486 HIGHLAND AVE - BUILDING INSPECTION 1�
-
PUBLIC PROPERTY
` DEPARTNIENI T
AI.%MFJU.EY DRISCOLL
MAYOR 120 WASHINGTON STRFJ:T•SALLEK MASSAcHLshrrs 01970
IFJ:97&735-959S 0 FAIL 978-740.9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTLNG
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address: c
,-/8�0 l �1a)nj Au 2 sa1evyl �'YI
property is located in a;Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION CC. +D h A- G
2.1 Owner of Land
Name:
Address: 73 o o6K
_ ll Hw /l?,4 G goy
Telephone:
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 (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of theBuilding? ��1e$ S CO W1Vh u n Cc '0 h S
Material of Building? 5E` If dwelling, how many units?
Will the Building Conform to Law? Asbestos?_)1e
Architect's Name
Address and PhoW14 �'Z,4-
Address
Mechanic's Name
and Pho /f19 Ol,��✓
Construction Supervisors License# O S A )9 0 HIC Registration#
Estimated Cost
ooff Project$�,,no d 'oo Permit Fee Calculation
Permit Fee$�t —� 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 u to the abo stated
specifications. Signed under penalty of perjury
Date i D
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O 9
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workws' Compematlon Imurence APQdavit: RadoyContraeten/EleeWdansPhmbers
A
Name 1 �; AM Print 1AWbtv
� G
Address: O
City/Statemp: e�
phone - I 9 9 /
Aro you as employer?Cheek the appropriate ban
I.[1I am a employer with 5-6 4. 0 I am a po ad contractor and I Type ofproject(r"dree.
employees(11111 Anwar pamdme).e have hired the 6. ❑New construction
2.0 I am a sole proprietor at parmm, listed on the auwjwd sheet t 7. 0 Remodeling
Ship and haw no employees Then sub•eaatucteas have, 8. ❑Demolition
worldns for me in any capacity. woriters'comp,imufmc 0 Building addition
workem'comp insurance J. 0 We are a corporation and its 9.
xauired.1 Odle=haw axaeeised their 10.0 Electrical repairs or Additions
3.0 I am&bomeowner doing all work right of axamptiou par MGL 11.13 Plumbing repa;re or additiona
my (No worlms'comp, c. 132.41(4),and we have no
mmusaos required,)t employees,(No worker• 12.0 Roof repairs
OAOY camp iownaooe requite
d) 13.0 Other
t amaow�.�VA"�nets rd.a®arm.«we.11M d"b6 ierr.adra�omp�.,yea ad�eY�4m.uoa
rCemaetae mw e6ad�min ear mow asechhrd�aeN�tiWA i°rark•0d m•tie aadds aaoeawwr muw raemQ.aw alEosvit aa�r6Osanr sr mrae gem.sabesaeswwe and mdr trartoae•amp,r>�aY irlbimatlea.
/ew►an eaeyloye that 4provldliq worhor'eoarpearaafoa►wsaawee s►
tnjoraeaiosa ! url earaloyeea Below b alaoo/IGr and job sAsr
Insurance Company Name
Policy N or Self-ins.Lie.M y �� �j
Expiation Date:
Job Site Ad�as
Attach a copy of the workers'eom City/StatNT.ip:
pollution poBry declaration a
Failure to secure covers pap(showing the polky camber sad.apb^atloa dab).
M as required under Section 25A of MGL a. 132 can lead to the impwitioo of criminal penalties of
fine up to 51,300.00 y dloraping
One-g th ear imprisonment,as well"civil penalties is the form of a STOP WORK ORDER and a fine
of up to f2S0.00 a day agsimt the viohuor. Be advised that a
Investigatic an of for inweaace coverage verification,ropy of We statement may be forwarded to the ORW of
I do hereby erdA r the n aµpe olPerlwy that'Air 1a/ jormadoaPtw+Md abort is bat and correct
Phone
OJJ9old use on/A Do not WHU in thla are;At be eo
a'0�61'city or/awn o,Qlelal
City or Town: Permit/Licesso N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/rown perk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person
Phone p•
Information and Instructions
MPIOYCM
�asischusetts Gen"Laws chapter 1 S2 mpaitcs all emPloYer to Pu`�o workers' compemdeoano contract r of him,
s defined as"...evay Peron in the service o[another untie Y
Pursuant to this stattts0.tin t+sP�Yn _
express at mPUA oral at written" err other legal entity.or any two or mom
do
An e+apfeY�is defined as"as isdivtdnol.PprigII6 and wh Wives of a decried employer.or
th+ However
of the foregoing engage i&vWk jointn a icy fm at Other legal entity.eaP�Oy1Og gmor upaot of the
rcceivar or��°f �v s thee• m do mainaanaOCe•fin°or` as such daroltin{haeN
owner of a dwelling lrsuss hsvmg of such employment be deemed to be m UWWYar."
o f on do
or buadisg aP4�naot thereon shall not heeanu
or on the> wtd"d the baaasa or
that"every hate er load gosta ft agaeay� eomseswealft for any
MCiI.chapter m"so("also stew bush"er a eorstrset buslidlsp requiroV
[eeArai o(a tlasM O<psrmlr a opersta sce"AAlsavldee o o<temprneae with the buurasa envwga !halt
aPP done .M_�� l52,1 "Neither
69 acceptable evidence
°vtda of compliance w dnor any of its political ie insurance
wformance of public ..
eateratott chf r the
eam p to the contracting swhority.
Appldesste by checking the boxes that apply to Your stwsdon amd.ut
p�fili out the wicker'coos anWavn y' nombas(s)along with their catifiate(s)of
inecesunnstasncof..Supply Limited Liab Hft aCo 0 wOr Liabilityorkers °O Parnistships(L1 P)vrith r employees other than the
LiW" unauraace. If m I.I.0 ac I.I.P does have
UW
members or permew,are ear re Bea that thia may be submitted te the Depsrtwtir of laduawit
employees,s Poliq b unathatma� mOScovaags. Also ssswat*sip and date the affidsvIL the afil of
shnaW
Accidents for dosappl for the Permit or license is being reque�d,
he returned to Should You have any 4n�ogm of town the law to Se are requited ro obtain ate' their
indusuial compensation Pow.plMW an the �number dinned below. Soli insured companies
self-iormsna liemte siiiiiiiiiiiiiiiiiiiiiillillilliiiiiiiiwtimba m the
City or Towt•Olnelsb The Department
P��s�e at the bottom
Pleas be sure that the afildsvit is complete and Printed legibly.of InvcsdPdOnf haste contact you regarding the applicant.
of the affidavit for you to fill out tniecoass the event �will be used as a mference number. In
addition,as applicant
Please be sure to fill is the paint vm ear.Hoed only wbmit one affidavit indicating cursenr
that must submit multiple PamiNkenag applications in any gi to Yappliant should write"all locations is--(c*or
infoc�(if necessary)and under"Job Site Address" the city or town may be Provided to the
town)."A copy of the afidavit that tens bum o[ficially stamped a A new aindrvu must be filled oat each
applicant as proof that a valid affidavit is on file for flame Permits not related te any business or eommactsl vmtitro
Year.Where s home owner or citizen is obtaining a license at P to complete this affidavit
yea' license permit to burn leaves coo.)said Person b NOT required comp
(i.e. s dog or
The Of @ of Investigations would as to thank you in advance for your coopartion and should you have any 4uestiona.
Please do not hesitate to give us a tali
he Depacmncot'
T s address.telephone TM we"of MitSa bmtO
DePuMed of lmit>.*W A=dwts
o}dtd of Vvudp&0/
600 W&SM09"SUed
Boston,MA 02111
TeL #617-n7-4900 Cd 406 or 1-877-MASSAFE
Fax#617-727-7749
Ravised 5-26-05 Wwwm& Vv1diA
r BOARD OF BUILDING,REGULATIONS,' '
t License CPNSTRUCTION SUPERVISOR ?
(g' Nuµm�ber CS,' 082190 "
s� : BfftbdW o-a12sTss, >_
Ezipir" M912008 Tr.no: 22454
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