19 MAPLE ST - BUILDING INSPECTION EI`� OF��1L __
``' ' PUBLIC PROPERTY ��
` ��� -y������ DEPt1RT'NiFNT �
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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' .
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Mail Permit to: �r� S�c • :1 '� � l� �
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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�
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' GT1Y OF $ALEM
' PUBLIC PROPERTY
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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:
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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.
'i't�e DePac�s�°t�'addceu,ukP�O and f�numbar: �
T�C���th Of Mi4StChuSetb
pepsttrncnt otIn��denb
081a ot Isvad�►noos
60o w��sata
s�,r,u�ozi t t
Tel. #617-727-4900 cxt 40b or 1-Sn-MASSAFE
Fax N 617-T27-7749
Ravised S•26-OS WVYW.ID89S.$Cv/dii
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