18-20 MALL ST - BUILDING INSPECTION e ,
What is the current use of the Building?
Material of Building? W o o 4 If dwelling.how many un'Ra? .-
Will the Building Conform to Law? �¢�•! Asbestos? ND
Architect's Name
Address and Phone
Mechanic's Name_,� DST �����lE„�
�
Address and Phon
e
Supervisors Ucense M
SO �'O HIC Registration# �-2.T
Construction
Estimated Cost of Project i� Permit Fee C Cost
Xtlon
�t Estimated
� ) ated Cost X s7IS1000 Residential
5-O�J
Permit Fes i ----
_ Estimated GoatX S4VS100O Commercia -asr--------- -
�I'y� 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 -
Date 9 Z—
N
it —
Crry-OF
PUBLIC PROPERTY
DEPARTMENT
10NCSFJ"I)RMC 1. �e o
�(wvo11 130 WAR1W(.'WW SIltBi *!MAW%USI c.HLsk-rm 01970
Tn-9. 7aS-9"S•FAX 976740."U
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILD
1.0 SITE INFORMATION
Location Name: Building:
--- - Property Address:— - _ o -
S4L-L'zrl ✓MA D 210
Property Is located in a.Conservation Aroa YM Historic Dbkk1 YIN
2.0 OWNERSHIP INFORMATION
2A Owner of Land `
Name: t}A2P464' 4' F*,Vlek- 464-L1 00vv4f
Address: S7)e
Telephone: 7 7
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 �Sp
of existing building New
Brief Description of Proposed Work:
elf771 fio 7 A'et- iCoovc
-------Mail Permit to: �41 4�Ae --
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1vr.,yu�.::aclaEEt�l�tifl,
To.9Tf74i•)s" •F..x 979a40-964
Construction Debris Disposat Affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 7S0 Cl`1R section 111.5
Debris, and the provisions of v1GL c 40.S 54.
Building Permit N - , is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by N1GL c
11 t, S 150A.
The debris will be transported by:
livama of hauler)
fhe:lcbris will be disposed of in :
(awne of facility)
faci ay)
iL
!� CITY OF SALEM
PUBLIC PROPRERTY
''�`'y DEPARTMENT
nt\tnf'R[F.Y URIS[:ULL
MAY(* 12...WAilILINGTONStRUT 4 SAIEM.WA11ACltt\FAT%0J97'J
'rr1:978-745.9595 •FAX:9M740•9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Infilrmation I / Please Print Leeibly
Name tBu<itxsstorpnizatiotvindiv,duni): 13 i-Le rr- —r'
Address: �/ �'Lrtl7-24e J�T
City/Stare/zip: P 0,0129AA
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1
6. New construction
employees(full antlJur part-time).• have hind the sub-contractors
2 1 am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑ Remodeling
A:hip and have no employees These sub-contractors have S. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance.
Y9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
Electrical repairs r it'
rcquiretl] officers have exercised their 10.❑ W rs o additions
3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12•❑ Roof repairs
insurance required.] l employees. [No workers' 13.❑Other
comp. insurance required.]
-Ally applicaua nut chucks blot el must Also fill out the section below Allowing their workers'campataatiws policy infurtrWiurL
'lfomsetwrers who submit this affidavit indicating they are doing all wait am then hire outside raa cootors most sulanit a new amdavit indicating utch.
�Cantrxttes that Omit this bax must attached an additional fret showing the naae of tlm sub-comricion and their wohan'romp.policy inanmaaun.
l am an employer that Ls providing workers'compensadon insurance for)ny etnployeer. Below is the polity and fob site
information.
insurance Company Name: ----
Policy q or Self-ins. Lie.>f: _._ ... .__._ Expiration Date:
Job Site Address: Cityislate/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
(tn canganons ul'thc DIA for insurance coverage verification.
Isla hereby certify nder the pains and penalties ufperfary that the informallon provided above is true and correct
Si•:,:uure: �� Date'
Milne— : 7199G
Uncial use only. no not write in Ntis area,to be compleled by city or town official
City or Town: Permit/License tl
Issuing Authority(circle one):
I. nuard of Health 2. Building Department 3.City),rown Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: — Phone N:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire.
express or implied,oral or written."
:Vt eotployer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of ao individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally.MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance 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
Industrial Accidents. Should you have any questions regarding the law or if you am required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by Elie city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
year. Where a home owner or citizen 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.
Thu Otiix of Investigations would bike to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call. -
The Departnnent's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
O®ee of Investipdons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
MORTGAGE INSPECTION
BAY STATE SURYtAt G ASSOCIATES .. .
200 CUMMINC,S CENTER, SUITE 316J, BEVERLY;MA.,slim
SAL�MLOCATION :................... (MA . NOTES:
SCALE : V = 30 DATE Sl hi- 197 1)+This is,q mortgage inspection survey and not an
•� ;t �lnstrument survey, therefore this plot plan is for
REFERENCE : )ta (7Z9S� PG�So9 mortgage inspection purposes only.
5S� OVTN D I Rler > Z)T►iis survey is based on survey marks of others.
X 'S *T••• $)Bushes,"shrubs,fences and tree lines do not
R151'2�/ 0 . PEQS necessarily indicate property lines.
4 Whenever,an offset is 1' +_or less an instrument
ro: ..� IoRTGf)GE NE71✓o ;K u µ is .:.i;, ,
••'••• u�i .. . -•,ava. s N�,.recpfnmehded to determine property
The location of the building(s)as shown, either lines, and any possible encroachments.
complied with the local zoning setbacks'aftime of `5) Offsets shown are'approximate, and are to be
construction or is exempt irorr dpn•I4r for the-determination of zoning, Not to
enforcement action under Mass G:i Title VII.� t,agw be' used to establish property lines.
Chapter 40A Section 7 N/a '" F � I)�{n r�iy,p�ofess'ional opinion the building(s) are not
h. .. located (n the special.flood hazard zone, as
:u UMiIIY " T �: efinedbyF�UD.Y•,F
, " SEE:JVUTE*g
I I ') Thi_ is a nortpaa: :n,
iK c Y'ci �pii �jjG mortgage insprcULI
Al hrs burl.ey is *10 0f
At •f.I
M[ir oa oy
DF-;! .r 5:r wnec S's3r ply ii ,p G
When'.eGer r .o „i ROBERT
4)
• -� W.D�C•.14 1rV�C.
`� JAMES ..
.'.-. . . �. . . . ,. . survey Is rec. nrt en-t SOTiROS �'
No.26094
_)rtstts show..,..; 9
. r+: s -vi•aat �:; used on':;flr �FP �r+15T£Q'�P,
- - '„ss. G.L. Title VIl be uses 1 � Al , NO S`� " • _
,a4'"
6) in,fi`i p fessiunai
located in the spec.;! ..
>,''kdeflhed by H.U.C.
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