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62 JEFFERSON AVE - BUILDING INSPECTION (2) EI`P��JF��LE� -- �`' • � PUBLIC PROPERTY `' DEPAR'T11�IE1�JT ,���"� I:I�ME��DRISCWl � �twroa 130 Wwuricttx�a��7'� ' . a,_.s;�(.�,�a�st�-rs 01970 . 1t�1:9'.l-73S-959S�Fex:9767i0.9846 APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION. DEMOLITION. OR CAANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING . 1.0 SITE INFORMATION � � � J Lacadon Narne: Buildfng: PropertyAddresac — -- ----- -- � �FE� �1 e • property is located in a;ConaervaUon Area YM Historic DiaWct Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owoer of Land � Name: 1� a� � �t�-+�� � o sii Address: �a �(=�e � �v� � Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN E)fIQT�N�= BUILDINGS ONLY Addition Exiating Renovation Number of Storiea Renovated Change in Use New Demolition Exist(ng � Approximate year of � Area per floor (s� Renovated construction or renovation of existing building New 8aef Description of Proposed Work: --- Mail Permit to: —�5� -- �/� , .- --- - -- What is the curtent use of the 8uilding? ������� � Material of Building? �� �N dwelling, how many units? Will the Building Coniorm to Law? �n C�,. w'h^^• �lsbestos? Archited's Nam Addresa and Ptwne ( I Mechanids Nams Address and Phons Construction Supervisors License# �'`�� � HIC Registration# ��a�� Estimated�of Praject S �.T� PermN Fee Calculafion PermR Fee i 3� � EsUmated Cost X i7�S1000 Residential - -- --- -- — EsUmated Gost X 51 Vi1000 fAmmerclal— M AddRional $5•00 ia added aa an `` AdministraUve charge. Make sure that all flelds are properly and legibly written to avoid de�ays in pracessin9• The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Sig�ed under penalty of perjury /� �ti� Date i f� � r S ` � I I N � � S ? 9 � ` � � r �, ,� ` a = �� ��� a o . '.. � o � '-"� b ►. � u S p'�( � i .4 � 4 �� � G 4 - . _ C.1 Qr- - tr -- �- — 4 -- `�- -- - -._. ._. . _ _- ._ _ _._ _ .. . _..___. . ----� - -�- ..�— - " d'r'- -- - . , CITY OF SALEM ,,, . � PUBLIC PROPRERTY DEPART'MEN'I' ��� a�►,roa uovtivmucror,sn�er.s,�,eswss,►an�rrso,mo 'I4L•97N4S954S �FNc:97i7�O9tK Worlcen' Compen�atlon Inswance AtBdavi� Baitden/Contraetors/Eieeti{efanyplombers AnoUcant IetormaHon Please Print t •e+�ti• Name l ' ' 'aua�y. � PYl C Cc� �� L�1trr� �(7 naa�• I5� 'i,�1�s �.:.�,C�r, s�(" . � c►ry�stawz;p:.f�('av2 �9vteQ �G� (11��� Phone�I: �-1� - �G 7— �J o.� An yo�u empbyvi Cseet tA�aDprophb pos� 1.0 I am a amptoyar aith 4. Q I am s imenl conaaaor and I ��P���(�: employea(flili and/ar paR-time).• h�ve hired t6e a+b�wnau� 6• ❑Naa c�on 2.�I am a aole piop�ietor ar p�emer- liued on the anaehad aheat� 7. ��odelin� ship snd Eave no emP�I� 77�m+b-�nuacmcs have 8. ❑Demolition world� f�me m any capaaity. workas'comp,ian�r�, INo wo+ken'eomp.inwnnce 3. � We ue�coepontlan aad iO 9' ���i� KQ�dI o�s have mce�cieed t�r 10.0 Eleetrical ropain ar add�Ons 3.� 1 am a hoauownac doins all worlc right of mcmnpt�P�MC3L I 1.Q Plumbiai roPair�a addit[oa� myself.(No worken'comp. a 132,¢1(4�aod we have m ��.l� �P►�.[Nu wor,car.• I2.0 Rootrep,;,, �,�rc9��� 13.Q Other f�►�r wa��areb eoa r�mow,ta eu ar�e.�ewo.baon reo.��6dr.oh..r _ � ifaaro�'m w�he a�6eit M6�6va md�tlnf�Y��i�vadt aod�pin auufdr rnoOacmu muR�� =Coshryan tlM eAeek ihb bmt mu�t rheE�d�o�d�l ihrt rho�in�tlr n�mr oflE��ub.eantrsto�ud i6dr rarteM comR tel6rm�tla�. I a�w aw s�ploya rhaela prov/dlnr worken'eowp�n.ratlowlnrwrawe�jor my employ�ea Below tr rh�pa!(ry ow/Joi s�Ar lnjorwoatow�— _ -- Insurance Compaay Name: Policy M or Self-i=u.Lic.+W. Expiradon Date: -_ Job Site Addraa: Ciry/St�te/Zip: Anaed a copy ol tIr worten'eompewqo�potley daclu�qe�pa�(s��ty���a���e:plraqo�dab Failuro w sauro cm,aaye si requi�d uade�ga400 25A oPMGL a 132 eau lad ro the' � fine up ro S 1,500.00 aad/m one- ear' �aa�otcrimioal penalpp of s Y �P�wement,as well ea civil penalda in d�e Pocm of a STOP WORK ORpEg aad a qno oPup w f250.00 a d�y agaioat t6s violuor. Be advised that s copy oPtlua mtemeat may be foiwarded w the Of1lce o[ Investi�tiona oPtha DIA for inauraoce coverage verification. /do hsnb�ce nnCii�poLy and na/Nn ojprr/�ry tAwt thr fajoiaiwdow provWid /t nrrt an/eornd � t /� — / � 0 � Phone#: � �(l - �'Yc1� — � � �� O,Q?c/af wt onlp Do aat wrW 1�th4 ars;to b�caayr/sfsl6r dry oi foww oJJfelaL CIry or Towq: PermlNL(tea�e N Is�uin;Aut6oriry(cirek one); I. Board of Haltl 2.BuUdtn;Department 3.CiryRown Clerk 4. Electrteal Inspector S.PlumbinQ InspeeWr 6.Other Contaet Per�oo• PAone p: Information and Instructions 152 cequira all employees to pmvide workers' compeasadon for theic emploY� Massacbuuas Generd Laws c6apta�is defined as"...every pnwn in t6e xrvice of aaother unda any coaaad of hiie. p��usnc w thia statute.an m�P�Y� expcess ot implied.aral°c wntt�'" asfoeiatiu4�°II a°�tegal eoatY.or any two a mae An sarp/oya is definod as�'n oi�t ec�.�'���0�S���va of a deeeaxd emPlo7r�.a d�e of ths foce�ini esY+i� . . ���n a othar le�l e�►�Y.�P�Y�i�P�Y� Howeva the reeeiver a tcustee of an ind�v�ual.P�P. �aho��ac ths oe��W�°f th° ownac of a dwelliat hw�°Esvini�mace dun eh�ee� �«��oo sueh dwallin;b°�° dwellinf b°�°ot�oothar��P�OY+P�m do m�inmoao�4 ��P��b°�°d oo be m employv.• �on the� ar buildiai aPP��°���O shall not bceause "every�tW er loeal tle�aist����w�t6l°Id tM fs�aaee�or MGL chaP�a IS3.425����a a buslmsr or te eo�d bdldln0 V tM eommo�waMY for W reu��ot a tleeo��P��tO ue�P��M�0°�y eI eomptlsau wdtY th�in�urasa eovenN�M���sh�II ipp�yeant wYo ha�sot P� 1°��23C("n s+ate+"Neither the eommonwalth nar anY of us Poliucal subdividons AdditionaltY.MGL chap� ��ylic wodc until iec�ptabl°avidence of complisnce with the inwsanee • mter inw my cantnd[ar dbe p� to fl+e eont�actinf awhoritY•• ' �q�ot�his ebaPta have been�ted ppptlea�b aPHd�vit eomPu►dY.bY��i the boxa that app1Y w'Y�aiNati�and.S Please fill out the wotken'w�O° a and phoae numbu(s)aloni with their�d�)� neceswrY.suPP4!