2 MCKINLEY RD - BUILDING INSPECTION Fhe ('ontnuntweahh of Massa
chuse(IS
t Boar) or Iiullding RCL!"IJ(IUns .old S(andaids I I ilt f
i *%IJ"Jch1lscfts State Building ('odc. 754) (AIR. 7i' edition YII NI( II' \III 1
Buildim_ Permit Applica(ion To Ginstrur(. Repair. Renm ale (h I)enxilish ,i I R:
i
011" i,r r1l o-1,u hi 11111 i fliriv
^� Thu .Section For Ofhctal Use l hlly -- ---- ----
` 1 Building Pei III[[ Numhr ---_--Bld h
— ------- ---..- ..
----- ---..-�
Date
JV\ SLIL TION 1: .SI M INF ltu%i t fw:N'
j1.1 Properis \ddress: 11.2 \ssrssors Slop .'k Part cl Nuwbcrs ---- - - - .
I la Is this an ,iccepied siiee(�' Nes no .\IJp Nniilher P.u.rl Numhcr
——1.3 Zoning !nformation: 1.4 Property Dimensions: l
4 l Zoning Dutnct Propised Use l_ul Area Isy tit Fru:nuge I ri i
1.5 Building Setbacks (fit
Front Yard .Side Yards Rear Y'wJ
' Required Provided Re uneJ
4 PnrviJeJ Rcyw rcd Pii:udrJ
1.6 Water Supply: IM G1 r 10. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: —�
Public ❑ Pn cote❑ Zone: _ Outside FdwJ Zone?
Check if yes❑ Slumapal ❑ On sne Jules nal �s,tnni ❑
SECTION 2: PROPERTY OWNERSHIP'
I2.IrOr�"n/erlofRej o°rd: 64 �C �'w/�� �� / / 00'�
Name (Print i Address lur Service: --
Signature Telephone -------..
i
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building Owner-Occupied ❑ Repairsls) Alternionls) ❑ .\JJnum C
Demolition ❑ Accessory Bldg. ❑ Number of Units Other C Spcaly
Brief Description of Pniposed Work: r/ou !ir w�� y sw I
I
SECTION J: ESTIMATED CONSTRUCTION COSTS
hem Estimated 1 1s:
abor:m Official Use Only
r Ld 1 Na(enalsl
~— 1
I IiwlJing 15 I. Building Permit Fee: $ Indicate hiss tec is Jerei mined.
It. @lectncal 5 ❑ Standard City/Town Application Fee
❑Total Project Costi I Item 6) x multiplier x
?. Plumbing 5 ---_-.__.
'. Other Fees: 5
.1 ;blechamaJ IHC:\C') S List:
I i Mechanical iFlre
I Su t res,innl S fot.il All Fees: 5 - - - ---- --.--
Check No ('heck .\mount <',nh \ni:ann
o fatal Project Cost > -- ---
/J 0 Paid In Full 0 Out t ndol B.d.inae I tar ----. _ - —
— —— SEC LION 5: CONSTRLC'I[ON SF:R% R'F:5 C;
;.1 Licensed l'unstructiun Supervisor ICS1.1T/0�'
— i
IInIJiI / / LLt (',d 1'%lie
I nii'n 1,led 'it io :• lX111l a I'I _ —_ _
\,ldw .
—
1 R Re,(11,tell
Rr J l JI R
i .. J
I:I:ph one —
1��IiJ I
p "Jew'.'l Ur:nodnuM
r :.2 Registered 11ume Improvement Contractor (lilt 1 --
__— Ri l,li Jnun ♦na.her i
111( l\nupam NJnle or IIIC Regulrant -little
r�l IgIlJllll l'
— SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAN"IT (NLG.L. c. 15'. § '_SCtM1u
Workers Compensation Insurance affidavit must be.urnplejed .utd +uhmltled \%oh Ihi+ appllLatnv). I .ulure to pl
this aftidavit will result in the denial of the Issuance of the budding penmt.
Signed :\ffiduvitAtWched Yes ..........
SECTION 7 OWNER A H UTORIZATION TO BE COMPLETED 'A HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the suh Kct property hereby
to art .al my hchait, u1 all m.lucn
aut!u;rlre _— — -- --.—.
j �e!.nL e to •.york authorized by this building permit apphral-11
—-- --- -- Date
i
Sl¢nalure of Owner _—�
SECTION 7b: OWNERI OR :AUTHORIZED :AGENT DECLARATION
as Owne or :\ulhm i . .\gent erehy der lair
I. iL2
that the statements and information on the tiregoing application arc true and ar orate. «1 the best ,A my knowicdge and
behalf.
F'n>Nainc
�l1
UurctiieOwner ur Authorlted AgentSrer d1e aul, .utd enalues or perjury NOTE$:
I. :\n Owner who ohtalns a budding permit to du his/ own wrlrkf im)Itw 111 /rot+t ha\ehli\«�+)I,, the III'hllrathrl tl.l.h��
(not reguItered In (he Home Impml ement Contractor (HIC) Pn�g .
program or guaranty fund under M.Q.L. r. 11_IA. OIher unportant tnrurmat:on on the HI(' Pn,��rem .old
( n,uu u n St p r t r I I n log it, m he tt and in 780 CMR Regulations I Iq.RO and 1 10 R5, le+pertoily
When +ubstan(tal work 'I planned. plo\Ids the InG I man n below Imrludulg BaregC. tllll,hed baIelllelluattl\,, decks "r
L p�a.hl
-rural ttors area ISy. Ft.l
hcmg drcalSy. Ft.l _ H.IhlWhle room rnunt
Number hedro„m. -_. ---_—.
