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130 HIGHLAND AVE - BUILDING INSPECTION i L`SAL. 1 r PUBLIC PROPERTY DEPARTMENT KINWERLEY OR szx LL MAYOR 120 WASHINGrON SIAEEr 0 SALk:u \L%ssACHLSLj-IS 01970 Tm.978-755-9595 0 FAx:978-740-9W 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: (:;/( 7�_ � Building: Property Address: Property is located in a;Conservation Area Y/N ram_Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: )+L1 C' aFA--5>AJ Address: 3 SA-1 " V t `+'" 1= c o/2Gi-o—),v M 4 18-3 Telephone: j `]8- 3 J (9L- 7 31 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: ,CAN—-- �n Mail Permit to: one c What is the current use of the Bui ding? �lvl� Material of Building? W Dod If dwelling, how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone ) Mechanic's Name rn0 Cov l;or,\ Address and Phone n n Construction Supervisors Lic se# 038--a--7 HIC Registration# 1 y 7 8a 1 Estimated Cost r ct 4G ` Permit Fee Calculation Permit Fee 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 buildto the above stated specifications. Signed under penalty of perjury %K � Date ra S 6 7 a � F 6 % a o C� a9i c Ilk WFL - - --o— ar --- -- ------ - - -- - -- -- - a n. CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT MAYM t10 w.�amacrou Jtaesr•swr�, rn 01970 TM-9WO."" a FAX 034404% WorkM' Compematiop Insurance Atsdavit:Bniid=WContractonM nbm Applicant Informadoe Me ^"PdM* gmtt Name( ):_17rn0 Cer�SkfUc �iOf� TnCorPorP+eN Address: 13 Moon-e City/SWWZip:__ 'U `lem 011 11) Phone# Are yea as eaPleyea?Check tie appropriate bem — 1. I am a employer with ` _ 4. 0 I am a goad coaeaaor end 1 [73 :,J_,, _ . employees(fhB attd/erpart-time)• have hired the g 2.0 1 am a sole proprietor or peruser. listed an the attached sheaf t ship and have no employees These sub►caonaceors have woririag far me is any rapacity. wotltera'comp inmrrany (No warken'rpmµ insurance J. ❑ We ate a corporation and its m41 ofAcaes haw esereiaed their addidaos 3.❑ I am a homeowner doing all work right ofmtampdon par MOL gddidona myself[No worltaa'comp a 15Z 41(4),and we have no i�'OCe •)t employees,n'lo wmltms' dcornµ inausaoa ne4teieed j W,n arils *Any�am lash sea e1 mnw Wee,a ae ae laden Well rowing ask weekaa'peep. sedne, attar faamwuaa tCoasemw ash rash HOMODW�Who�bo x am BUKW w ad WInman EMOMENEEN� oofilacedus d a eg war rag a.ta.artraa aem.aen mott.�6elt.ue..tmevr teaore,geed►e6awsig ash am otae eab4onsen ew and aafr nobles,amrp,Poky 6&ee adoa. fwjonwaBoR that mebOrevldlns workers'rowpeawdow/nseraweejoshary rasployeaa Behr br rbepo!!ry and fob sift Insum=Company Na :_T'h a4t 0f Policy#or self-ins.Lis#: (pSb C xx -0(e 1 1 n E pkiW,n Date 5-4 =©7 Job Site Address: OI-IJe City/Shte/ *p alert lea• 019 0 Attack a eG"of the worken'compensation Polley dedaradea page(showing the P01107 number sad o:ptratloa date). Failure to Sam coverage as requited under Section 25A of MOL c. 152 can lead to the fine up to 3I,500.00 aod/at one-yea imprisonment,as well as civil imposition otcrimioal penalties ola Of up to S2J0.00 a a pmehics in the form of a STOP WORK ORDER and a line �D tior the ante or. Be advised that•copy of this statement may be forwarded to the Ofliee of Investigation of the DIA far inrutaoce coverage veri}ipGon l do hereby arri/y wader doold nalBp ojPer/ary rbat the In jonwadme provided above Isduo and Corr-oft 2S o Phone Ofjleld rue onl3t Do not WPAN Gs this area to be complerd by CI&or town ofJlda( City or Town: PermlNLttenst# Issuing Authority(circle one). 1. Board of Health 2.Building Department 3.Cityffowa Clerk 4.Electrical Inspector J.