181 MARLBOROUGH RD - BUILDING INSPECTION . r
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wl\1DFR[F.Y URIXaIIl '
M. Ayott I2C WA-.4C%GT0IYSTREbT a SALEM.MAaAclu.Ir'I'n0197:1
Tea:979-743.9595 a FAX:9M74C,9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADnlicant Information / _ / Please Print Leeibiv
NaMe lHuaitwWOrganizatioNlndivtduul): /,7 `��t✓ / l///�,C 1C,4, /L _
Address: / e4 / rt,60 C/ /¢t,,s`_
City/Starcvzip: r���� ��SS Phone
Are you - mployer? Check the appropriate box: 'rype of project(required):
I. ama employer with � 4. ❑ 1 am a general coutraetor and 1 6. ❑ New construction
it
(full and/or part-tine).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner. listed on the attached sheet. ) 7• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q• ❑ Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its
required.] officers have exerciwxl their !0.❑ Electrical repair or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or udditions
myself.[No workers camp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] r employees. [No workers 13.❑ Other
comp. insurance required.]
•Any apph"A lima checks boa 41 most also Fill out the section l>Llow showiag Chair workers'cumponsado,%policy inrurnntiwa
'i lumw,wma who submit this affidavit indicating they am doing all wont and than Alm twtsilla emtrauon must.uhmit a new afrdavil lndieaing wch.
:Cauracuws that cbmk this box must anaehad an additional*heat*hawing the nam:or this kub•comraaots and their workers'comp.policy information.
I um un employer that Is providing workers'cotepensadon Insurance for illy employees Below is the po/ky and Job.site
information.
Insurance Company Name:,/T✓rC 1 r'f r<K_ ._. f!/ /�t ii'4a o.
Policy q or Self-ins. Lic. 2.- Expiration Date:
Jub Site Address: City/Slate/Zip:
Attach a copy of the workers' compensation policy declaration pale(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A u1'vIGL c. 152 can lead to the imposition of criminal penalties of
ti ne up to S 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 0111ce of
Invasngatiuns ul'the DIA for insurance covcra.,e verification.
1 do hereby certify ur er the pains red ult' of erjury that the in/annallon provided above is Irmo 'lid correct.
tii•a;iturc' Dot
Phimc,'*
Official rise ant, no not wrhe in thtr area,to be completed by city or town oj]11*L
City or Town: Permit/l.icense
Issuing Aulburily(circle one):
1. Hourd of Ilealth 2. Building Department 3. Cityffossn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Of her
Contact Person: — __ Phone N:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\Uuw l!c W.%at".-.:ONS auT 43.%t V.�tA:tu::u *.R5::9/:
To.yn74s--)"5 I)M741S9644
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CMR section 111.5
Debris, and the provisions of M. GL c 40, S 54;
Building{ Permit N _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by M. GL c
L L L. 3150A.
The debris will be transported by:
haul
The Jcbris will be disposed of in
._ In:+mr of ia2tirty)��
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PROPERTY
DEPAR'I'1biENT
r:,.mW3LSV ORMCUL
�I Ivoa 130 WAMUNCrCW b`M=•1nttil4%I.%StAOU:ShTiS 01970
TEL-978-745-95"•FAX M740-98N
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: Suilding:
Property Address: --- /---- -- — --- --
�I / G tR G v ,4
property is boated in a;Conservation AWs Y/N Historic 01strld YIN_lam
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: 69
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK.IN EXISnUG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated yr..
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Ekid Description of Proposed Work:
lCy
------ Mail Permit to: 00e"L;
What is the current use of the Building?
Material of Building? If dwelling, how many units?
WiU the Building Conform to Law? Asbestos?
Architeas Name
Address and Phone
Mechanic's Name Jh
Address and Phone
Construction Supervisors License#
0 7 /6 7 HIC Registration
Estimated Cost of Project$ 3 76 Permit Fee CatcuWon
Permit Fee i M:1� Estimated Cost X$7151000 Residential
Estimated CoOd X S411i1000 Commemlai-- ---- - - -
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the abov to
specifications. Signed under penalty of perjury
Date D
N
s
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