146 MARLBOROUGH RD - BUILDING INSPECTION (2) PUBLIC PROPERTY
DEPARTMENT
Nwrol! 130 WARUNGUW hMEhT•SAU K MASIAUrl:SUM 01970
I4i 97e.74&9S"•FAS M740 gw
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING.
1.0 SITE INFORMATION
Location Name: 4V Buikting:
Property Addreew--
-- ----
1-4h,4
Property Is Located In a;Conservation Area YIN Historic District YM_ate
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: /Lr I jr,-e(i-5 70A tl /h
Address: L/
Telephone: —S
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition ®Renovated
Renovation Number of Stories
Change in Use
Demolition
Approximate year of Area per floor (sf)
construction or renovation
of existing building New
9def Description of Proposed Work:
--- -- Mail Permit to: /ff�
s/
What is the current use of the Building?
Material of Building? B dwel .how many units?�—
Wiq ttro Building Conform to Law? Asbestos?
Architeas Name
Address and Phone ( )
Mechanic's Name G� � G
Address and Phone <� l��Q eel z46
Construction Supervisors License# HIC Registratbn#1d!'P� �
Estimated Cost of Projed S 7 C�._ Permit Fee CakuWW
Permit Fes
�_ Estimated Cost X$7IS1000 Residential
S —
Estimated cost S41/S1000 Cammercia�----------
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 abov scat d
specifications. Signed under penalty of perjury
X—Z
Date 6
7
Y
��� CITY OF SALEM
, tr PUBLIC PROPRERTY
�` DEPARTMENT
.I V ili of I'1':1NIil:,n 1
!st\I.,to 12CWASH1\GIJ\SIRLLT • 5,\l1`.\/,MAss%( 'It iP:I'IN 5197
l'Ia.; 978-745.9595 • f.its. 978-741C.I846
Workers' Compensation Insurance Affidavit: Builders/Contractors/El P Plumberslease Pri
nt-\ ) )licant Information
? Tzuv�l�
81T1t: l du.i Ixss/nrsnirxtinNi ndty ulua4:
Addi-c55:
City,starcizip: Phone •-
:\rc you an employer:' Check the appropriate box:
'Type of project(required):
i 4. ❑ I ran a general contractor and 1 6. ❑ New construction
1,❑ 1 :ern a employer with
have hired the sub-contractors 7. ❑ Remodeling
employees(lull antllur part-unx).' listed on the attached sheet. :
2.0 1 ant a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
workers' comp. Insurance. 9. Building addition
working for me in any capacity. 5. ❑ We are a corporation and its
IKo workers' comp. insurance o e are have exercised their 10.❑ Electrical repairs or additions
requirud.] 11. Plumbing repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MOIL
❑ b ,p.
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) employees. Lno workers' 13.❑ Other
comp. insurance required]
•,gym:,p phcant ilmt chucks box rnl rnust:dsu lilt nut the section bcluw showing their wurken'compensation puticy inlinntatiun
' I lomeuwren who submit this unidav it indicating Ihcy are doing aft work and then him outside cwnrxtors muss nuhmsil a new afndavn inJiukmy.nch.
ontractors and nccir wurkun'comp policy infurmadun
( t a i Ili t ck this box m,lsh artxhcd on additional sh I h w'tg the name of the sub-c . .
l ann all employer that is providige workers'compensnmoh insurance fur my employees. Below is the policy andjob sire
in/urination. L
Imurancc Company Vmne: ----.
s ._ /-. -�- -------
I'olicv :r or Self-ins. Lie. t:: ----- - -
Expiration Date:
CitynStateiZip:
Job Site .--\(tdress: ---
Attach it copy of the workers' cornimmution policy declaration page (showing the policy nuinber and expiration date).
hailure to secure coverage as required under Section 25A of.%IGL c. 152 can lead to file imposition of criminal penalties of a
line up u)51.50o.00 and/or one-year imprisonment, as well as civil penalties In the furhn of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violater. Be advised that a copy of this statement may be lorwarded to the Othcc u[
Inccsugaunits ul the DIA for insonrce coverage \crilicaUun.
l do hereby certify an er die pain at I penalncx of perjury drat the ulfurma o tion provided a.b e r ru J wen cr
�i�t:rwtro: �' c
O[jiciul use only. Do tint Ivrite in this area, to be completed by city or town official.
City or'fotvn: _._.
Pcrmi[ll.icensc X_ _ _.
Issuing;:ituthorily (circle one):
t. Iloard of I[calrh Z. Building' Deparuucnl .i.City:form Clerk 4, Electrical Inspector 5. Plumbing; Inspector
6. Other _ -- -
Contact l'cnoo: - Phone tt:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an ernplUfee is defined as "...every person in the service of another under any contract of hire,
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
or the t0regoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of aai 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,cunwuction 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."
`IGL 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, 1`vIGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomhance 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-contractor(s)name(s), address(es)and phone nuniber(s)along with their certificates)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 confinnation of insurance coverage. Also be sure to sign and date the affidavit. The aff idavit should
be i cn2ned 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
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of die affidavit for you to till not in the event the Office of Investigations has to contact you regarding the applicant.
Please be.cure to till in the pennit/license number which will be used as a reference number. in addition,an applicant
that must submit multiple permiulloense applications in any given year,need only submit one affidavit indicating current
policy inibmation (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 ar fdavit 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
f i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he ()i f icc 01 Investigations would like to drank you in advance fur your cooperation and Should you have:my questions,
please do not hesitate to give us a call
The Dcpurnncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Otflce of investigations
600 Washington Street
Boston, MA 02111
Tel, k 617-727-4900 ext 406 or 1-877-MASSAFE
R,,%i.cd 5-20-05 Fax # 617-727-7749
www.mass.gov/dia
' CITY OF SALEM
PUBLIC PROPRERTY
Irt ,'S
DEPART'.10ENT
Construction Debris Disposal Allidavit
(required lix all demolition and renu"Itiun work)
In accurdance ttitlt the sixth edition of the State Building Code, 7SU CMR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
I11. S 150A.
The debris Will be transported by:
i
nJn1C of hauler)
1 he debris will be disposed of in
(name uI I i11ty,
Iaddres.of gr111tvl
.reuatwc rp. nu[ .ipphc�nC
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tr