6 MARCH ST - BUILDING INSPECTION CrrroFSALEM ---
PUBLIC PROPERTY
DEPARTNIENT
KI.%A*.R NpRM[VV•
NAYM 13)WMMNGWM br%EU
5_s,\l,&sSncHt;stTls O1970
I's-97e-745-9595•It=978-740.9$"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Na Lvt; er i3
me: Building:
-PropeWAddress -
b ArC
Properly b located in a; Conservation Area YIN Al Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land L;,;g G-r+ ,A is Ven-+vr,-
Name: Lc/[ vd U -4 rc.
Address: oF9170
Telephone: —2yS- S-Y13g
3.0 COMPLETE THIS SECTION FOR WORK IN EXIST NG BUILDINGS ONLY
Addition Existing 3
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
BriW Description of Proposed Work:
lYe,no�e + 1,&PlAre Frco4 and SI"Je PvAcAi sa✓I-L aS ekfS41ti9
--------------
Mail Permit to: 6 6o
What is the current use of the Building? Re je, ><
Material of Building? WW If dwelling,how many units? 3
Will the Building Conform to Law? Asbestos? VIAI
Architect's Name
Address and Phone
Mechanic's Name �? otsiS/! /-�i7a'- 53 fib- 51 rI36
Address and Phone ri � �� P� ceyj��
Construction Supervisors license# <4 `D t to HIC Registration# l2L-2Y
Estimated Cost of Project$ 26 $Sa Permit Fee Calc uMm
Permit Fee S Estimated Cost X$7/i1000 Residential
--- -- - - - - _ - - Estimated Cost X$`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 t the�.Pbo stated
specifications. Signed under penalty of perjury
Date d
II
' y C
b Y
F a o
Z
CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tcnraeatar naacou.
MAYOR
IM WA*OWM STRW a sUM4 M&%M> W rs 01970
Tts:971-745-9S" a FAX 978-74G."%
Workers' Compensation Insurance Affidavit: BnIIderslContractorsMec4{cta=/Mmbers
Anokicant Information Please v.4ne r If
Name(Busimworpnibaodradivi"): ppr�,.Y
Address:_ /6 A,L,.
City/State/Zip:—po.. �L A/!.. Phone
A,n-,y�on an employer?Check the appropriate best
I.L� 1 am a general contractor and I �of proles Joe"
employer with�_ 4. ❑ I am a
employees(fiuli and/or part-time).• have hired the sub-couuactars 6• ❑New construction
2.Q 1 am a sole proprietor or partnerw listed on the attached sheet t 7. [Remodeling
ship and have no employes Them have S. WEN:
working for an in any capacity. workers'comp,insurance. 9.
(No workers'comp.insurance 5. Q We ate a corporation and its Q Building addition
required.) offices have exercised they 10.13 Elecuied repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.Q Plumbing repairs or additional
Myself [No works=' comp, c. 152,41(4),and we have no 12.Q Roofrepais
1n ]t employees.(No works='CO 13.Q Other
S Dance required)
*Any wpm dut ebeda boa#1 o oel alp aU out the secdca bolo.showed tb<tr waken - -
xoero.oen wbo gubedt"Ofilbvu mdteatloalthey a dokygal work red the hke ooWdr om omie a .tlids.tt hdlalleal.rL
=Coaaaemrs dot cbeek No boot none rueb<d an adMieca rhoet shming dr ng of as nomommunno� sob.eonoscoon god thetr workers ramp Policy bdbrmseaa
Inam an employer orwa"- - that L<provtdbrj workers'eowpenratlow GtsalraAee jar twy easployees Below is tAe polkyand job stela
I - - - ,� - - --
Insurance Company Name: ire-e 'r 1J e7 see
Policy#or Self-its.Lie #_ K U 13 - S%R CS YO -•/ 0r7 Expiration Date: /-cG5?