NUITIber Cf hrcplaees -- Numhcroth.11t'h.ully
: Nunlbcl of h.uhrtu,ms .--- Numhcr,d Jej,/ p,n.hc,
I \pe „r he.unlg ,v.tem _--
l \pe ,I I\Item ------- ---- -- -- -- - --
'I 1. inrd Payer( Syuarc Fonn.lge ntav he ,uh,ntutrd for tol.11 Pit yc.t (',"( ------- _.
r S
CITY OF SALEM
y
r PUBLIC PROPRERTY
DEPAIZ I'MENT
III 'I's.'J;. I"y5 I \\. 'i-.q.'J_ • i Ji•
('onstruction Debris Disposal Allidavit
(rc\lithed li)r all demolition and rcnu\:uiun `01
In accurdance \%ill I the sixth edition of the State Building Code, 780 C NlR section 1 1 1.5
Dcbris, and the provisions of MGL e 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 facility as defined by MGL c
1 t 1, S 1 50A. ,
The
debris wiII be transported by:
I name oC hnultr) _ ..,
r
I he debris will be disposed of in
�D/ f Gf 7 �-✓��" y
Inane ul tau rty)
IuJdre+. ul laeillrvl �� /
vt-
.I�uutwC or penun .grpllcant
,late
� R
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,I\I I{;Rl IN'1AI NCI It l
?Lsst la I-)--WASHING ION S'I ALL Tit S.su M.M.\Y\nc:rn sr.rn u1970
11:1.. 978-745-9595 • h.%x. 978-741^A846
Workers' Compensation Insurance :V'Gdacit: Builders/Contractors/Electricianan P�nt Lebers
PleasA ) rlicant lnformrtion
Nam l0ueilxti OrganbatinNlnJry ulua4:
A.htrcSS: 0 U/�
Phone 0:
�
City State;%ip'
:\re yours employer? Check the appropriate box*
Type of project(required):
i 4 a
. ❑ I ;tin a general contractor and I 6. ❑ New construction
1.❑ I ;tin❑employer with have hired the sub-contractors
engsluyces(lull anrL'uc part-tune).' 7. ❑ Remodeling
listed on the attached sheet. :
2.❑ 1 :tin a sole proprietor or Banner- These sul>.contractors have 8. ❑ Demolition
ship:old have no employees workers' comp. insurance. 9. ❑ Building addition
working for me in any capacity.m 5. ❑ We area corporation and its -
INo workers'cop. insurance officers have exercised their ❑10. Electrical repairs or additions
required.] 11. Plumbing repairs or additions
righ[of exemption per h1GL ,y❑,y� ,, b .p
3.❑ I am a homeowner doing all work C. 152, §1(3),and we have no 12.�Ixuu1•repairs
myself. LNo workers' comp• m ioyecs. IKo workers' 13.❑ Other
insurance required.l r comp. insurance required.]
-r\IIV dilhLlLLI11 IhYI cl:ceks box fit nlllGl:IISU IIII UUt'he tiC11U11 rN:IUw sllowtlltl their worken�cumpenfal Wll trolley inlilrmutiun
g I lomw,wmn whu abrml this anlJavit indicating Ihcy me Joint'all wad mW Ihcn him umstg cwrxlonia meal auhmit a new a1f:Ja ,li y infix ng tion.
( t I that i beck this box mass j:twhcd an additional ii t h g the ame of the sub-<omracturs and their wuden'comp.parley informs-
l and un employer that is providing rvarkers'c•ornpensntion iusurnuee fur Illy erupluy ecs. Beltnv is the policy und/ob \tie
ioforuratioa !iv! _ h,r /G
Imurancc Company Name: _ fah �O
—_ _�8 � Expirauun Date:
I'oli::y S or Self-ins. Lie. *: -
//// //n City:Smteizip:
Job Site Address: �CZZA-/7
Attach a copy of the workers'catnpcnsation policy declara lion page (showing the policy nurnber 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
tiny up u,51.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 it day :Igalost the violator. Ile advised that a copy of this slattornent truly be forwarded to the Office of
Incesngaunns ul the DIA for inSul:u:ce .:overage %ciitic.uum.
l do hereby certify III r the painsUG-peludlnev of perm y that the wfunnuhon provided above is true uud correct.
ofliciul use only. Do Imo rs'rite in this area. to be cmupleted by city or torvrt oJJiriu/.
_ Pcrmitll.icense --
(:iiv or row•n: _--
Issuing Authority (circle ouc):
I. llt,ard of Ilealth 2. Iuilding Department 3.Cityi 1-own Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other _ -- Phone tl:
Conrad ersou: - - —
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant to this statute, an CMp(Oree is defined its "...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 l0regoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee VI :nl Individual, pantnershnp,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."
`1GL 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 cite insurance coverage required."
.additionally, bIGL chapter 152, §25C(71 states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence otconnpliance 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 number(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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be rcumied 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/licease 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 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. is dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he Otlicu 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
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia