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10 LEVAL RD - BUILDING INSPECTION (2) CITY-OF - 11.E �. PUBLIC PROPERTY DEPARTMENT o I:ImLLfE1t1.EY DRIS(:OIL / HAYO4 �js _ Q� M WASHINGTON STU-gr 4 SALF.M. IASUCHLSEI-IS 01970 TFU 978-74S-9S9S*FAX:978-740-9846 APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION, DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION 6� Location Name: / D /�, Building_ Property Address: /U Property is located in a; Conservation Area Y/N Q/i) Historic District Y/N y 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: C Address: Telephone: 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 (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: Mail Permit to: What is the current use of the Building?/______( S r r Material of Building? (P/U0-� If dwelling, how many units? -t Will the Building Conform to Law? Asbestos? /'0 Architect's Name Address and Phone ( ) Mechanic's Name 4 _ Address and Phone �� a 61 7 2— Construction Supervisors License# HIC Registration# G0 Estimated Cost of Project$,G O Permit Fee Calculation Permit Fee$ y7 Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional$5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Perm lid to the above stated specifications. Signed under penalty of perjury Date �I o O N 4tl N a a \ t 9 p ° o u -- - W - rL - - --uo� EITY OFSALE PUBLIC PROPERTY �34d� fyOd DEPARTMENT KI%MrALEY DRISCOLL MAYOR 120 WASHINCCON S1RFEr•SALLu .MASSACHLSLI-R 01970 1Vi 978-745-9595♦FAM 97&730-99" APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION. DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: 3 0/c/ Building: cfi (� Property Address: CJ Property is located©in a: Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: Mail Permit to: c� /� I - ` r What is the current use of the Building? � ' Material of Building? f/ll If dwelling, how many units? Will the Building Conform to Law? Asbestos? A/l Architect's Name Address and Phone ( 1 Mechanic's Name Address and Phone o >` s2 9 7 2 J Construction Supervisors License HIC Registration# Estimated Cost of Project$�5 Permit Fee Calculation Perm Fee$ 0 Y it 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 b ' to the above stated specifications. Signed under penalty of perjury X Date 0 N O ^ a 'O xt Y Q � a o 0 0 -- -- - _- W - cam- - o-- --ar-- -- a-- ------ -- ---- - -- — -- q, " s 1 tattoosntP y'yhgourd of Buflding�oBu EMENT CONT,RA�CTAR -. .�, ReBi� on'` 403394 =. - r on�7�2008hid - '°" N Ftk/A�TtE�RPORATIO IAUGHtIN CON, RoDerl I.au901in .4Bepo�tor 9`CHPS? BE�IERLY,MA 01915'A,..v II 4 CrrY OF SALEm ' PUBLIC PROPERTY DEPAR'TUENT wMMM"cancoLL al ma 13swASIDIGMsnmr•S"nl6Me96%0a'sa 4IW6 TEL-gW746.9SF11 Fae Y/a t W9W Construction Debris Disposal Affidavit Cagaired 63r sd daoondoa and mnomadom woeW Is aesotdsoes wilt tbs dxt6 edidoa of dw Sew DuUdisz CWI%780 CUR seedon 111.5 Debris.and dw provisiaw of MCd.a 40.S 54 Sund r4 lennit M it issued with dw soodidas that e6a dells n dit Dos Lids wait dad be diaposd of is a property►dean"wsw digm d bdiitlt an deQnad by MC IL s 1t1.31J011. The dd x%win be teas V*Md by: V , l� -- (ame a[bo*4 Ths debris win be disposed of in: 24Z L _ 7-,--, , S� � (Mies f rawo (aedeusr of lheitiry) ussas"dpan* dKe , CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIlNRERL.EIf Da15COLL MAYOn 120 WA%MIGTON STRM•SAt.eu,MAssACHuseTTs 01970 Th:972-745.9595 4 FAX 978-740.9846 Workers' Compensation Insurance Affidavit: Bullders/Contractors/Elechicians/Plnmbers Applicant Information / ) Plea n Le Name(Business/Orgaanirauowlndivi&Wy Address: Ciwstate/Zip: V Phone#: _9� k 9-22- Are you as employer?Check the appropriate box: 1.[Z I am a Type of Project(require*: employer with�_ 4. ❑ I am s general contractor and I employees(&H and/or part-done).• have hired the sub-contractors 6. New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp. insurance. 9, 0 Building addition [No workers'comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no insurance required]t employees.[No workers' 12•0 Roof repairs su Comp,insurance required] 13.❑Other *Any WPlieas the esoeb box e1 must atw NI out the section below showing their works s'compmsatbe policy iaformstise. Homeowners who submit thin aA1Mdt odWtins they an doing dl walk sod th®hka atatida eaotratscrs must suhor s mew stMava soh rCoeuersosa t!s check thin boa mot athched s additional sheet showing the was orthe aw*ok '�l�ky <hubrmade ass an employer that Is providing workers'compensation ineurance Information for my employees. Below is the pocky and fob site Insurance Company Name: Z/ Policy#or Self ins.Lie.p: O�/ G Expiration Date: 2 16 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and exptra a date)L Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigation of the DIA for insurance coverage verification. /do hereby ce n the pains and pen tier a that don information provided above Is awe and correct Si Phone C O/jfclal use only. Do not write In this area,to be completed by city or town o, let City or Town: Permit/License p Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone* Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eemlOye hirer. purwsot to this statute.an employef is defined as"...every person in the service of another under any express or implied,oral or written." o r is defined as"an individual.partnership,association.corporation or other legal entity,or any two ot intro An foregoing engaged in a jointenterprise.and including the legal representatives of a deceased employer.or the of the of an individual,partnership,assocution or other legal entity,employing employees. However the receiver ot trustee not more than three apartments res and who ides therein.or the oceupant of the owner of a dwelling house having construction or repair work on such dwelling house dwelling house of another employspersons to do not becaust to be an emp ot on the grounds or building who thereto shall not because of such employment be deemed lOY«• MGL chapter 152.$25C(6)also states that"every state or local lkensiag agency shag withhold the Issues"foror renewal of a license or permit to operate a business or to construct buildings is the commonwealth for eras applicant who has not prtddtited acceptable evidence of compilacs with the insurance coverage requh ed MGL chapter `nC*$25C(• )states"Neither the commonwealth not any of its political subdivisions shall Additionally, of public work until acceptable evidence of compliance with the insurance enter into any emu"for the performance red to the contracting authority-" requirements of this chapter have bien proses Applicants affidavit completely,by checking the boxes that apply to your situation and.if Please fill out the worker' compensation es and phone numbers)along with their certificates)of necessary.supply sub-contt°r(a)natne(s).address( ) with no employees other than the insurance. Limited Liability Companies(LLC)or Limited Liability insurance.Partnerships(f a�n)LLC or LLP does have members or parmers6 are not required to carry workers compensation employees,a policy is required. Be advised that this affidavit may be submitted to the Department Of Industrial Accidents for confirmation of hunuanee coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested.not the Department of have an regarding the law or if you art required to obtain a workers' Industrial Accidents. Should you Y q number listed below- Self-insured eompeniaa should enter their compensation policy,please call the Department at the self-ftwxanee license number on the a line City or Town Officiais Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at bolt of the affidavit for you to fill out dli erase umber which will be used as as in the event the office of Investigations reference to ncumber regardingt you addition, applicant Please be sure to fill in the permi lications in any given year.need only submit one affidavit indicating current that must submit multiple permidliceose app hcant should write"all locations in (city or policy information(if necessary)and under"Job Site Address"the app town). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to die applicant as proof that a valid~affidavit is on file for future permits or licenses. A new aMdnvit must be filled Out each year.where a home owner or titian is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do.pot hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Depaltment Of Wustfial'Accidenft OfRee d InvlstiptlOns 600 Washington SlIeet Boston,MA 02111 Tel. #617-727-4900 CA 406 or 1-g77-MASSAFE Fax#617-727-7749 Revised 5-26-05 www,nl M&OV1dli