74-76 LINDEN ST - BUILDING INSPECTION i
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PUBLIC PROPERTY
DEPARTMENT
Ki%Q*Jd.FY 02151:(1LL
MAYOR 130 WAAUNG"S-MEEr•SMA3%.S1A%AGHLSL17M 01970
Tt3-9:1e-745.9S"*FAX 976-740-9846
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION.
DE"WAOLITIM OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Loo;W Name: { Building:
Property Address: i
property is located in a; Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: s v✓o
Address:
Telephone: K�E
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:
clior-VVI
-------- --Mail Permit to�l�—�Q�+�
What is the current use of the Building? citi R 1 Red/�
Material of Building? %• eo n r�l If dwelling, how many units? �
Will the Building Con{orm to Law? f Asbestos? V 0
Architect's Name(l—
Address and Phone A
Mechanic's Name Ad ov-\
Address and Phone /a e--
Construction Supervisors License# HIC Registration# 'J D
Estimated Cost of Project$ � 0 O b Permit Fee Calculation
Permit Fee i D Estimated Cost X$7/$1000 Residential
L Estimated Cost X$11/$1000 Commercial
L k 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 Q ��
Date
of
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------ ----
CITY OF SAL.EM
PUBLIC PROPRERTY
DEPARTMENT
xnr.eata,t
N.►voa
uo wArmvcro SMW e JMM4 X"UXM= is 01970
'ItL M745."" a FAX 97sa40-M"
Workers' Compensat[on Insurance Atsdavits BnlldwWContraetGrxM*epjclanWj%M
Aoodeant Informationbem
Int .gibl .
Name(9utieea.�Orpniauoe/tnmvidvaf):�i : 1 °� f_ ( /
Address:_.f_4� �
City/StatNZip: n[�L°�_ phone#:_ 7 l t�
Are you an employer?Cheek the appropriate boss:
1.131 am a employer with 4. ❑ I a general contractor and I Type of pro] ( .
MPIOYOM(fhU and/or part-time).• havehired the atbconnacton 1. ❑New congroction
2. I am a sole proprietor or parOM6 li on the aneebed sheet t 7. ❑Remodeling
ship and have no employees T subcoanacmn haw 8. ❑Demolition
working for me in any capacity. Wrs'comp,ioummee
No wmkma'comp inntnnq 3. Ws a corporation and its 9' 13 i additim
req�at] on have exercised their 10.0 Slecnical repair or additions
3.(] I am a homeowner doing all work rif
myself.(No workers' ex01D�d Pe MOL 11.Q Plumbing repain or addition
inauance ] comp o YceL and we have no 12, Reofrepain
em;!-
yeeL(No workers'
coinwuaaee required] 13. Other
t� WIND a�dds ban aaMddwk eg as do asedan belowMint;Ask�a� .ooeyMpyya poft iedsutloa
rCam.e.ms dais dwk ids bar man ao.ae. addfandals�duenil Ann doing i°vadt d than erm soots.eoraea.r.m.s sent.new aaldwo Waco ne ane<
MMMMMMMOMMOMM� dwries dw ant.of dw aobeana.elow and dek abeam.'camp,p.aey
/am an ensployer that Is providing worbrs'coarpeneedea hssarouc� or
injormadow f my enrpleyeea Below Is the paltry and fob rise
rnsurance Company Name: v�t ye.V— w
Polity M or Sepias.Lie.dk
Expiration Date
Job SiteAddttsa �� C,r ��v� f
City/State/Zip;_ Sa e t v��
Attach a copy of the worker'compensation policy dechvsttlou pap(showingthe
Failure to secure coven as e impPalle number and eapintloa dated
coverage required under Section 23A of s ci a nsi can led te the imposition otcriminal p@zWde ofa
feu up to S I,300.00 and/or one-year imprisonment,as well as civil penalde in the form of a STOP WORK ORDER and a fine
of up to 5230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of}Ice of
Investigations of the DIA for insurance coverage verification
/do hereby c
'eOWder the paGsr and pens/der per/a9'that the I%iaradow providsd above is
aw and comrd
hone M:
3 �(
o lefal use on/Se Do not write is thb area,to be completed by clip or town ofjTc/o[
City or Town: PermiNtkease M
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/rown Clerk
6.Other 4- Electrical Inspector S. Plumbing Inspector
Contact Person:
Phone p:
Information and Instructions
_ rovids workers' comveosation for their mployae•
aws chapter t 52 requites all MVWY s top an contract of his0.
