450 LORING AVE - BUILDING INSPECTION (. EITY-OF aALE1G
PUBLIC PROPERTY
DEPARTMETNT
IJ.mE)1LEY�wswu
MAYOR Q 120 WASHINGTON SWWr auger,MAiSAOiLsll'IS 01970
T-0:97&74S-959S*FAX:97&7i0-96"
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: VSV Building:
— -Property Address:— -
Property is located in a:Conservation Area YM zt Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land Alrf2C/
Name:
Address: /to kGR[y (, U
Telephone: 7�
3.0 COMPLETE THIS SECTION FOR WORK IN EXISII 1G18E LbiGLSILbiG BUILDINGS ONLY
Addition Existing f
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation
of existing building I I
New
Rrief Description of Proposed Work:
Mail Permit Y5D
h y
1
What is the current use of the Building?
Material of Building? l 4 /QO F�) If dwelling,how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name k6 C 2 5
Address and Phone 70 ����
Construction Supervisors Licesn�se�# d ���3 c/ HIC Registration# /� 3
Estimated Cost of Pro act$sL 0 Permit Fee Calculation
Permit Fee $ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial - -----
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the abov led
specifications. Signed under penalty of perjury X
Date r 3 `
of
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ttwaeat$v aaacou.
MAYOR
12o Wasm=pa:tracer.Sn[ea,MwssnCtsUsffTI3 01970
7%L•M745.9595 a FAX 978.7e098/6
Workers' Compensation Insurance Affidavit: Bnllders/Contnetersmecwcian&Mh mben
Applicant Infotrmadou PrintMease 1v
Name(eusioewoepo;aaodfndiv;dualy
Address: 7 Z) &12� k
City/State/Z[p:
=/%�L;�J Phone 1, 3
Are you ployes T Cheek the appropriate best
1. a employar with 4. ❑ I am a gtmeral contractor.and I [7.
Type of project(require*:
employees(Aril and/or part-time)." have hired the wb•contractors . ❑New eaoetrnction
2.❑ 1 am a sole proprietor or patmer6 listed on the attached sheet,t ❑Remodeling
ship and have no employees These sub-coatrscsoa haw . ❑Demolitim
working for me in any capacity. workers'comp,inanance[No workers'comp.insurance 5. ❑ We sm a corporation and its Building addit[m
required) OMCM have exercised their 10.13 Mccuieal repairs or addidoo;
3. 1 am a homeowner doing all work right of mmmpdm per MOL I Q]Plumbing repair;or addition;
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Raofrepairs
rnsu ce ran required.]t emplayem[No workers' 13.Cj Other comp.imams"required.]
'Asy ws�did chub boa et omit Yap tm nut the uedoa bdow s6oarfa4 stabretkys - -
stom.oyam,Who 0 6"tkis said" thy m daty ep.ak aed the bier ouulds eaetraeoys om�tt f
tCoamom that cock deb bee WM madad as adM=d zbe t doming to acme orthe mbeossaemta yid tadr rodosa•am*,
lass an emphryer that isprovidd4sr worhero'compensedon/nsuraycefor My employees. Below Is the
lnformadva - / - - paltry and Job s!a►
Insurance Company Namo:�l L�
Policy#or Self-ins.Lie. A 7J 2 7 ee-'
Expiration Date: ' 3 / - 7
Job Site Address: City/Stgwaip:
Attach a copy of the workers,compensados policy declaration page(showing the potlry number and exp(ntloa dab}
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the
fine up to$1,500.00 and/or one-yea im imporitim of criminal penalties of a
Y prisonment,as well as civil penalties in the form of a STOP WORK ORDER and a Rae
of up to$250.00 a day against the violator advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for' coverage verification.
/do hereby a rtijj an and penaldes ofperfyry AN At lnformadow provided above L bye and coded
Date- z -
23 —
Phone A I
ral rueonly, Do noe write Iw this area,to be comp/ped by tier or tows O lelaL
r Town: Permlt/Licenseg Authority(circle one):
rd of Healtk 2.Buildlag Department 3.Clty/rowa Clerk 4.Electrical Inspector S.Plumbing Inspector
er
Contact Person: Phone#•
Information and Instructions
isy
tts General Lava chapter 152 requires all empbyeu to provide workers'compensation for their employers of hire,
: .
pursuantthis staerm.an e.p&yee is defined as"...every person in the service of another under any contract
Massachuse
express or implied.oral or written."
aaso Wio4 eocpoeacon or° legal entity.or any two err more
of herpfoya n defined engaged in a oint wt"Pris%and��the k� ova of a deceased emPloym.or the
m the er Or trust aofnindividuaL association at other legal entity,employing employees. However the
owner of+dwelling house bavmg� 0�II thm apartments and who resides thereto,a the occupant of the
dwelling bouse of another who employs Pin+to do maimenow^ fconstruction��wort on to be such RM�
thereto shall not because 1 be deemed
b "
or on the groom or building appurtenant
MGL chapter 152.12SC(6)also stems that"every state er local&am'"agency shag witthoW the lasr+nee or
reaawai of a tleeost or permit to operate a business or to eoestrnat building+in the commouwaaith fee OW
acceptable avideaee of eompllaaea wkb the insurance coverage regoirad.
'o appaeant who bas not pr lad Scod 2 n "Neither the commonwealth nor and of its political subdivisions slosh
enterinto;;.MGL cb+for the petfornasoce Pm< lic work until acceptable evidence of compliance with the insurance
���of We chapter have bien presented to the contracting authority"
Applicants if
affidavit completely,by nu b the boxes that apply to Your(s)of
and.
Please fill out the workaW compeosentm
necessary.ruPPh! +)nama(s),addrere(es)and phone numberer(+)along w s than the
Limited Liability Companies(LLC)Or Limited Liability n insurance,
/O mbers to carry workers'wmpensati�i>uen+nCO• If en ep err ent dos have
0°6II1 a °c'ate not & Bye advised that this affidavit may be submitted m the Department of IndustAal
�Osp�ds'a wont policy u Hof ins rsnce coverage. Ababa sure to s�and date the affWAVIL The affidavit should
Accidents fer confirmation application for the permit a license is being requested,not the Department of
be returned m the city er town that the app' the law er if you are required m obtain a workers'
have any questions a the number
fndustrisl Accidents. Shot"You et the number listed below. Self-insured companies thorned enter their
compensation Policy,please call the Deparem lies
self-insurance license amber on the
City or Town Off
printed legibly. The Department his provided a space at the bottom
Please be sure that the affidavit is complete and prim fin y to s has tocontact you regarding the applicam.
of the affidavit for you to fill out in the event the Office of Investigate
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
locations in any given year,need only submit one affidavit indicating current
that must submit muff ne permi)and n applications applicant:should write"an locations in__(city er
policy. (if necessary)and under Jab Site Aransas"the a�by the city or town may be provided m the
town)."A copy of the affidavit that has been officially stamped tt er licenses Anew atudrvir must be filled out each
applicant as proof that a valid affidavit is on file for firers permits permit
year.When a home owner or citizen is obtaining a license err pernmt not related m any business or commercial venous
to burn leaves etc.)said person is NOT required to complete this affidavit.
(i.e. a dog license or Permit
would like to you in advance for your cooperation and should you have any questions.
The Office of Investigation
s
please do not hesitate to give us a call.
The Departmenes address.telephone and fat number.
The COMMOnweeth Of Massachusetts
Department of lid %UW Accidents
offiee of Iavadpdona
600 WLAM80on stoat
Bost^MA 02111
TeL N 617-727-4900 ext 406 to 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26-05 www,mmgov/dia
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