80 LEACH ST - BUILDING INSPECTION E=-OFSAL 1 _-
PUBLIC PROPERTY
iOP6 a� DEPARTMENT
KI.%DIFRLEY DRISCOLL
MAYOR Oa 120 WASHINGTON SrnEEr•SALEK MA AACNI;SFTM 01970
TM--978-745-959S 6 FAX 978-740.9816
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1A SITE INFORMATION
Location Name: qb Le A 57 ,-e f ilding:
Property Address:
o°� Le,1011 (!T.
Property is located in a; conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: e,11 , 9y _ Sly
3.0 COMPLETE THIS SECTION FOR WORK IN EXtWJUG 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
Md De cription of Propose Work:
Mail Permit to:
or
What is the current use of the Building? �
Material of Building? If dwelling,how many unfts?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost Of Project$ /Q, L9° Permit Fee Calculation
G Permit Fee$ Estimated Cost X$71$1000 Residential
I Estimated Cost X$11/$1000 Commercial
(7 s An Additional $5.00 is added as an
i Administrative charge.
45
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Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT,
KEWMA EY DRI SCOL L
MAYOR .t
120 WA51@ICTON SI T a SALEK%IMUCHUMM 01970
TEL 978.745.9595 a FAX 978.740.980
Workers' Compensation Insurance Affidal BuUders/Contractors/ElecMcians/plmnbern
A licant Info atio
Pleas n L
Name(Business/Organiaoowbdividual): MBc�P(;v
¢rytces
Address: 7g NTo�I St `
City/State/Zip:_ EfgH,1 MA 01915 Phone#:_ �`d -S'�z —5ti ►3
A
iJyoa an employer?Check the appropriate bob.
1. I am a employer with Z 4. ❑ 1 am a general contractor and I Type of project(regnlred)•
2.❑ employees(&U and/or part-time).* have hired the subcontractors 6. ❑New construction
I am a$ole proprietor or partner. listed on the
ship and have no employees These su attached sheet,t 7. ❑Remodeling
working for me m any capacity. workoutado ntrscttua have S. ❑Demolition
[No workers'c ❑ We are a corporation
Lionbsu nd it `
required]. �� � 5. corporsti�and its 9' ❑��g addition
3. I required.]
a d. officers have exercised their 10.11 Electrical repairs or additions
meowner doing all work right of exemption per MGL 11.❑"plumb
myself.[No workers'comp. c. 152,§1(4),and we have no m8 reps or additions
insurance required.]t employees.[No workout' 12•❑Roof repairs
comp'uutuance rsquired j 13.0 Other
'Any epplkam that elreke box el trust also w out the taetian belay showing Mur wakes' polity ietbratadae. .
t[amaoevoen who submit thin w iud+atlna May an .
rContreetom Mucha*Mb boa naval uhehed w Wditiaoel hash w�a ro�Me*�aeetese mwt submh a new affidavit mdl�welt subeonu.dam cod their workno'comp,vohay iofana.tlaa
I am an employer that la provid/ng workers'catnpensadon insurance for my err ! ees. Below Is rite !
injormadon. P oy pa k7'and—job site
Insurance Company Name: lr&\j Q I ow
Policy#or Self-ins.Lic.#: dh ��
Expiration Date:
- Job Site Address;9 7 C�4 S 1
Attach Is copy of the workers'compensation City/StatelZip: _' A I e M -_.M R- 0 tg 7 p
Failure to secure coven pow declaration page(showing the policy number and expiration date}
coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal
fine up to 31.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a des a penalties of a
y against the violator. Be advised that a copy of this statement may be forwarded to the Office oP
Investigations of the DIA for insurance coverage verification
I do hereby cs ndsr the pa end peaalNer o r a
jPe ry that the in/orn►adan provided above!s blue and correct Si
OJJlelal use only. Do not write In thin area,10 be completed by city or town o/Jlciai
City or Town
Perm(t/I(name#
Issuing Authority(circle one):
.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Impactor
i. Board of Health 2
6.Other
Contact Person:
Phone#:
'2
moo ,
Z'� V