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176 MARLBOROUGH RD - BUILDING INSPECTION PUBLIC PROPERTY DEPART1�fENT AOR7F U.EY DRISCOLL MAYOR 120 WASHING oN b`Wmr SALLK MAh&ACN1Shrrs 01970 Tm-978-74S-9S9S* FAx:978-740-9&W APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION. DEMOLITION OR CHANGE OF USE OR OCCUPANCY, OR ANY EMSTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: 11a,-& lef Building: Property Address: /76 L a rzio -o u l Property is bcmed in a;Conservation Area YIN-=Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land o Name: /YOr/ f rC t a cl z r-. Address: Telephone: -V7,r-- 37.r- y Y 3�" 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use Z— New Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: j hs�� "Veal —Mail Permit to: What is the current use of the Building? Material of Building? 4 O-' If dwelling, how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone ..yMechanies Name y�ecOi.vr '� ��u C yn r�yy Address and Phone P�Yi lid ti rod �^' r yh 3 3i. Construction Supervisors License# HIC Registration# 139 fJ63 Estimated Cost Pro' 1 10, 000 Permit Fee Calculation Permit Fee$ b Estimated Cost X$7/$1000 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 to the above stated � specifications. Signed under penalty of perjury X ! Date 0 IS 4O1 � � N F p V > d I CITY OF SALEM 1 PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASHQdGTON STREET♦SALEM,MASSACHUSETTS 01970 TEL.978-745-9595 •FAx:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual): i7N� Address: y fyh, /a.to- City/State/Zip: Gal .`cAll /f1110.901?. Phone #: Are ou an employer?Check the appropriate box: Type of project(required): 1.yI am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.El 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' comp. insurance required.] 13.❑ Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infotmatiom t Homeowners who submit this affidavit indicating they arc doing all work and dim hire outside contractors must submit a new affidavit indicating such. tContracton that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / �� / Insurance Company Name: 4O/Cs'2`X t.4/K 4,,-(. Policy#or Self-ins. Lic.#: We //Sq 3I S33 /7.e2 eo/ l— Expiration Dater C/3i/o 7. Job Site Address: uGiL�DrOK.9�i rt/ City/State/Zip: �m ,, If-LA . Attach 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi n r he pains and penaldes of perjury that the information provided above is true and correct Signature: Date: 1.1;7 Phone#: 6'�9-�—TrT--5 2 r y Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts 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 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 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." MGL 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,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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-contractors)name(s), address(es)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 Please be sure that the affidavit 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit 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 afidavitmust 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. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.man.gov/dia C ITY OF SALEbi PUBLIC PROPERTY DEPARTMENT �.,.�.•m,nusooti 130 WAOU .�1(UM blVR T•SusN,XWACH SKM 01970 lla:M745•9S"•PAic 97a.740.9346 Consimcdon Debris Disposal Affidavit (required for ad demolition sad renovation work) In accordance with the sixth edition of the State Building Cods,780 CMlhl section 111.5 Debris,and the provisions of MGL a 406 S-% Building Permit N is issued with the condition that the debris resuldn3 ftm this wort shall be disposed of in a PrcPaly licensed warts disposal tbeility as dented by MGL a 1 l 1.S 130A. The debris will be transported by: (p.,m.a[Magr1 The debris will be disposed of in: (Sam of heility) (address of facility) sispamts of path*app(iam tau i