41R MARCH ST - BUILDING INSPECTION — n l
What is the current use of the Building?
Material of Building? d?- i C✓l If dwelling.how many units?
Wig tM Bufiding Conform to Law? Yi S Asbestos? "
Archited's Name 4 . 1q` r'1 C V n7`r
Address d Phon 0 2-9-1bw Ck^931/t�16a✓ Sr �QLf a ( )��tp `l LI d S3S
VA
Mechanic's Name tA, J, i / 13 n� Tkl�z2 ppC
Address and Phone 37— c 4�CIV.0 Lbl
Sup��License 0 S-S a ZS3 HIC Registration
ConstructionEstimated Prof:
o Permit Fee Calculelfon
Permit Fee7tb—DEstimated Cost X$7/$1000 Residential
Estimated CostX$41/:1000 Commercial--—--
�� An Additional $5.00 is added as an
Administrative charge.
ar Mom sure that all fields are properly and legibly written to avoid delays in processing.
"J
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
x4LL==::L--
Date
i
T �Wi
a
EiTy-OF
PFWIQ) PUBLIC PROPERTY
DEPARTMENT
Uwroe 130 WAnaNGww brew•smA-,KwsAan:sr-rnot97o
APPi.ICATIO V FOR THE REPAIR. RENOVATION_ ONSTRUCTION4
DEMOLITION.OR CHANGE OF USE OR OCCUPANCY_ FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION '
Location Name / A O(L Xu& f� Building ti / �
Property is bested in a;Conservation Area Y/N N Historic District Y/N S
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land J V E d t Z-'
Name: S V 6 1 A +
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN 015MNG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building Now
abet Description of Proposed Work:
�12�9M �AILY'IyIG/v ( Jl✓� Z �ILI� Zn fyVLL Duo2pJ
A'l
C�c>c. /'billic� �/�re.izr.+ �dn.. Ph.K=u-h C97kJ
----- - ---Mail Permit to: - bLI A c..-r6& L )jqca ),(,n/ U g-sg5 C1�2 C C
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
..uWrier� ua.av�
\t.,,.• I��.�IL�Y::.x�5 at:sT�5.u:11.N..VL,t �t.t,1 s::aY.
To;97i7W)m O W40"
Construction Debris Disposat Affidavit
(reyuind rot all demolition aid renovation work)
In accordance w ith the sixth edition,of the Stu Building Code.790 CUR section l 11.3
Debris.and the provisions of M- GL a 40.S A
8uildins Permit A _ is issued with the condition that the debris resulting 11tom
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
1 It. 3130A.
The debris will be transported by:
O/LYW Fi/7 / lryl 4f)&V
(nam at hauler)
fhe debris will be disposed of in
h+ame ui iacdrty)
r .
Information and Instructions
Niassachusetts 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 hive,
express or implied,oral or written."
An employer 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 an 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."
NIGLthat"eve state or local licensing agency shall withhold the issuance or
chapter 152,§23C(6)als
o states "every
renewal
p
wal of a Ileenx or permit to operate a business or to construct buildings In the commonwealth for any
rene insurance coverage required."
not produced acceptable evidence of compUance with the Insures g eq
applicant who has p subdivisions shall
PPS an of its political
'+ '23C 7)states"Neither the commonwealth nor y
Additionally,into an,MGL chapter I S_,
enter into any contract for the perfomwnce of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to due 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 are 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
Phase be sure that the affidavit P idavit 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 fill in the pc:rmiblicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense applications in any given year,need only subunit 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 the 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 filled 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.
fhc Ottice of lnvestigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Dcpamnent's address,[elephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
O®ee of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
a
t
CITY OF SALEM
�. PUBLIC PROPRERTY
DEPARTMENT
nIURF RIF.Y URIR:ULL
M. yoR IY'WAiMNIG ON STREET•SAtEM.MAanu a.a rn 01979
TEL,978-745.9595 4 FAX:978.740.9846
Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers
Applicant information Please Print Leeibly
Name lducittcs/OrganilatioNlndivtduall: - 1 FJ( �(r✓I�L
Address: P-o.f 6 C- 12 LC cT
City/Statc/Zip: P 6 110oOP : Ali dV , 009 Phone N:_77? C,? d hlf Z
Arc you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 um a employer with 4. ❑ I am a general coutractor and 1 6. ❑ New constructionmployc_s(full andtur part-time).* have hired the sub-contractors
2 1 am a sole proprietor or partner- listed on the attached sheet. : 7. Remodeling
ship and have no employed; These sub-contractors.have 8. ❑Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its 10. Electrical re
required.) officers have exerci.�tcxi their ❑ pairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
-An)applicata lima checks boa 01 must also fill out the%ocliun lwWw showiag their workent eumpanataiot pulicy inf,nma n,
' Iloenvtwnrrs who submit this affidavit indicating they are doing all work and then him outside contractom must submit a new amdavil indicding",ch.
�C.n im,l n that cluck this box must artached an additional Aaact%hawing the nataa of tha sub-comraciam and their wer imni,comp.policy infwmatiun.
1 am an employer that Is providing)vrkers'compensadon hisurance for ray employees. Below is the pat/icy and job site
information.
Insurance Company Name: _
Policy k or Sclf-ins. Lis q: _.._. . ._.._ Expiration Date:
Job Site Address: CitylSlute/Zip:
Artach 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.IGL c. 152 can lead to the imposition of criminal penalties of a
rinc tip to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a 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 011icc of
lutc,ngations of d;e DIA for insurance amngc verification. i.
l da hereby certify an •r 1h «i •and penuhies of perjury that the information provided above is true and correct
tii,•�luture' Date•
Pntineri: 9�� 5� i tads-�
Of
ricialuseonly, Do not write ht this area,to be completed by city or town oJjic iut
City or Torn: _ Pvrmittl.iccnse q
Issuing Authority (circle one):
1. Board ur iteauh 2. Building Department 3. Cityffoi%n Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
C"Illaci Person: -- Phonc tf: