87 JACKSON ST - BUILDING INSPECTION EI`I'Y--OF �i�L
PUBLIC PROPERTY
DEPARTMENT
'c
V:I�MFJLLEY DR1Sl:OLL `r
MAYOR / ��.�(� I WASHING-mNS'TRE,Er 0 SALEKMAZACHM--crs01970
1VL•978-735-9S9S 1 FAx:978.740-9846
APPLICATION FOR THE REPA_M RENOVATION CONSTRUCTION. d
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING --�
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: R7 3 NUCS6 ST, Building:
Property Address: S ,4A.,Q
Property is located in a; Conservation Area Y!N N Historic District YIN N
2.0 OWNERSHIP INFORMATION
2.1 Owner of land _
Name: Pf—i-e �oHT2
Address: 10 M-r• ✓-er^`oM
rtl;atdle�onr.wtq, 0�014(
Telephone: 978— 64'7- 0-50e
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:
Seal teak inn w.A;r.� rooF (r�pa,r�
t eS'�d� Zasrl �ts ou/y
Ft,a-� rya t= rePg�rS
Mail Permit to: 1D P^T• y-ecz"O^r wt rdd('eT-0"s NIA 0 rg 9�
e
What is the current use of the Building? L4,SeA C/t-r- lOT
Material of Building? If dwelling. how many units?
Will the Building Conform to Law? s Asbestos? No
Architect's Name
Address and Phone l )
Mechanic's Name A - C- C`.45-r t. c_ C.Z
Address and Phone 4 �KC! P PRs a d x t t 'A .
Construction Supervisors License# 05188,;k HIC Registration#
Estimated Cost of Project$ a sbO-� 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 build to the above stated
specifications. Signed under penalty of perjury X "o
Date
� J00
�
96
-
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
andtaatratt tattscou
MaYoa 12o WARO MSMW a SWsa,M,►"aarWM019y0
Tsu 97W43.9393 a FAX 978.740-9W
Workers' Compensadoa Insurance Amdawt: mwdervContrutor,/Elt,&(daaa/Plumbers
Anotkaut Intormadm PI an Print r bly
Name] : _c.z
Address:
City/3ummp: 00-0 )'IA. visGo Phone#: aJ-7 8
Are you u employer?Chock the appropriate bon
1.01 am•employm with - 4. 0 I am a Settled Contractor and 1 T�W @[prof(r"dnwW.
employee(ra and/or part-time).• have hired the sttb contraaora 6• ❑New construction
2.01 am a sole proprietor or parmao- listed an the attached sheet t 7. Remodeling
ship and have no employees These suA caotruceom have L Demolition
working for use in any capacity, works='camp.ink.
[No works+'comp.ioinsuranceinsurance3. ❑ eat Wa s a corporation and its 9' ❑> i addition �
Kam] offices have exercised their 10.0 Elochic•1 repair;or addidoc s
3.0 I am a homeowner doing all work right of exernpdou per MOL 11.0 Plumbing repairs or additions
myseiL[No workers'comp, a 132,¢1(4),and we have no
insurance required]t employees.(No workers, 12�oottepair=
� insurance13.0 other
;A•Y aFi11=ttt*A Castor ern et matt an®of the tedga below� tart waloe•ee.p..riae pdky bttetaadrs.
xam.•....res ttt6•dt tw.eldrwa mer..say dI.edr e1 thin tdm oatidr ea.asrma taott stems•aw•mdtwb
tCoaeaetom ter eeaelt del.lea matt rseed r addutaad wb•r d»ele=dr ate•star tot+sort•gsta and ON*eeekt•'coon Pdky fohno kso.
ha &Pri_dng awrhea'eoepeneodow hwnnue�INf /or my a#Y/ayees Belo�r 6 rAe
Insurance Company Name: ),4-f- _
Policy 4 a Self-ins.Lie M�S. 9k CiZS�R 137o9oS Expiration Date: / 0
13
Job Site Addrera ✓/4Ck-50At .S l Cih/S sWe.ti,w/sA- o t 4 t o
Attach a copy of the workers'cons
petnatlon poBry d«Vradou pap(showing the policy aambor and expired"dab).
Fadure m secure coverage as required under Section 23A of MOL c. 132 can lead to the imposition of criminal fine up to S1,300.00 and/or one-year imprisonment,as well ar civil P eta
of up to$250.00 a day against the violeme. Be advised that s copy of this statement
may of a STOP WORK ORDER and a fins
Investigations of the DIA for insurance coverage verification. tn+Y be forwarded to the Ofnae of
I do haebp enagy nnCer rAtt paters aA,/peae/ap olad�that the lw/orseadow prov/de/abovelr�aw/eorrres
Signature*
Phone N rl -2 v
o cial rut on/p Do not twdtt in th4 area to As eompkied by e(tp or Iowa o,QlcAd
City or Town: PenstIVI Icense M
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cltyfrowa Clerk 4. Electrical Inspector s.Plumbing Inspector
6.Other
Contact Person: Phone 0.
Information and lnstrucuum
se wolkew compensation fa dteir employem
%tassachuse�Gen"Laws chapter I S2 requires r areployera to o Provide
service of another under any contract ot�M
pursuant to this stamen.an s is defined as ...evaY pawn
is mP •Deal or wriae"
expcesa rporation a other legal eatitY.or any two a mom
An•aspfaYar is defined as"an individual.psnnessbiR mfingassoc the L- repasace va of a deceased emPloym,Or the
of the foregonsg egaged in a joint anmtPriae• 1OC
receiver a trustee of an individnal.partnership.asaociatian a othe bonne bsvb34 not nacre than three spuenusaw r lattice thsa oa open of die
boom
owner of•dwdliog
d,,,welyrt idmuos
ata�of another who empbYs persons�so becaxAM of such seiplo a �0°0�to Yar•�
a on the dcoun&or bttildina apptttarint
Mfg.chapter 132.423C(�also states that"r ay stay er fecal tlewb t atttaky tiag'�0V the�°a�otr
a balsa or a eeeutrsd buddlnP in tie eae.senwaalti for aq
renewal of a steam sr peed b le avtdteee of eosuPrstaee w&tie hwraw eevarap thee
applicant wits bee net prcetloesd grams Neidaer tie eommonwealti nor any of its political subdivisine's
Addr into;;. WNW chapter 152.125q7)"for the elAIR - wo i until acceptable evidence of compliance wits the Waatence
��� dde cbSPSK hxve him presented to die Contracting wdbOM'r
APpliCab checlang the boxes that apply to Yore situationand'tf
please fill out the wa raw'aa®Panandon sfHdavit camp y a with their eertiIIcam(s)of
a)namCosepnnieso(s),addtesKes)and phone number( )Along neeesary,supply,a COOS (LLC)a Limited Liability Psrfmssbl"C'��no eas o�dun the
insttrancs Limited LtabititYnot re to carry wakae'co�sadon insurance if an LLC a LLP does have
II1e�at Pubm1. roquited Be advised that this affildavit array be submitted m the Deportment of industrial
amP�Y Me, pennyAUs be gran m alp sad dace tie andavl6 The affidavit should
Accidents fa oon8emada6 Of inaaaOCO end Pam a liresso is being requested,not the Departtnald of
be returned m the City at town that the application m obtain•wrorkae'
��me. Sinewyou�w Ong the lawd b lo if you -i required �
industrial c policy.pleaee tatnri tM Dapsmte��numbs llamd below. Self-insured eaopaniee tbon►d enter
Self-insurance liconse usnobw
City or Town Ofelar
legibly. The Deparomant has provided a�°u the boemm
Please be sue that tie affidavit is complete and printed f Investigations has to contact you regerding the aPPHcan.
of the affidavit for you to fill out in the even the 0 hie of ill be usedas
licant
please be me to fill in the permittliaame number which will be used es a reference tmmbs. Ice addition.an ePP
that moat submit
);cation in any given year,need only submit one affidavit indiCa ft carrant
Policy infamadon if necessary)
permit ana Applications
((if eseeasary)and under"Job Site sterns e" a he applicant
marbed by the city or town ml sy be Provided ns is or
m the
town)."A WPY of the affidavit dot has bee otficiaRy stamped a lieeses. A new afu"davu nut be filled out each
applicant es proof fiat a valid atTidsvit is on file for finum Pamits not related to any business err commercial venturear.Where a home owner a citizen me a is obtaining a UCe patnit
y to burn leaves am.)said parson is NOT mWired to complete this affidaviL
(i.e. a dog Heesee os Patna
The Office of investigations would like to thank you in advance for your cooperation and should you have any quastionk
please do not hesitate to gin us a call.
The Department's addtesa6 telephone and fax ortmbs
The(,` MMMWUA of Masswbnetts
Depgtftncd of lntiusoid A=denb
of Iavad
Of>Za aptm
600 W&AM&M ShVd
Boston,MA 02111
Tel. 0 617-727-4900 W 406 of 1-877-MASSAFE
Fez 0 617-727-7749
Uviseds-2&05 WWWviam Ov/dia
CITY OF SAtE►m
PUBLIC PROPERTY
_o DEPARTMENT
MUNULMOMCOLL
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