22 HERSEY ST - BUILDING INSPECTION ----- EIT'sr-OFS-ALETN -- — --
PUBLIC PROPERTY
DEPART'M&NT
MUYM 130 WAIMMGMw ME=• '�,LLty,.MAYtACl/l3l11S 01970
7bL 973-743-95"•FAW.975-740-95"
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION,
L' t DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: J*V& lAleoien— Building L'aac2e �Loc%
Properly Addross: 2,�p
\0 Property Is located in a; Conservadon Area Y/N /-I _Historic Olsirid Y/N A_
V
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land ,rA-M6 &1g25—A1Z1-
�`\ Name: LDS'
Address: A-0
a—a—
Telephone: `/79' 7`I '1 ,3 b
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing /
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing Z�'t✓rs
Approximate year of Area per floor (so Renovated f
construction or renovation
of existing building New
Sdet Description of Proposed Work:
00A/S 17 u c 7/On of 9 N<ITi 01A-6 f-fP-e/QP12WG;,L+nw"c,,
PRJ UZ?D S� 70 i rld COC
- Mail Permit to: -��ry) in7fCMS1 5o i2-oA0L4.±4 S>� fr k
v
f
What is the current use of the Building?
Material of Building? CJr✓lW ZWL If dwelling.how many units?
WiU the Building Conform to Law? y e> Asbestos?
-y l a
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Consuucdon Supervisors License# HIC Registration# /d77/
Estimated Cost of Project S`40Y ago Permit Fee Calculstlort
Permit Fee$ Estimated Cost X$7/$1000 Residential
Fstimated Cost X 511141000 Commercial
An Additional S5.00 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 I to ve t
specifications. Signed under penalty of perjury X
Date
a
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n
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V 04
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-- - 4 01
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.01 CTTY OF SALEM
PUBLIC PROPRERTY
} DEPARTMENT
ta1R'RtF.T!*la[aal
)Awir 12C Www.w`r NftWr o SAUK► .MALIR !!s01973
\� TILL 976,745.95" 4 FAX:97L740.9946
Workers' Compensation Insurance AfAdavit But(ders/Contracton/ElectrletaiWPIumbers
"Anallcant information Please Print Legibly
Varne!bu.inwckWirniOrdlmuvKmn: 1` a b e. V, 1YI ct
City/Stsrc/zip: l I ,t,✓vll i) I i"'lQ CIR30 more N: 9'7�3 i '7 ` U31
�.F . ."%re you as ampbyya�9 Check the appropriate box Type of project(requilmlo:
1., 1 am a empbyw wilk 4. 0 1 am a 1P�contractor and I
tbnpluycat(full andrw pen-time).• have hired the sub-contractors b' new construction
2.�1 atii a sole pmpdcuu or panner• listed on the attached sheet t 7• ❑ Remodeling
ship and have no employees Then wbwnuacam have V. ❑ Demolition
working for me in any capacity. workers'comp, insunnee. 9. Building addition
(no workers'comp. insurance 5. 0 We am a corporation and is
require.] officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing a6 work right of exemption per MOL 11.0 Plumbing repairs car additions
myself.(No workers'comp. c. 152,¢t(4),and we have no 12.0 Ri of repairs
insurance required.) t ;mployeaa.(No workers' 13.0 Otltar6?Ft7761of J6t
comp insurance required.]
Any-pp4ur that chocks tar at map also!ill um ar mcuoa Wow Am.ice badr wartars'eumpaaacim pultoy isawatwiaa
I Itanatwb who uuhnit tin anldevh tsttkatuta they am tbiw as wwk ass tam him ttatsida eommoem"a subbnk a ttbw anhi inJiarina"ll.
:Capmnun thin chuck nil/bat mum anaeh et ion addnitmah Am.Mwing 0e mane of as albcommosen sae Ihim wa/l!am,fm v.Pi m6 m!Yhtla
asr ionou etnpfoyer that&providing wanton'compenwd
i NYnfY/ f(Y�
os huarance for my employees Below is the policy and Job site
Imurancc Company Vame:
policy if or Sclf--its.Lie. 0: _ .. Eapirauon Date:
Job Site Address:
Attach a copy of the workers'compensatlnn policy declaration page(showing the policy number and expiation date).
Failure w wcum coverage as required under Section 25A of HGL c. 152 can lead to the imposition of criminal penalties of a
tine up it)S1.500.00 and/or one-year impristlntncnt,as well as civil pcnallics in The form of a STOP WORK ORDER and a fine
.tf up to S250.00 a day against ilia violator. Ile sdviscd that a copy of this statcusi may be furwarded to the Office of
lua.,ngauut!s al the DIA for aiiurarce ;ovcragc varirtcatiun.
l do hereby certify under the paims and penalties of perjury Chet the inforaeW/em provided above is era and corrrct.
