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16 HEMENWAY RD - BUILDING INSPECTION EI`I`Y©F�ALE - -- PUBLIC PROPERTY DEPARTMENT 14.0ffim EY muscom MAYOI 120 WASHING ON S` ZEEI•SALLK MAssACHLSETI501970 T'M--978-74S-9595• FAX 978-740-98" APPLICATION FOR THE REPAIR: RENOVATION, CONSTRUCTION. DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: Building: Property Address: ��- property is located in a; Conservation Area YIN AJ Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: V tUC9 5 Address: L9 l��vv� 2 rJ c3U � /cam Telephone: 7g—7 q 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 (sq Renovated construction or renovation of existing building Q New Brief Description of Proposed Work: rr / — - Mail Permit to: ((9 inn 'hi ;j A _�i—cl -- What is the current use of the Building? ��c A-A ram Material of Building? WAID-1- If dwelling, how many units? Will the Building Conform to Law? i /y 7 _ Asbestos? .VO Architect's Name /,2.4:6 � Address and Phone -0-0 W/ c ( ) '�" W21 Mechanic's Name ✓1"'r ,2,( s Address and Phone Construction Supervisors License HIC Registration# 15 a7D17 Estimated Costef P $ 3 G •06 d Permit Fee Calculation Permit Fee Estimated Cost X$71$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury xaz�Ls— Date 3 f S -D'7 i V o (M� N o �� ,�s O S v a. a 96 u �M a a CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT MMWxt.EY DaacOLL WAYCa 120 WASFm40rW SUM a SALEK MAXM:IRJag'rn'01970 TEL 978.7459595 a FAX:97&740.9846 Workers' Compensation Insur ace APHdavit�uilders/Contractor$MecbictaaWpinmbers Name(Business/0rpni2asaa4ndividad): C 1-D LO AJ Yr9 r tJt Oil$4 ra Y b✓ Address: Pe,yrl aN A 0 city/state/zip: %.,� �11-",f�i 9/D Phone#: S�� Fa.M employer?Check the appropriate boss ployer with 4. ❑ I Ir7. QL"do Type of ejeCt( : ea(firltand/or part-time)• have hired the sub contractors co>utnsctioa le proprietor or primer- listed on the attached rhea s hag have no employees These sub•contsaceon have tian Pro me in any capacity. workers'comp•insurance. ers'comp.insurance S. ❑ We are a corporation and its ding addition 3.0required.) officers have exercised their 10.0 Electrical repairs or additions 1 am a homeowner doing a8 work right of m emption per MGL 11.0 Plumbing repairs a addition myself (No workers'comp c. 152,§1(4),and we have no insurance t 12.❑Roof repairs requiiedJ employees.(No workers' 13.0 Ocher comp ioatnance required) *Any RMUCI a dut aheeb tax N aurae ale tm OUR the seetlaa bdow show*dmk werkms' Naetaowams was""d b aAld"mdesft any we dory aE watt sad due Whm ami POW 1Casasetam that check We tm amw a t hW as additlood sheet c•aOM�core sulaak a am sladnit htdlmgag smL saawhm dr more ottb sad dwk warkme'aomp.Palley khm adm - am aw employer that Is providing workers'compensation inearneer for my emmployees Be %w Is the poUry and Job rite information Insurance Company Name: Policy#or Self-ins,Lic.#: Expiration Date: Job Site Addreaw Attach a copy of tit workers'com natloa City/State/Zip: Pe policy declaration page(showing the policy number and expiration date). Failure w secure coverage as required under Section 25A of MGL G 152 can lead to the imposition of criminal penaltia of a fore up to$1,500.00 and/or one-year imprisonment,as well as civil peculties in the form imOf a STOP WORK ORDER and a fine of up to5250.00 a day against the violater. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificapo L I do hereby cerdA ender the peers and penalties of perfary that the information provided above is urns and carreea Phone#i F6.01ber as*only. Do not write in this area,to be completed by cdy of town o eleL n: PermINLlcense# hority(circle one): I. Health 2.Building Department 3.CIty/Powo Clerk 4. Electrical Inspector S.Plumbing inspector son• Phone N: Information and Instructions allemployers to provide workeW compensation for their tmhploYees Massachusetts General Laws chapters d fined a s contract of hits. purwant w thin ststrte.�ynPloyan�defined tits"...every person iw the service of another under any express imps oral or written" _of_ as"an individual.partnership,assoeiatio4 corporation er°�legal antry'or or the o f herploYa is defined vas of a deceased employer,ow m a joint enterPciaa,and including the legal representsn loy� However the of the forgoing engaged association or other legal entity.emPlWJm1 �P receiver or trustee of an indivtduaL pattwersh+R and who resides therein.er the oceuPant of the owner of a dwelling boom having not more than three apartment conrtnseti"a tePeiT wodt on such dwelling homed wed bouse of soother who empioYabecause f such employment be deemed to be an emploYec" or on the grounds at building appurlenant MGL chapter 152.guC(��O s�that"every stab or local IleeuaERS agency shag withhold the lemena or b operate a business or b construct baiidiail►fro tbo cwusnonweaft tar Say renawsi of a kense or t��bblo uslumWWW of eomptlaaee wl*the insuruw coverage required' � applicant wMGL cha not pter 152.$2SC('n atams"Neither the commonwealth nor any of its political subdivisions Additionally. le evidence of compliance with the iffienwye ter into y trail far the performance of wont until acceptable " coequiremeots of this chapter have been presented to the contracting autboaty. Applksuts se fill siUrttian . affidavit completely,by checking the boxes that apply to your plea" out the workers'compensation n sale with their eertifieatda)of necessary.supply svb'CO°�OKs)name(a).address(muted and phone umber( ) °g with no employees other than the insurance. Limited Liability Companies(LLC)or Limited Liability partnersbhPs(LLt� members ct patthess,are not required to carry workers' i°°OnIICe If an I LC of LLP does have that this affidavit may be submitted to the Department of Industrial employees,a policy is requir d. Be advised and date the ettidav% The affidavit should Accidents for confirmation of insurance coverage. Abe be sore b sign of be returned to the city at town that the application for the permit or license is being requested,not the Department Industrial AccidentL Should you have any queue regarding the law or if you are required to obtain a wo era' compytheft should enter self-insurance olio Pines call the Department Irt* number listed below. Self-insured ccomputed,computed,Ucanes nonber on the urance city or Town OtlidaM provided a space at the bottom please be sure that the affidavit is complete and printed legibly. The Department has of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant applicant please be sun m fill in the parmitftense number which will be used as a reference numbs at iindicicating ccumet applications iw coy given year,need only submit that must submit multiple Fermi an "Job Site Address"the applicant should write"all locations in___(city or policy information(if necessary) or marked by the city or town may be provided to the town)."A copy of the affidavit that has been officially stampcd r or licenses Anew of hdrvu mart be filled nut escb applicant as proof that a valid affidavit is on file for figure perm not slated to any business or commercial venture �.where a home owner or citizen is obtaining a license or permit lyre this affidavit (i.e. a dog license err permit to burn leaves ate.)said person is NOT required to comp you 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 Depummeot's address.telephone zTM V Wth of Mmuh11setb DePNIMeat of I &*W Accidents Ot!!a of Iavesdgadona 600 Washington Surat Boston,MA 02111 Tel. #617-727-4900 eA 406 or 1-877-MASSAFE Fax 0 617-727-7749 Revised 5-26.03 WwwalaSS.gov/ilia CITY OP Sit PUBLIC PROPEM DEPARTDENr ,nk# 464M6ragW4& w Coss&ucdea Ddwb poral Atfidawit 08"d 6tAd�edd�s am a.w,dI Wade is�eeo�sa*GM*0"000 Q. at @ �f$Gods 70 Qa me"ttt.! Ddbk timb• Isto o/wt*do somOke do dw dib e��ba aboa s�i atb s�►tie�eni war dt'ari fliiC�ao doAei by!/a.s ttLiIS" Z!aditbwMbeh II I Iby (fir The ddais will be dtspoud alto: l�r aI reutM u�alprrnb�p�lk [ 1 - spa i ✓�te L�omtmw9uooa� o�✓�aeeaGEu6oQ` Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registratiop\152700 Ex Wild CROWN POINT CONSTRUCT1ONy ARNOLD JAYNES 16 HEMENWAY SALEM,MA 01970 _ Deputy Administrator ttp3 �iEe �owinwo..... D£ a�./ amru/uuelA BOARD OF BUILDING REGULATIONS License:'CONSTRUCTION SUPERVISOR` Numb CS� - r 072450_ � . Birtttdate 10W.1957 , 10/22[�007: Tr.no: 7811.0 7+ 5 ARNOLD L JAYNE5' - 16 HEMENWAY.RD �x,,. ov. I SALEM, MA 01970 Commissioner T 1