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19 MAPLE ST - BUILDING INSPECTION EI`� OF��1L __ ``' ' PUBLIC PROPERTY �� ` ��� -y������ DEPt1RT'NiFNT � ---� i:l�MFILLEY DRISL"OLL � ` MAYOR 1�A Wtiwt�cttu�5[xEEI 1"'.�,,,�-,W,vSncH�st�-rs O1970 � 1Fi 97&7�i959S�F,�x:97�7i0-9846 ' _ r� APPLICATION FOR THE REPr��- RENOVATION. CONSTRUCTION. DEMOLITION OR CAANGE OF USE OR OCCUPANCY. FOR ANY EXISTING . STRUCTURE OR BUILDING 1.0 SITE INFORMATION /g �'� Location Name: Building: ii Property Address: �C' �J��� P S% property is locate�'sn a; Conservatlon Area Y/N HlsWric DlaMct Y/N 2.0 OWNERSHIP INFORMATION II 2.1 Owner of Land T-e�% �v�' ,�,'�c c �� • Name: Address: ' �7�� �� � Telephone: , 7g 7S�/ 6� 3.0 COMPLETE THIS SECTION FOR WORK IN FY�aT�N� BUILDINGS ONLY Addition Existing �� Renovation Number of Stories Renovated Change in Use • New Demolition Existing / y-c>� Approximate year of � ��O Area per floor (s� Renovated construction or renovation of ezisting building New AriPf Description of Proposed Work: �� �p G C �>c�S �; �. � �����— �v�c'/� /c'�' ��, ,C� �` � /�ir �� G / vti �-`3i 'vzf `3 • �v D!` �!� �v/�'C�'f U �L� /lT.�/ /z �S /,S' . _ _ -- - — __ _ _ _ -- --_ _ _ _. __ Mail Permit to: �r� S�c • :1 '� � l� � L What is the current use of the Buiiding? ,�Jc37 ry e Material of Building? l-���� �f dwelling, how many units? � Will the Buiiding Conform to Law? "�° � � Asbestos? � Architect's Name Address and Phone /� � � Mechanic's Name ��� -� ��" "�''b'` Address and Phone�i /`�l�e.- �,P �j�/ ���99��y 5'�S- S?2- /G3,f' Construction Supervisors License#�J7S�og HIC Registration#� �.�� i Estimated Cost oi Project$ Uvv Permil Fee Calculation Permk Fee S 71 • �� Estimated Cost X$7/31000 Residential EsUmated Cost X$11/51000 Commercial � M Additional $5.00 is added as an AdministraUve charge. Make sure that all flelds are properly and legiby written to avoid delays in processing. The undersigned does hereby apply for a Building Permk to buil ove s specifications. Signed under penalty oi perJury �G � Date l� a �'- o� � �� �� i � � 0 N O .+ r1 � y O � � � � a a � �: � `•' S, � xc a "� �� a � o F '� C� C� a9i `' "' � � O � � u �+ 4 u� L " y - W . . � ---�0�--_ �_ ;- -.�__ - .--_ --- - -- _. . ___ i - � d a� r a/. q 71 , . ' GT1Y OF $ALEM ' PUBLIC PROPERTY :, D�Au�rr �� w�. ,�����.�.��o�.,. n��.�+�.�,���..�. ConsWctiae Debrls Df�posal AfUdsvit (ceq�irei�c:�ll daootldoa�oe emov�das w�oeb fa aaa�a with��ub adido�d16�Shet�tW�Cod�730 CbQ seedc�tl t.! ���p�v�o�dbiQ.e�0.��t By�'�py�� is l�o�i�r[t►�000d[da�tdt th�da6rir e�ault�s Aa� c1d�wart aAdl b�di�pa�d otis�pope�j►lledd�rra dlapad ddltt�t a�d�ned by A(R8.s 1 l l.S 1JOA. 'Ih�dedets aiil b�teampoetea by►: ��r�re ,l�vl9/�1 (oi�OtbM1� 7't�dcb�{s wiq b�di�po�ed o!in: ��o�s e / V �v` ' (naae�o(heiliM �r ��.� ���� �� � � uw�+�t��� ,, � � . �J ...29 — OG eu. ' ��;..,r�w. / • , CITY OF SALEM ;�. ;. PUBLIC PROPRERTY DEPART'MEN'I' ��� atiaroa uo Wwv�vcror,srneer. S.�c�.Mtiuu��artr�rrsot97o 741:97i74S9S9S �Fex:97t-7�G9SK Worken' Compensatlon Inswance AlHdavih Bnildera/Contncton/Etectr(¢lana/plumben Anolkant InformaHoe Ple � ptint Name tHusioes.rapn;auodrndivi�ai):__��Y�c�g s .y - ��o�r� �s,-�,P Address•--� /�/�.�— /� �X� ,� r9��v ��S'Go . ciry/statdZip: Plwne#: ,S'7s- ,r7.Z /6 � — wr.yo■ ..empiey.rt c3«t M..yproptf.a�oss 1.0 I am a empbyer wit6 / 4. Q I am�Ymen►conteacror aod 1 �°�P�OI�(K9dre�: �P�Y�+(!Wl and/or put-tima).• luva hieed t�wbconteactas 6• ❑Near canrteuction 2.0 1 am a aok pmpriewr a pumar IiseM on the aaached eheat t 7. �Remodelms s6ip and have no amployaa 'Thae wb�onh'acoon luve 8. �Demolidoa worldn� f�me m any cap�ciry. workas'comp,innuancs. 9. IAIu workus'eomp,inauranee . 3. � We ue a wrpaapon aod in ��°t+ddidon �4��) olHcaa hrve exeieised theis 10.�0ectricai rep�ies a addiHans 3.� I am a Lomeowner doin`rll work rig6t of mcampd�P�M(3L 1 I.(]Plumbiai repairs a additlonr myaeli[No worlceo'comp, a 1s2,41(4�and we hsva no 12.Q Roof repaics ��II��I t �P�aY�INo wcrken' 13.0 Other comp'i°au°°ce r�ui�,l f�+�r wv�ror chab baa rl mmt dw eu ou[te.+xdae Mo.��m.tr wa�t.. F(amqNues rAs a6dt�Ab dlld�vk 6�Neatln��y u�ddo��r��od ihe Mq auodd�om��o� ���a0td�vtl =Cantr�eton tmt e6aek tht�bmt mwt�thebd m dditlmJ�hMt���o�m��� �p�' � wb-oum�clas md�bir rarlm�'mmP i�Y�muiw. I ani aw e�pfoyn that!s provldJel work�rs'coap�naaJow Guwnwce jor nry emp/oy�ea Below/s Nb palfey andJob slAt LrjanwaWow� Insunace Company Name:�`g"� //T.� � .��t� . Policy M or 3elt-ina Lic.M:_ ��'.��i 7 S�O c� � Expiruion Date:_/ — .?D - O'7 -- Job Site Ad�w: � / ���P S/� c; is �9�� • Attaeh s eopy of tIr worken'wm nutb� ry ��� P� P��Y dalarado�pap(�Aowta�th�polky nom6ar and eiplratlo�dW), Failure w secum coveraQe ai requiied under gectioo ZSA oPMGL a 132 can lad ro rhe• fine up w SI,300.00 and/or o�-yar imPrisonmen�ai wep as civil �t�otarimiaal peoa(dp ots oP up to 5230.00 s day agaiaet the violstor. He adviaed that s copy of t6is mtement may be forwarded w the OfRce o nd a tine Inve�igations oP the DIA for insuraaee coverage verificatiey . /do hsrrby c�raJj� er na/d�r o/perjerp t ln � f w provld�/abaw!i prrt anl eorrrct ' - - 6 Phone k: S'7�'— ��oz �- 6?�� O,QTcla!ure on/�c Do net wrlt�!w di6 orsq to bi caeral�/bp�qp w tows o,dlclaL Clty or Towo: PermitlL[eewe M Iauln`Authoriry(cirele one): ' 1. Hoard of Nealt6 2.BuUdtn;Department 3,Ciry/1'ows Clerlc 4. Electrieal Inspntor S.Plumbin�Impector 6.Ot6er Contaet Penou• P600e p• Information and Instructions Massa�huseas General Lawa cIlaptac 152 requires a11 emP�oY���Provide woricas' compeasaaon fa their emPaY� sa ���������...every pe�soo in the service of ano�her undes auY contcad oELue. p„��ant w this suwos. ot implied.ocal°r wtttta�'' e� as"an individual.Pa��P+asaoeiadc4�R�tiO°°t°��0����«oy�,a the An�sptoyo is defimd m a oint eotap�ia�.������ntiva of s daeasad mP Y of ths foce�oini�Yri� � �ar ahar te�l m�i�Y.e�°P�Y���Oyca. Howevc�e ceceiva a austee of m individwi.P�'�R �who caidet t�aan.a�hs aaW��tbe ownat of s dwdlint hou�°hsvint uo�moca dun thraa�a �a�W��s�h daellinf ha� dwellin�h��ot amt�r w��P�Ys P�°�oo d�mainomanc0. ���m bs m emploY�-� ho �em si�all not beeausa of such emPloY�� or on dfa�a buildini aPP�O�°� �Wuaae�� 152.42sC(6)a1s°�"h'��°"°ry'�or�oeal tlee.sW���7�w►cekoW MGL chaPmr �o�yq a busine�or m eoWe¢d belWtaO i�th�commsaweattY tor W na�wal of a tleeost or peemk �e��l�evtdana ot eomptlun witY th�lasurasa coverap�Md�� 'pplkant�vM h�s�ot prodae� y�«Neither the commonwalth na anY of its political subdivisioor�iull Addition�lh�.MGL chip�132.$23��� ���wock until aceepvbl°avidence ot comPli��the insurana mter�����0����the concactini w+��Y•� rW ppplleub at8davit eomDkWY.t►Y��°IIi ehe boxa thu apP�Y�Your situadon and.it neceswry.o�FP1Y�'°O '�s)asme(s).�+�a)°°d P�O numbei(e)a1�i with their ce�ti8eate(��°t �s�¢aece. Limimd I.iabitity Compan��N-�oc Limirod Lisb�ti�Y Pa�°�P���)with��D�Y�°�thfn tha m�y�a p�mass,ate not iequired�°°�Y WO1�•�1D°�II�� If an I.I.0 oc I.[.Y doa hays ��p�y�q,s policy u ee4ui�d� B°°��this a89davit may be aubmiaed w�he Departmeat of lad�utrisl Acciden�s f�con6ssoado�04 inaasnce covaa�e. eWs b�san to ai;a and date the a�davif. '!he aPRdavit ahould be rowmed to t�s city or mwn t6at the applicadon fas the petmie or liceuee is beinQ requ�d.��s workers' Shaild Yon hsve snY 4�K��tha lsa oc if yw aza ro4u�d eompensaco°p°licr.n�O o.0 me Da���nnmbar uaed eelow. self-inaued co���'hdr seit inauanee 1�°°1��°II dte Cit�or Tow�0� Ptea+e be wre thst the affidavit is complete aad prisced legibiy. The Depar4neat has provided s space at the botmm of che atTid�vit for you to fill out in the eveat the OS'ica of Invesa�ns has w contact you regardinQ the applicaat. Pleaae ba wre to fill in the pem�iUliemee number w6ic6 wiil be used ar s referenca number. In additio4 sn aVP� t multfPte Pe���°�6�P�onr in aay�iven ywr.need ody submit one affidavit indicatini�°� tt�at muet wbmi ����Job Site Addraes"�applicaat�hould write"ap loatiom in__—��1�Y� ���cy infurmation(it necawY) or marked bY che ciry a wwn may be provided to the town)•"A copY of the aftidsvit that has been otAciallY s�a� or license�. A uew af"udrvu mu�t be 6lled out ach appllcaot as proof that a valid affidwit is oo fik for flmue pe�m►a ial venaue year.Whae s home ewner a eitizan is obuioini a li�ense°=P�ca�related w any bueiaeae a commae (i.e. a doi l'uenae a P�u m buen leava em.)said perwn is NOT re4uired t°�°mPieoe chis affidavit ou in advance for your eoopeeation and should You have any 4��� The Offica of inveaagation�would lika w thanic Y please do aot haitaca w give us a call. 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