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions ylssachuseta General Laws chapter 1 S2 r V*" to vide worked compeetaa°a for their employtxs. Pursuant to this stautts.an eatpbyee is daft as � PerSOa 1°the service o[another under any contrail of" express ac oral of wctttea" anociadoa.eorperari"or other legal enaty,or any ,,or the vidttal, empl°Yef rods partnership. a deceased o or MOM as"an 'va of An earPl°Ya is defined m a joint eo�pnxde a°d tneludaK leaf aaaployees However tb of the fore®omg engtgedWdWWML association or other laipi entity.emploYlat receiver cf a dw"a of an house hav Mgt g so ���rost Wurrogets�46 who � Rpan er the n such °f tb h� wodt as such dttroliing dwelling homer of another wba t persons� nt b dew m b m empbYer•" at on the grounds or bur'tdinf apPu mna°s ed stesdog army shag wUhtaid tM huasses at MCsL chap w 132.12S(6)also antes that"es��tO eoeattraet bafidlap IS ehs toaaseawesMh W reaawd at a sesese er perms to°� �aap wNh tY Iaenraw cot' r*qu�"sbll ant wbs ho not predueed> a��dow �Ad�tiooally.MGI.chapter 132,123C(1)stares otpubl�until' acceptable"Once of complisnee with the inwrame eatQ in,any e W61101not ~W have him prpaoted w the comeacang authori<Y'w of an Applicants tion afcbcldag the boxes that apply to Yew t cad.rf Please fill out the Owply NCO a s lei phone rtnership(L�ng w0hvArh the insurance- Liability Comp!ales"C)a Linseed Liability tnatnanee If an LLC or LLP does have Membra or paromrs,are not required ro e>nsY w°skera CO O° of lodoatrial employe a policy is requited. Be advised that a siI may be p date the affi avv% The afIIdsvit should Accidents far ad°O of inn the a application for AMbsfor&a pan*or license is being requeaoed.am the d be reauned Of WwaShould you have asY gwadene m>pding the law or if you are required io obam a worluna' Industrial policy.Plana calf theat the number head blow. Self-ionaed campaniaa should enter rhea >eManceiinaa'esmberonthe sopqm4mflee City or Tower OAkiab The i�ent has�„�a�st the bormm Plane be core that the affidavit is complex and Punted legibly.Inv' has to contact you regarding the applicant. of the affidavit fa you to fill out is the event the Office of lnveuigations number which will b used as a mferenee number. In addition,an applicant Plase b sure to fill in the permiNic��ns c will used need only subait one affidavit indicating eusrent that must submit Multiple perms'iice°a° the applicant should write an locatious in----(�Y of and under lob Site Addreo" policy infatuation C or marked by the city a town may b provided m the town)."A copy of rho affidavit that has been fibfoofficr lye�a or licensee. A new afudrvu runt b tilled out each applicant as proof that a valid affidwit i a license or permit not related a any buainas err commercial venue yea.where a Mama own"err citizen is obtaining is NOT required 0 corttplea this affidsviL (i.e. a dog license or Permit to burn lava ea.)said Pen°° The Office of Investigations would like to thank you in advance for your eooperaaon and should You have any gtteadoas. please do not hesitate to give us a WL Th.D p roneet•s address.telephone and fax number: JU Con=Mwftth of Massachuatt DepuftnOld of mid Accident Offt tdIawadgR OGS 600 Waa111110M Sit d BadM MA 02111 TeL #617-727-4900 W 406 of 1-877-MAMM Fax M 617-727-7749 Revised 5-26-05 WWw.f'niS Vv/die y CrrY OF SALEM tie PUBLIC pItOP S'i'Y DErARTURrrr MOM :s�iwa�erf:us•s•�ax�..oa�,.aa►s �+�+s�r•�+s>a+.awa Coas&ucdoa DAr% Dismal Affidavit 0" rd h ar doedidos ad rar--—M WMO is mordeos wide do aA son albs sdr som"CO "ao soda ttt.! Odtidml ad*A p- O 'oti dual s,4 tl 5%Adbe _ *0!s dlpom d of iD a�Mom dd skis&Vmd Adit &d d��s t t t.i tlOA attwlri The ddx%will bs dl;owd of in: NOTICE w NOTICE TO TO a � n O A EMPLOYEES EMPLOYEES �4 / y O,,M SVg The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As re uired by Massachusetts General Law, Chapter 152, Sections 21, 22&30, this will give you notice that I7we) have provided for payment to our injured employees under the above mentioned chapter by insuring wllh: HARTFORD UNDERWRITERS INSURANCE COMPANY NAME OF INSURANCE COMPANY ONE TOWER SQUARE HARTFORD, CT 06i83 ADDRESS OF INSURANCE COMPANY (6S60UB-7728B70-7-06) 05-24-06 TO 05-24-07 POLICY NUMBER EFFECTIVE DATES EASTERN INS GROUP LLC 233 WEST CENTRAL ST �- NATICK MA 01760 NAME OF INSURANCE AGENT ADDRESS PHONE # ARNO CONSTRUCTION INC 23 MOONEY RD A=M SALEM MA 01970 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A co of the First Report of Injury must be given to the P P PY P j rY g� injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS