300 LAFAYETTE ST - BUILDING INSPECTION EI`rro - 3XLEti --
PUBLIC PROPERTY
DEPARIIvMNT
uAYM 130 WMMNG CW h',M=�. SMk.K v(AAAcxLst1'rs 01970
To.97e-74S-9S"0 FAX 976740.9146 -
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Locatlon Name: b Building:
-Property-Address. 3.bo a S-4- --- T— —
S& ce�
Properly is located in a:Conservation Area Y Historic 0
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: 'Da.V-e- G b 1 V1
Address: Soo L4�a Ye
Telephone: 976� Sys=a G —
3.0 COMPLETE THIS SECTION FOR WORK IN EXMI NG 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
aria(Description of Proposed Work: C J }t s IA4
Mail Permit to: 7 7U
What is the current use of the Building?
Material of Building? WLZI If dwelling, how riany units? y
Will the Building Conform to Law? ° S Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$J— Permit Fee Calculation
Permit Fee$ �0 Estimated Cost X$71$1000 Residential
-- Estimated Cost X$11/$100o 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 t� build
to the above stated
specifications. Signed under penalty of perjury
Date o
N
a � N
V y
I
a � �
9 g`
a
CITY OF SALEM
PUBLIC PROPRERTY
. DEPARTMENT
anrtaasarnaocott
Mnvoa I"pASE046 M STMT a Setter,MAC 01970
Tit.WI.745-939S a FAX 9W40.9W
Workers' Compensaden Imureence APRdawt: Sunderst/Contmtora/Eiectdda=jphmlbera
ADDUcant Information Plum D..tnt Legibly
Name/ ): rl��� �(�V1S�Yii �,�ii�� \1P �17nlYl of 1r7�
Address: - c C�-n a g Y o p
c;lyisrawz;p: Le rn N\A D�G Pw»e q 8 542 f q u
Are you am esphsyw?Cheek the appropriate best
1. I am a employer with+ 4. Q I am a general contractor and I Type of Praia"( :
employes(fbil andlar pat tim40 have hind the wbeone a000n 6' ❑Now construction
2.Q I am a salt proprietor or pamer. listed on oho auached dheet t 7. Q Remodeling
slip and have no employees The" have 1. Q Demolition
working for me in any capacity. worker•comp,imuranM
(No warkas'Comp.iMRMWCe S. Q We an a corporation and its 9. [3 Building addition
required.] officers have"Weis"their IO.Q MW&ICal repulse or addaiow
3.[31 am a homeowner doing all work right of axotaptian per MOL 11.13 Phuabing repairs or addition
usy"hL(No worker'comp. a 132,41(4).and we have no 12.Q Roofreptir
innraocs ie4�]t employees.No worker' 13.Q amm camp.;Dia an re"ired.j
Aar sat err drab ton rl onto ales fro also os satyr tMw reoNea dWr woven
Hameowoaraswbodt SO*b10adeiQrwddgad we*ddmWmoas&co cmea a6eit awe�rl:aawaeaa MM obak dW boa roam ntabad r addttlaaat rasm r6wlea tlr arms of da robaaatraearr d o suwaka a•eomF tkoksI am on 0AMPAR)w Shot aaa
brjorwadaa d workers cowpemsadow bmraweeJor my ewo/oyea. Below b&aPolfey andJob sAtr
u
Insurance Company Name: ` 1 a-Y-L O-Y-d
Policy 4 or Self-ins.Lie t> ` -3(,,,b U�-[,�,
1?spieation Dare: I i I G-FS
Job Site Address WO L tx p 4c S( Cityis )l ky AAA 0l G�
Attach a copy of ebb worker'coon don Poley deeiuratlen pals(showy the policy number and espfradon da"),
Failure to secure coverlt+"required under Section 23A of MOL a 132 can lead to the imposition of criminal penalties of a,fine up to S1.300.00 and/or one-year imprisonment,as well"civil penalties in the torus eta STOP WORK ORDER and a fie•of up to$250.00 a day alaiont the violater. Be advised that a copy of this statement may be forwarded to the Oflfce of Investigations of the DIA for insurance coverage verification,
/do herby rerat/y awCer the pahu aw/pewddes ojper/wy that rAt InfWASedoe providW above 4 eve and tarred
Signature•
Da
Phone M
F,Ojffl,kckkds ox4% Do mot wite iw rh4 are&,te bar eowphW bydryorteww o,Qlc4d
wn: Permilluemethority(circle one):
fHealth 2.sullellnl Department I Ctry/rown Clark 4. Electrical Inspector 3.Plumbing Inspector
.
Contact Person: Phone M:
Information and Instrucz 1Um
tea.--chum G�� 1 S2 requires all employers to provide workers
compeos>ti°°for
their employ
Laws chapter "...every person in the service Of another under any eottttact of bite.
Purstant to this stet v m u defined as
express or mtPlted.sal or° "
asweiatio4 w�O°or°�legal�'a my two a mow
An empfeYer is defined m"m iedividual.parmasbilh the 1� of a deceased e>np .Or ths
of the foregoing a mmdi .!>�a eomwpruwk aaweta ica of other left entity-m'Pit",empweo
receiver or trusty and who resides therein.at the ocatPam of list
owner of a dwelling house bwAag not mew thm thma ttpasunmu mpskwodt an such dwelling bousa
d try Room of mkother who employ+lnotbecom ofsochemp be cOOsuucdm deemed to be m empbye•"
Or on the poundsat building sW
MrJL chgow 152.125CM also states that"rr�'�or teal setting agency ss eossenweaW tar aS►ytar err
renewal at a Beemm or Pttrtsit to Spares•deviasea e a a eesaorset bai{dis0
appa.m whs has sat Predated aeeaptabie avMaw et a conmcee wk►the Issuraw eel"s required'"
Additionally,MC%ebapew 152.12SC(f)states"Nerthar the comntmweahh id auy ce of ib pOliacal with the
shall
sneer into any econam fpr the pafammtm Of public wall omit acceptable evidence otcompliaace with the insumOa
ccq dremme of this eMptw bx"bean presented to the watpedng swhor" •"Y
APplICS1115 chwjem$the boxes that apply toyour silustim and.it
Please fill out the wakes' aglan a phow umber(s)along with their eertifieate(s)of
neees"SY,supply mp. (S)name(t),addras(L �Wnft fps CLLp)with no
employea other than the
;wee. Limited Liability Comp!n16a al-C) insurance. If m LLC a LLP doe.have
nag required to carry wotkms eon of Indvmw
members 416 16employsa ia�regdre& as advised�this affdavit may be stbmitted to rhs IJepartmens
covers@& Abe be sure to sip and date the affldavlL The affdavit sbcold
Accidents for conArmatiaa of imrranea a license is being regtusted,net the Depafisu�
be returned to the city Or town Mm M you have any 4ue�Ons to dr iaw a if you are required toobtain a w9>haa
InClustricompensation poft.plow all the DapeM�st the number listed below. Sal!greased eempaniea*cold enter
self-insurance license ssssdtt on the
agoto line,
City or TWO Ot!lelab has provided a since at the boa=
Place be we that the afildsvit is complete and Premed legibly The hem
of the affidavit for you to fill out in the event the Office of Inve used
has to contact you regarding o apapplic
Please be sure to fill in the pm=Wliceme number which will be used ,a need
owce mtmi o a addition- i applicant
that must Submit muitipls pantit�llceaaa
lieatiooa in any scum year,need only submit one affidavit indicating icilycurrent
tntarnsatine(if necwary)and under Job Site Add me the applicant should write"all locations is -iO+tY or
policy a marked by the city a town may be provided to the
town)."A Copy Of the affidavit that bm be"Officially Or Itcenas• A new dL-1&va must be filled OW each
applicant as tsroof�a valid affidavit is os file for thane pertntb not telatsd to my ttusineaa a commercial usenet
yew.Whets a home owner a citizen is obtaining a Geese a permit
y to burn laves etc.)said person is NOT required To complete this afIIdavit
(i.e. a dog Geese a P�h
ne would like to thank you in advance for your cooperation and should you have any gm&nk
The Office ofMvestigatio
please do nor hesitme to giw us a call-
The pepyyment's addta%telephone and fact number•
The CommWWOkm Of Mal Wb SCttS
DgmUngd of b&stnd AmdieLb
O®a at IaveSdSMIsm
600 Wa Amgwa Sind
Boston MA 02111
Tel. #617-727-49M 09 406 of 1-877-MASSAFE
Fox#617-727-7749
Revised 5-26-05 www.IIlgg Vv/dig
Crry OF SALEM
PUBLIC pltopE m
DEPAE1MFNT
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