162 HIGHLAND AVE - BUILDING INSPECTION . , — en�oF�xr.E�r- -
' ��� O� PLBLIC PROPERTY
. DEPART�IE,�1T
I:I�OIFJthY D��v-�r 1
�IAYOI I�WALi1M4�7N J�i1F3sT� '
S��y,�oasr�not9�o
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APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION.
DEr10LITION. OR CHA,'�iGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRiJCTURE OR BUILDING
. 1.0 SITE INFORINATION � �
LocatlonNams: � tz e5�ca NG Buildtng: �s ,�'
property Addreas: f 6c H�9h L�in+� q�� '�R�c+ /�t.schec� .�e
���le.� � MA
property Is bcated in a; Coneavatlon Area YM �l Historle Ofsbict YM�L
4.0 OWNERSHIP INFORMATION
Z.1 Ownw of Land � '
Nams: �;:� � c e a
Address: ib d /�/J/1/ci n d /}v�
S�-i e m �
Telephonr. y7� %79- 7/ ��-
3.0 COMPLETE THIS 3ECTION FOR WORK IN E7GSIli�d BUILDINGS ONLY
Addition Exiating
Renovation Number of Stories Renovated
Change in Use New
OemoliUon Existfng
Approximats year of � Area per floor (s� Renovated
construction or renavation
of exiating building New
FIriP/Descriptian of Proposed Work: � �
Ne� CoNs+2.�c+�o� z4 '�c 30� (a�reA��
— Mail Permit to: �C-,�f oT7 — -- - -
What is the curre
nt use of the Buildingl
Mate�al of BuildinqT ' ""'^ f If dwelling. how many units? , . .
WiU ths Building Conform to Law9 �_�___— ��gt°s? /�kml�
p,rcAitecYs Nams
Address and Phons ( )
Mechank's Name ����� v ����T� —
Address and Phone`� � �.9�..��N.v�'•P l.� ,N1.9- �/9��
Construction Supervisors License+� C��24�i3 HIC Regiatratfon� �'�7 243
Estimated Coaty/ f�rojed S �n�.� PermM Fe�Calcularion
Pertnit Fee i—��� Estlmated Cost X S7/S100a Reaidential
Estlmated Coat X S11lS1000 Commerclal
An Addkbnal S5•00 is added as an
AdminfatraWe charge.
Make sure that all fields are propery and tegibly written W avoid delaya in procesaing.
The underslyned does hereby apply fa a Buildiny Pertnk to build to the above stated
X�� _
speciflcadons. Signed undx penalty of perJury
Date y-l3-o�_
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�.�� LicenBe: CS � 82443
. � Expirallon:� 1/4/2010 Trle 7
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Regfstration: 737243
Expirdtion: 10/21/2008
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TODp y pROTZ
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L1'NNFIELD.MA 01940 ��i��
' - � ne��tYAdministrator
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� CTTY OF SALEM
PUBLIC PROPRERTY
� DEPARTMENT
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Wwken' Compea�ado� Iosurante Attidwit: 8uildenlContncton/Eleetridans/Plumbe»
Anntleant Information Plea� Print LegiAlv
Vame�Iw�n;:,rcxa,m:alloN�rnuv,anl►: � ! _rr��` `/ �} 2�7'T7
AJdress• � o � o q y
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IG CitylSt3tc/Zip: " I'hone H: 7 - 2
Are yoo aa eapMrv'!Ctiacl[eM aPpropriau!o�
'ryw orP.nJ��(►.9W.�.a).
I.� I;ua a cmybyar wi�Y 4. Q I am a Ycrosral taotnetat oad 1
�mpl.iycex(full uLYur p;uo-tinu).• have hin.-J che,uA-cwunctas S' ❑ P'ew conrtruetim
3 1 yn a,wk propricca or puutu. lined oe tAe attaehed shcet = 7. ❑ Remodelias
ship and have m omptoywr 7'hes�wbconaaemrs haw tl. ❑Demulitioo
wMcin; �'or me in rny capacicy. woricen' wmµ inauronae.
(He warkcn'ewnp. inwranc� 3. 0 W�an a eo�poradan unJ its 9' � �"�•rdd�uaa
roquired] ot7icen hsve cxciciaal rheir lO.Q ElxtriCal repain ot additions _
3.O I am a hameownc Join�all work riy6t of exemption pu MGL I 1.0 Plumbin�rcpain or uJditiwu
myxlf.[I�o workcrs'wmp. e. !32.�!(4).and wa havc rw 12.Q lGwf tnpain
insunnce rcquitrd.J � �mpbyees.(l�o woticea' 13.0 OIGm
comp iawran�z rcqu'ved.]
. .,.n>.pp4�a.r ier clwcrs uo.�� m.n alw eu a.u.+«eae IKaw.eo.la�ir'v wino•ar�wW+u�vdiry�ne,r.�ius
' I i.ru�.An r�a��Owi��efllAwu i�disaiuK tlwy ao Juiq YI wA a�tl 4�E4e wddr emroosn saw.udn4 s n�w ilRJ�vil inJiarin�aw�.
�(',wurxtw+ihr�ks!Mb ba muq atixlrl r addiUmd+Awl.Mori�y We naor of��aM�Yeir wuAaf cv�0.PAKY Ml6rma�fa�.
/unr un euipfoytr fhat!r provldln,q worbri'compenmdoa lruaianer joi iny tmp/oytas Bilow Ir rhe puNay unJ/ob�i#
iy/�rar�rlvla �
Incwancr Company Vame: _- _ - -
Policy M ur Salf-iN. LiC. p: _ .. _ F,apirraon Date:
Job Site AdJrow: Ci�pSWwZ,p:
vacA a.oyy ol�M warken•wmpenaatloa q�11ey dac)ar�tlos pak�(showinR the pu0cy number and u:plratluo d�te}
I�ai luru w x:cwe co�erree ss«quiral unJcr Sec�ion 23A ul'�IGL c. I 32 ean lead to�he imposieion of eriminal penaltid of a
ti n.up c��S I.SAO.(M�nJ/ar ona-yeu irnprixmmcnt,a�well us�ivi1 pcmltiu in�he form of a STUP WORK OROER arn!a fint
e(up m 3�30.00 a Jay a�uia� ihe v�olarnr. Ik advi.�cd Mut a wpy uf this 5�atcuunt muy be 1'urwarJud to ihn UQice of
(il\'�ph'�'JltOlb UI lI1C DIA COf 11}'iu(]CCC CpKl:I�L' 1'CCIF)�dIlU11.
� /Ju hereb���.di�y unJti�hr puina und/mrtu/Ilrs ujperfury thw d�r ie�orwW/ow OroriJaJ ubow is uri uuJ conret
E �i•�,:,r��r•• _.11�l� �c�� I)�rc• (�—/2 Y��
r�,l:��: ��'l z2 3 7q�3
�)/Jlcid�x up/�c /ao war wr/i�/a iAlr arre.JY b/ClIMvIlJ!✓�I C/q nr Mww o/Jli•!�L '
Ciry or fnwn: _ PermiNlJernse Y
I��u1nK .\whurity (eird� onc): — -- - .
t. Il���rJ uf Ile�lth 2. BuiWin� Deparhne�rt J. Ciqlfoen Clerk J. Electric�l lusp.ctor S. Plum6in� Inspeewr
G. O�hrr
C„nl�.l Pc�tou: _ 1'honc p:
uchons
n Instr .
Informat
ion a d
�tass:+.hu;atu Gcncral Laws chapter 1 S2 nquitrs all employ���xivice u anoi�un�du any�convact o[hire.
tLcwaiu co�his�:uw�.����s defined a'...evaY P°
oapress�x impliod.ural or wTitted"
nsoeiaoo�.aorPontioa ar aha k�pl enti�Y.ar auy tvro a mo�
.au rr�lbYn is deR°°d as"�ind�idu�4 P�ea�+h�Y. lo a.or rhs
e �����tbe lepl rryreunuuva of a 1eee:ua!emV Y
.�i�he fuce�o�n�en�a�ped ia a joiet aae�p►ia�. Ho�rcver th�
�aweiarion or o�har le`al eaeitY.�P�OY�t���Y�
e
receivet or ttuues of ys iudiviAud.Pum��+V• ted who residet tAetei4 er the aocu�of dr
hours h�vi oot�ooce�e tlrae ap�rm�a�
owrot of h�����bYs P��m ifo s•^•••••^•�e,���oa or repait work oo such dweUia�Roua
�IweUi� �Kep smll aa bepmt of we�m�pluy�be deamed w br yn employa.•
ur on the�nd�ar build(n$appuetenart
�iGL chapw t 52.4�(6)�O��.•„,fry stW w leeal lke�t ip�+�wit�YoY tY�furuee or
b o nN a Msl�as or b eoWrud bdWln=s h tM commo�wedtt fir ur
n�►d of a Iteew or p�rmtt W
�ppVe��t wM W Mt yrud�e�d�ceeptabM wid�aca ot eo�Ptluw wtti t4lssun�d eover�s rcqutrad.'
�Jditwmlly.MGI.ehapn t 32.$23Cf71+W�+'Naid�er the conunaawealth oor mY o[ia poliucal wbdividom�Aall
�� e����y�a�f'puWic worlc undl aaept�bk evidance oFcompliaoce wit6 t6e inaurance
mar inw my awhacity."
requirsmena of�his cbapur haw been preaenud ro tbe eona'aeanf
�pptleasM
Ple�ae fill out �Ae aakan' canpensaaon aASdavit compkceb.bY�heelcins�he boxd chu apply w yaur situatioa sad,it
neceaary�a'PP�Y��s)name(s��a)�P�m emnber(s)alon`witA theic certi8cate(�)of
innu�nce. Limuod Liability Compaaid(LLG�or Limtred Liability ParmenhiP�lu-P)wit6 no empbYw other rhan the
membas or Patloen.�+°n°����O e�'MO��'���0°����. [f an LLC or LLP doas hsve
employeet.a poliey is roquiied. Be advised dut thu sttidavit may be submit[ed to the Depum+
ent of [ndustri�l
Accidents for contlrnution oP insursnee�°v�a Abo b��un to yip aad dsite the Lffldavlt TM aft5davi[should
be rctumed w dro eity w rown that t6e apptication for the penait or lic.enss is bein� reques[a4 sW el�e Depacootent of
ro
leWuYtciul As.:iJenn. S6ould you have any questioo�reQar�n�the low or iPyou ara required co obwin u worken
cuiuperuuiop Po�Y.V�eall�ha Dep�ent u�he nuwbet liarcd below. Self-inared companies a6ould eater their
.elf-insuraoee license number on the line.
C(ty or?ow�Offlclsb '
Ptca�e 6c uue �hac ehe affidnvit ia complete and printed IcQibly. Tde Depsranant har p�ovided n rpuce'rt the botWm.
of ehe u'ficL�vie far you a fiA ou�in the event du Oftiee of Investiyacions has w conwct you reQnrdin�the aDp���
1'lea� be sure ro till ia ihe p�cmitllicense nwn6er which will be a+ed aa a rcference numbar. In addidun.an app
ih:u mu►t.ubmie multipk permir/Iicense appluadons in any�iven year.need only submit one affidovit indieacin�curteat
policy information lif necessary)and u^dar"lob Site Addrc�s"the�pp4�ant ehould write"uU luca[ionr in__(ci�Y ur
rown)."A wVY of tM uftid�vit�hat har bem ofToiaUy etampeJ or muked by �he ciry or town may be pro�idcd w che
�pplic:uit as prooPrhat a valid affi�levit u on file fw future peemiu or licensas. A new afl'3dsvit mwt be fllled au ach
yw, �y�►ure a hwne uwner or ciuun is obuinins a licenye or pennit not related to •ray busiuess or commercial venturo
i i.e. a Jo�{licen+e or rermit w bum leav°a eta.)u�d p�w°�YOT required to complere this�ffidaviti
I'hc �)�'tix ot Inva,tigatiuns would li;ca w th�nk you in ,Jv;utce Cor yuut.00pen�iun anJ should yuu hrve any yuucions.
p:c:+ac du nut heticate eo giv¢ us •r c11L
Thc D.partmrn�'s aJdrcas. eelephone anJ fu numbK
The Commonwealth of Massachusetts
peparmoeot of Iudusuial Accidentt
O!�et I�wsdpdo�t
60o w.��sa�«
Bosoon, MA 02l t�
Tel. p 617-727-4900 ext 406 ot 1-877-MASSAFE
Fa�c N 617-727-7749
2,�„�� ;�,e-os www.mase.gov/dia
C1TY OF SALEbt
PUBI.IC PROPRERTY
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