24 LATHROP ST - BUILDING INSPECTION CITY-Or~ --
PUBLIC PROPERTY
DEPARTMENT
KI. MU"o { y
MAYOR 120WAS aricrrx+hrREEz•Sn►Lati XAssAttrt;serts 01970
Tm 97e.745-959S•JrAx 97&740.9er6
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
11.0 SITE INFORMATION
Location Name: Lt c St- Building:
-- -Property-Address: — ------ — -- — —
-1 S�
Property is located In a: Conservation Area YIN Hlstorlc Dletrict Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: Spy nN
Address: Zq LaVu St 5�112m ��
Telephone: G'93 - XC - 57 7r
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing Z
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
BriefDescriptioJn of Proposed Work:
Gnl;(
S/ H�^ � QiUG�
— —Mail Permit to: --
What is the current use of the I Building? SI y �'d'
Material of Building? �'7 �I If dwelling.how many units?
Will the Building Conform to Law? yC5 Asbestos? il d
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone l� /rVvh k h S
Construction Supervisors License# 6 HIC Registration# I6 C S6
Estimated Cost of P ject 6506 i7° permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
-- - - - - - --— -- —-- EstimatertCost X$i 1/$100o Commerc:at 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 2 o
Date /A,
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
snsaFatEr oatscou
MAra M WAstm,Mry SrRW a ULM4 MASSACHIMM01WO
T W 978-74S•9M a FAx.97t-740.9W
Workers' Compensation Insurance Affidavit: Bniidewcontractorlmectridana/pinmbers
Annticant Information } so n s
Name lBusineworpwiauowfndividud p): tl"P,kflit-
Addresa:lt7 wank La, s- .
CftyiStawzfp: -T4m AA 0rg70 PhoneN:_ ZZL 7Y - ga�23
Are you an employer?Check the appropriate bosh
1.❑ I am a employar with 4. ❑ I am a general contractor and I Type of w com(h :
employees(fldl and/or part-time).• have hind the sub-contracras 6.
[3 New °°ahuctian
2. 1 am a sole proprietor er parmat listed on the ausched shoat.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance.
(No workers'comp.insurance S. ❑ We am a corporation and its 9. [3 Building addidou
required] ofl)cars have exanised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of mrompelon per MOL 11.0 Plumbing repairs or additions
myself(No workers'comp. c. 15Z 11(41 and we have no
insurance required]t employees[No workers'comp
repairs
comp insurance required.] 13. Other
fAly Wdoo d a chum boa at mod den mt oat=sscom bolo.wowing b*w=b a
Hoorowma was submit this otgdevit mdlades they an duty AD wok sad dr atn cow& se Mar Minot wamY a We efiWav t
tCantraenn duet cheek dsb boa sera WNW as addidond shad Wowing du vama of dr '� -
and duo wodoes'camp pehhay khmWdM
raw an essployer that lot Pre vMMS worbers'cosepesssdoa haasreneejermy saep/oyees Blow b tb
injorwad" - - - - podey andjob Me
insurance Company Name:
Policy M or Self-ins Lie.N Expiration Date:
Job Site Address: Ciry/Statellip:
Attach a e:opy of the workers'compensation policy daelarados page(showing the policy number and expirsdas date
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the }
fine up to S 1,500.00 and/or one-year' imposition of criminal penalties of a
y unpriaonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Otlice of
investigations of the DIA for insurance coverage verification
!do hereby csrdp Mn* and penaGfer ojperjwy that the lnjorn edon provided above&bra and correct
'� / �T 07
Da
Phone N - 7T- 7ys -71L.2,
offleW sre only. Do not wdlh bs this area,to be cosrpleted by cUy or town o,Qfeial
City or Town: Permit/Lkense N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cltyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
ti.Other
Contact Person: Phone N.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employees to provide workers' compensation for their employees.
Pursuant to this statue,an�P�y ee is defined as"...every person in the service of another under any contrail of bier.
express or hnPlied.oral or written"
aaraciatioa Ou or O�legal C°tl1I'•or any two err t1101111
An sarploygo is defined as"an individual,isot an slip. ves of a deeessed employer,or the
of the foregoing cnaati� aloiett entapriae.and attchtdmg the 1� to However the
association a other legd wiry,employing amp Y�
receiver or,trusroa of an individual.parmushq. veho resides�je,or the Ooeulient of the
owner of a dwelling loofa b►ving not more then three spartnenis repair
Of wort on such dwelling hone
dwelling boom of another who employs Persons to do mmimmr^constmctiOe
or on the grounds or building appurtenant thaeeo shall not because of such employment be deemed to be an employer."
MGL chapter 132,12SC(6)also stater+that"every stab or local lleeeateg agancY dud[withhold the issuance or
b operate a business or to eoestruct buildings In the comtneeweakh fee aq
renewal of a tl has or partials produced
acceptable evidence of eomPgaeee with the insurance coverage regnirea.
has not Of its laical aub&videm shall
net NYO P " �nor political applicant the commonweal any
Apppatty.MGL chapter 132.$25C(n states-Neither la evidence of compliance with the insurance
performance of public work until acceptable "
iineto is cha contract ff have presented to the contracting authority.
Apptleeeb
compensation affidavit completely.by checking the bones that apply to-YOur situation and.if
Please fill out the wakaa'
sub-coatcwun(s)name(s).address(es)and P�number(s)90M with their Mei8cai*$)of
. Limited
partnerships(LLP)with no employees other than the
insurance- I incited Liability Companies(Ll�or Limited pens ttl
• insurance. if an LLC or I.I.P dot have
orkas
o w compensstion
not advised
t Industrial
members era �is wgsitr� He advised that this affidavit may bit submitted to the Department of
of insurance coverage. Alas ba sure b sign and dab the affidavit- The affidavit nt ould
of
Accidents for confirmation a license is being requested,not the Department
be renuted o the city or owe that the application Per the permit to obtain a workers'
Industrial Accidents. Should you have any questima regarding the law or if you are required
eomPmaation POHCY-Please call the Department lame. number listed below. Self-mi ued companies should enter their
self-insurance homes number on the
City or Town Officials
mete and printed legibly. The Department has provided a space at the bottom
Please be sure that the affidavit is comp Investigations die event the office of to contact you
of the affidavit for You to fill out Ulncense nuaoba w6icb will be u as as mPaenee number In�addt n.an
applicant
Please be nut o fill in the perermi ear,need only submit One affidavit indicating current
multiple pcemtNhoenae applications A any given y Y
that moat submit " Site Address"the applicant should write"aLL locations in_._(C1tY�
under Job
and o the
policy information(it necessary) or marked by the city er town may be provided
town)."A copy of the affidavit that has been officially stamped or licenses. A new afudrvit must be.filled Out each
that s valid affidavit Is on file Per Mine permits commereiat venture
applicant as proofa license or permit not related to any business err
year.Where a home owner or citizen is obtaining NOT required to complete this affidavit.
(i.e. a dog license or permit to burn leaves etc.)said person
would like tothank YOU in advance for your cooperation and should you have any questions,
� The Office of Investigations
please do not besitab to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Iil&whil Accidents
ogles of Investigations
600 washi1100111 sheen
Bosta%MA 021 It
Tel. #617-n74900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
Revised 5-26-05 VAVW masLpv/dia