1i•natnre' _ _ - IT
I)/flcirf are ua/7t fie nor wrim is rhG area,to be com phyed by dry sr reran a/f71•lai
City or Town: Permit/IJtease Y
Ivsuing Aulburily(circle ono): — —
1. Board of Ilealth 2. Building Department 3. Civrona Clerk 4. Electrical Inspector 5. Plumbing Inspector
b. Other
Cnnlaet Person: _ Phone 9:
i
Information and Instructions
,%lysachusatts General Laws chapter 152 requires all employeprovide urkene of�,' coin 10
Pew er any coaaaet of hits,
of their emp YCCL
Pursusnt to this atatuto,an ewpfoYN is defined as"...every Pe
express or implied,oral of writte6"
Art etayiel+r n defined as-to iattivnter .isea and
mc.aaeottiabW corporation or arbor kgad cnM'or any two or aeon
of the foregoing engaged in a join enterprise.asd itclw6ttg the legal representatives to i deceased employer,or the
uaoeiadoo of other legal entity.employing employees' However dr
receiver of
jwel of ao individual,o more
a q.thei and who residua thereie.or the oecup.m of the
own of a dweleng bananas having no mote than three aparttsteats
dweiind house of another who employs persoma so do maintenance.cunbliuctiom Of repair work on snob dwelling house
or on the grounds at building appttttenatlt thereto shall not baeauas data employ scat be deemed to be an employer.'
%tGL chapter 152.42SQ6)also stnces that"overy state or local Heassbg ageoty shot wUhboM the bsuaace er
e raw a bastaa:ss or to coastrtwt6 m
buildings Is the comoowes"for say
Applicant wee
reuwal of a drew or de a ed teeeptabb evidence of compliaaee with the bssuradee coverage required."
G1 trot prod
Additiumlly,MGL chapter 133,423C(7)staters"Neither the eonuttaassealth net say of its poetical subdivisions+Hall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
tar have been presented to the conuuting authority.'
requirements of this chap
Appikants
Please fill out the workers'compensation affidavit completely'by checking the boxes there apply 10 your situation and if
necessary.supply subconaaeto<(s)narrme(+). «) PbO00°Ytm +)along with their eertifica s)Of
�than the
insurance. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with tto employ
ees members or partners.an not required to carry workers'compaotoa insurance. If as LLC or LLP doer have
mt
employees,a policy is required Be advised that this 31fidavit may be submitted to the De
partment of Industrial
Ababa sure to sip aMdav sad date the amdavN Tlts affidavit should
Accidents for confirmation of insurance cov sage
be retuned to the city or mwn that the application for the permit or license is being requested, not the Department of
indusaiul Accidents. Should you have any questions regarding the law or if you tiro required to obtain a workers'
he Dumber fisted below. Self-insured companies should enter their
compensation policy.Please call the Department at t
self.insuratmce license number on the approorim line•
City or Town Of c"
picric be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the affidavit for you to fill out in the event the office of Investigations has to contact you regarding the applicant.
1'Iease be sure to till in the Ptrmitllicense number which will be used as a reference number. In addition,an applicant
,hat must submit multiple Penn applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Addrcm"time applicant should write"all locations in city or
town)."A copy of the affidavit that bit+been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
yew. When a hum owner or citizen is obtaining a license or permit not related to any business or commercial venture
a dog license or permit to bunt leaves ate.)said parson is NOT requited to complete this affidavit.
I'hc Otii:e of Investigatiuns would Ike to thank you in advance for your cooperation and should you have any questions,
picase du not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Depament of%dustrial Accidents
Oak*of Ievadpdeea
600 wathiodtm Street
Boston, MA 02111
Tel. p 617-727-4900 ext 406 of 1-977-MASSAFE
Fax 0 617-727-7749
;t:vi.cJ 5-26-05 yywwagass.11ov/dia
f CITY OF SALEm
PUBLIC PROPRERTY
DEPARDAEM
71L��.• l+.ttl.�e,t�r:�ci7ittT iu��>uvt�t:w*Ab%$.
Construction Deb- DI.Spad
(reyaimd for all denalidoe and sommation work)
►a aaonlanee with the dlxtb edition otdw State BuiWtng Code.7SO C1►IR Faction 111.5
oavi%and dw provisions a(MOL a A 9 A
OWIANS Pwntit• _ is isseted w idt the aondidon d►sl tbs debris rcmdft9 ho1
this wait shall be dtspostod of in a property licensed wam disposal Ateility as daMad by y(1L a
t
The debris will be transported by: t/0 L)e 412K 0164
/VDIc✓ni'L cogtz7xd�t
rho debris will be disposed of in : D /
hlxtle�r rktcltyl
77-75
4
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