�b"O°°°�O�s)�`)•addrese( ) with eo employea othec dun ths Limiud Liability Companias���ar Limited Lisbility PatmecahiP�(LL�) 1O�d°C6' to ca�sY wodca�•oempmsyp�1°°�nes. If an LLC az LLP doa have m��putyen,are not s�u�d�d that this aPHdavlt may be submitted w tLe Depa�mw�� ladu�a'1� emptoyees+s Po1�Y v��' covara�s. �Ws b�san W�I�and date tlu atadsvlf. The affidavit abwld Accidents fa conticmallon of inaasnee a lieense is beini r�ue�4 oot the Da�� the ci or mwn that tEe applicaaon for tha pecmit ro obuin s worken' be mauaed��36ou1d Yon hsve snY 4ue���ths laa a if you are mquind Indue�+°i at the nambac lirted below. Selt-ina�ed eomp�ni��d entar theic eompenaaaon Po1icY.Pt�call ehe Dapuommt� seli-innasnce►{emae m�ber oa the City or Tow�,Ot�daL � �aud printed legibly. The Depaioment ha�Proyided s spsce at the bottom Please be s�ue that the a�davit is wmp ona has to contact you ngardin�the applicaaE of the affidavit for yw w fill out����which will be uud as a cefereace numbar. In additio4�aPP�� Pleaae be wro w fill in tha pacmi Iicaaon�in any�veu yesr,need ody submit one affidavit indieatin�� ehat muet wbmit mvldPle Pe�Nu°°°O� the a licaat s�ould wrioe"all locadoos ia__(�1�Y or policy infocmadon(if neoa�svY)s�d���Job Sita Addreas" PP the ci a town msy be Provided to des of ehe affidavit t6at has bean otHeiallY st�or marked NY �Y town)•"A copy u on file!or f�hae Pe+min or licemes. A new af"udrvic mu�t be Atled out aeh applicanc as proof that s valid�affid:vit� s lieenaa a parmit nflt related w any bueineas or eommeroial vanaua year.Whera r home oaner a citizeu is obuinini u NOT requircd to eompkte this affidavit (i.e. a do�l"uenae or Perm�m burn leava etc.)said panon� ou in advaoca fa your coopecation aod s6ouW you have my q�� i The OfRce ot Inveaa�ation�would like w dtis�JC Y please do not haita[a w give u�a call. .�D���•��e�,rclryhone and fax numbee: The Conomonwealth Of Massachusew Depa�Ement oP 1nd�tcial Accidenb OtIIa of Iavatl�at[ons 60o w��sa�e a�,rM►o�ii� Tel. #617-727-4900 ext 406 oc 1-8T7-MASSAFE Fas M 617-727-7749 Rz�[��i s-26-os wvvw,mass.gov/dia CT1Y OF SaLEM ' PUBLIC P�OBP.�1Y :, DEP�lSTMFNT �...�.�.�.. w.a. �s..�Amr.sira�xN.wa�t.Ot+l� lticll►T��lM�fasf9�1�►lW COasdrnedo� Dee� DMpotat Mldsvit (�.qNtr�i ew.�l d�osWioa.e�wsw�daa.a�q � 1s aooaid�ms wid���•,4'�{ ��Cod�7S0 C��eedo�lit.! �ti�� b hrs�i�rhL�eoe�da��t�dib��Aw1 cl+Y wae!A�II�dl�a�o�i�s po��r 1fe�i�rrM dt�ad Adgqt a�dd�t b�r liti.s 1 l l.i tlOA. � 'I1�dt�rl��rill b�0�'a�oeb��t �� S���-P `���-�� (a�d�lrl n,.a�+a�+nb.ai�o,.+ott�: (a�o(A�rf , laJ��alAriliM ��//�—r LW��O�a�il�p011caat � ) � 1 � 1�� � � , �. �.��. . _: ;; � �OOfj � .!�'%/UJ1,Dt� -S'C✓��/.>U�F_ �} Q ,y,3� ��z,.15 II rG,--.-�/ST/NG _Doo�S _._T_o__���i!iL __ _ .___ _------_.. __ . - ' � / . 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