sure to till in the purmitttkense number which will be used a.ns 2 referencenlysu submit one affidavit indicating current
that must submit multiple permivlieense applications in any given year,need only
polity information(if necessary)and under"lob Site Addrese"the applicant should aria"all lacatioaa in__(ding ut
Polio A copy of the affidavit that has been officially stamped or marked by the city or town try be provided to the
,,own).-
n). ne as proof that a valid aflidavit iu oa file for finura permits or licenses. A now affdsvit etude be filled out seek
year. Where a home owner or ciazoa is obtairA AS&Iicense of penult nos related to any business or commercial venture
t i.e.a dos
license or petting to bum leaves ON.)said person is NOT required to complete this at'fidaviL
I'ha Oiiicc of lovesti�atiuns would like w thank you in advance for your cooperation and should you have sty questions.
[Cube ju wt hesitate to give us a call-
The Dcpsrtment's address. relephone and fax numket:
The Commatwealth Of NW"Uh usetts
Depatnaeot of Industlrial Accidents
w"of Iavedirldis"
600 WasAWSM Sbvd
Bourne.MA 02111
TeL /617-727-4900 em 406 Or 1-977-MASSAFE
Fax N 617-727-7749
%:.,j,cd 5-I6-05 www.tnass.bov/dia