Job Site Address:_ 6 /Y/n r rA J /o�, /�/ City/Sttte/Zip:
Attach a copy of the workers'compensation 9 70
pe poBey declaration pap(slowing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the
penalties of a
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form off imposition OP WORIORDER and a fine
of up to 3250.00 a day against the violator Be advised that a copy of this statement maybe forwarded te the Office of Investigations of the DIA for insurance coverage verification
I do hereby ceregp undeJr tAAepabu and penaMcs ojper/ary that the Injorese*a provided above/s burr and comrea
Signature: �i1/L Da• f �� O `7
Phone
o,(jfelal use on/jt Do not write IN this area,to be completed by city o►town oQleld —
City or Town PermllMcense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Ciry/town Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phoue#
Information and Instructions
Massachuseua General Laws chapter 152 requires all cuT uyera to workerrvice of another undo any.compensation for their
net of bir0.'
NMUot to this statute.an enPfoyee is defined as ...every Person m these
express or implied.oral at written"
as"an individual.Partnership*asweiado0.corPor'adua Or other legal entity.or any two or atom
of he fo to n defined m a oint mterprisc.and including the legal repreamudva of s deceased employer.or the
of the foregoing engaged assoeiados err other legal entity,emPloYmI emploYeee However the
receiver or trustee of aunhaving
ba�PLO and who Mid"thrxein,at this occupant Of the
owner of a dwelling not nroro than three apatmenis
dwelling bouts of another w or wait on such dwelling house
who tmtploys P�to do maintesaue0.construction
or on the grounds or building appurtenant thereto shall not because of such employment be domed to be an employer."
152.$2SC(6)also states that"wary state or local Beaming agency slid wdthbold the ZINC*or
MGL chapter to ap�b a business or to construe buildings V the eammosw*sft tar any
resrwal of s tlaaes or pordt le evidence of amPHasm with the lusurt acs eoveraga regsbw
applicant who has not produced acceptable
Additionally,MGL chapter 132,$23CCn stun"Neither the commonwealth nor anyof its political subdivisions shall
of public welt until acceptable evidence of compliance with the insurance
enter into any contact fat the perfnrpaoea t0 the eonttacnne authority"
requi<emenb of this chapter have been presented
pppgeasb
tion affidavit completely.by checking the boxes that apply to Your simadm and.if
Please fin out the workers! c tor(s)same tea)and p�number(s)along with their caditcatda)Of
necessary.supply sub-contra °der)°�Ka), with no employees odwr than the
insurance. Limited Liability Companies(LL'C)or Limited Liability Pat insurance.
(�)�at LLP does have
members or parbers.arc not required to carry workers compensation
employees.a policy is Be advised that this affidavit may be submitted to the Department of lmdustrial
ould
Accidents for confirmation of utatramcc coverage Abe Ise sera b aces and date the requested,
�DapsrMcut Of
be returned to the city or town that the application for the permit or license is being equeated.
industrial Aecidamb Should YOO have any questions regarding the law or if you are required to obtain a worker'
call the Department aat the self-insurednumber listed below. self-insured cOmpauiea should enter their
compensation Policy-P
Sew inairstm Iceman number on the
city or Town Ofecials
the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Please be seta that ns has to contact you regarding the applicant
of the affidavit for you to fill out is the event the Office of investigations
Please be curs to fill in the permit/license number which will be used as a reference number. In dgivit i m applicant
that must submit multiple permit/liceOae appluaaons p any given year,need only submit one affidavit indicating current
policy information(if accessary)and under"Job Site Address"the applicant should write"all locations in__(he Or
or marked by the city a town may be provided to the
town)."A copy of the affidsvit.that has been officially supped r figma permits or licenses. A now af"-&vir must be filled Out each
applicant as proof that a valid affidavit is m file f e license a Permit not related to any business or commercial
ventuae
year.Where a home owner err citizen is obtaining to complete this affidavit.
(i.e. a doe Ucmw Or Permit to burn lava etc.)said perm is NOT requited pP
ens would like to thank YOU in advamee for your cooperation and should you have any questions,
The Office ofiavestieatio
please do not hesitate to give us a call.
The Department's addreaa,telephone and fax number:
The Commonwealth Of Massachusetts
M"Vbnent of lnfilahial Aocidenta
Olga of Isvadgli tons
600 WLAMgton sheet
Boston,MA 02111
Tel. #617-727-4900 ad 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 3-26.05 www.meaa.gov/dig
CYTY OF SALEM
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