Pursuant;Massachusetts this s�Lan#atpleYw is defined as"...every person is the service of another under y ,
express at implied.Orel or wriress"
_ aasoeiatie4 corp°r+ti0u°r°�legal wry•�any two a mows
is defined as"an individual,pasmetsbrR va of a deceased emPIGM°r the
M��mg engaged is a joint entnspnsl.and inchndiag °
afft
receiver a trusty of as m&vndud.Partnership.assaena�a other teasdes °r ooc+tp+K�
owner �do Quenon or repair work an weh darellini bouts
amploysdwoWU*bo`WO(aDAWwb*4 of such employment be deemed to be an tmtploYW--"
a on the grounds or Wading appurm"thereto shall not becsom
or local licensing
withbold do ba""or
MOL chapter 152.42SC(6)also sum that ar t1b buildings O is�CO�oswealth for WW
resrwal of s unns or pacsit to°p GIs wldaw et eetsptlases with the harm secs coverage req°4ed'"rhaD
applicant who tut net produced tunes"Nei�er commonwealth nor am of is Political subdivisions
A"'; contract chsfor 132.performance work until acceptable evidence of compliance with the insurance
enterof this chaptor bzvg him p�to the conesanng aurboft"
«q
Applicants aacely.bycompensation affid"A am* chaelds;the boxes that apply to Your situation"if
Pteanecea ° s address(CS) Phone rid Liability ps 'hhips��q" )of
th no=WWYON o ff then the
Branco. Limited Liability Cary,supply omp!°1°+ norDesua insurance. If an LLC a LLP does have
members a partners,are not raprired to workers'
this s' - I may be submitted to the Department of Industrid
a pow is requited. Be advised
employees. coverage. Mao be sure to sip and date the afndavlt The affidavit
Accidents should
far confirmstios of insurance ication fa the permit or He="is being regmstad.net the Dapar�
Industrial
n Of
mauned�W°tL Should you htown that ave MY gue+tOns�d the law or it you are required to obtain s workers
Irk"l tease csil the Deparmment t the. numbs listed below. Self moored companies should carer their
compenssm°n P°�Y.P
self-inaaacoe license mtmber au the
City or Tows Omdak s space at the bottom
Please be tyre that
the affidavit is complete and printed legibly. The Department Provided
of the affidavit for you to fill out is the event the Office of Investigations has to contact you regarding the applicant
Please be sae m fill in the permivUcense number which will be used as a reference number. is addition-i as applicant
ting current
applications in any given year,need only submit one affidavit indicating eurtent
that must submit multiplepuntimiceass
under Job Sine Addrese the applicant should write"all locations is----(city of
policy information(i stamped a marked by the city or town may be Provided
town)."A copy of the affidavit that Ines been officially a licenses. A now afudrvu mwt be tilted out each
applicant as proof that a valid affidavit is on file for Rrnao permits not rotated to any business or commercial vsnonuo
year.` hm a home owner a citizen is obtaining a license or permit
buts leaves ems)said person is NOT required to complete this affidavit.
(i.e.a dog license a permit to ou have an questions,
would like to thank you in advance for your cooperation and should y Y
T}1C office of investigatio give us a ca1L
phase do not hesitate togi
The pepart nent's address.telephorro and SWth of MmaChusettl
DCWMUW of Indu5l W ACCI&Mtz
Otaa d Iavad;adooa
600%Alinsm street
Boston,MA 02111
TeL #617-727-4900 W 406 cc 1-877-MASSAFE
Fax#617-727-7749
Reviscd 5-26.05 WwW.IDaS1.80v/&&
�\ Board of Building Regulatlonalf and Standards . Winse or registration valid for Individul use only
HOME IMPROVEMENT CONTRACTOR. before the expiration date. If found return to:
Registration 149630" Board of Building Regulations sold Standards
9 r Expiration t126l2008 One Ashburton Place Rm 1301
o 1 Boston Ma.6210E
BIG BLOCK CONSTRUCTION --'"-
GARRETT SHEA I,\'+'
10 PEARL ST
SALEM,MA0197Q - Administrator - Not valid without signature. " '