40 MOFFATT RD - BUILDING INSPECTION (2) — —
%. ��� BLIC PROPERTY
`� �'� ���d� DEPARTMENT
K1%I1ERI.EY DRISCOLL
MAYOR 11-0 WASHINGTON STREEr•$AI.k1J,MASSACHl:561'IS 01970
1Ei 978-745-9S95* FAx:978-740.9846
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
lM,�k
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: rn Y
Address: (p
f _V% OA OLS S
Telephone: Cj 6L
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation ! Number of Stories Renovated Oh
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated ciC O
construction or renovation
of existing building New
Brief Description of Proposed Work:
1�,1N�VCti 0✓� Al �1( ST Go
V _
Mail Permit to:
What is the current use of the Building?
Material of Building? 1 A r&`3 12 If dwelling. how many units? r
Will the Building Conform to Law? Z S Asbestos?
Architect's Name
Address and Phone
Mechanic's Name Al
Address and Phone 151, 8
Construction Supervisors License#6 � HIC RegisUation it
Cost of Project$ 00 Permit Fee Calculation
Permit Fee$ 2
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
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CITY OF SALE.M
PUBLIC PROPERTY
DEPARTMENT
N.Maa 130VAndmGmuSnaur♦sww.also warms 0I970
Ttra.:97L7iS4W•FNe t+Te•740.9Na
Construction Debris Disposal Affidavit
(required for aU danoUm and renovados work)
In aceordance with the sixdt edidon of the Sloe lluildiag Cods.780 CMA section 111.5
Debris,and dw provisions of MGL a 44 S 341
Bui1dins!'e l it is imed with the condition that the debris m=Wns host
this work slug be disposed of in a grope ft Ucsnsed waste disposal thcility as defined by MCI.o
111.S 130A.
The debris wiU be b utsported b)r
61
(aaa+s dbtulsr)
i
i
The debris wiU be disposed of in:
(nam of&Wit»
(aldou or facility)
IT
spyu0us otpam�it eat
due
�A;.rr,ws
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xA18ER1FY DRLSCOLL
MAYOR
120 WAstmecTON STREET a SALEM,MASSACHusETTs 01970
TEL 978-745-9595 ♦FAX:978.740.98"
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aaulicant Information 1 / l 1' Please Print Leelbly
Name (susiaess/orgaairation/raaividual): yL 7S �c.�4�o'Y�-
Address: YJI l p
City/State/Zip:�• C 1i1t� 1 QIWne #: -N(9 - ego l9 "774
Are you an employer?Check the appropriate box:
1. I am a employer with 4. 0 I am a general contractor and iFCR
(required):
em to ees full and/or tune .* have hired the subcontractors struction
P Y ( pact- ' )
2.JR I am a sole proprietor or partner- listed on the attached sheet. t ng
ship and have no employees These sub-contractors have nworking for me in any capacity. workers' comp. insurance.[No workers' comp. insurance 5. 0 We are a corporation and its addtton
required) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing rcpairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.(No workers' 13.0 Other COMP.insurance required,)
'Any applicant nut cheeks box#1 must also all out the section below showing their wakens'compmsetjpa policy infmmatlos t Homeownan who submit this aHldavit m9mina they am doing all won sod td®kin outside canrcacton must atbmit•new afRdavit
tConuaeton the check this box must attached an additional shut showing the came of the sub-contractors and their soh
thec warkms'comp.Polley infosreatfm
lam an employer that is providing workers'compensatian insurance for my employees. Below is the policy and Job site
information.Insurance Company Name: c"(�
C{—tom
Policy#or Self-ins.Lic.#: /� // Expiration Date:
Job Site Address:I GGto'C//�1'01 f G
City/State/Zip: /1Uv 1
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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the fort 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.
l do hereby certify under the pains and penalties a per/ary that the information provided above if true and correct
Si arse
t 6 3O /0 !P
Phone#:
Ofjleia/use only. Do not write in this area, to be completed by city or town 0 ciai
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/rown Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation...every p for contract employ hi
e.
Pursuant to this statute,an employee is defined as" erson in the service of another under any `
express or implied,oral or written"
An employer is defined as"an individual,partnership.association,cotptuaaon 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 er trustee of an individual,Partnership.association or other legal entity,employing employees However the
house having not more than three apartments and who resides therein,or the occupant of the
owner of a dwelling who employe persons m do maintenance,construction or repair work on such dwelling house
dwelling house of another ent be deemed to be an employer."
or on the grounds or building appurtenant thereto shall not because of such employment
MGL chapter 152,§25C(6)also states that"every state or local licensing agency sham withhold the Issuance or
al of a license or permk to operate a business or to construct buildings in the commonwealth for any
renew
renewal 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
performance of public work until acceptable evidence of compliance with the insurance
enter into any contras for the
requirements of this chapter have bier presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation aWif
necessaOf
ry.supply sul_contractor(s)name(s).address(es)and Phone numbers)along with their certificate(s)Other
Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
insurance. Limited Liability mP workers'compensation insurance.members or partners,are not required to catty 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 f being requested,required to the obtain a workers'ent of
Industrial Accidents. Should you have any questions regarding the law or if you are req
compensation policy. should enter their
Plea call the Department at the number listed below. Self-insured companies
line.
self-insurance license number on the a
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 s a reference need only submit one n addition
affidavit indicating current
that must submit multiple permit/license applications in any givenyear,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
st be filled out each
applicant as proof that a valid affidavit ison file f a license oPe permits it not tieenses.d any business new 1 odavit r commercial venture
year.Where a home owner or citizen is obtaining Peien
(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 questions6
please do not hesitate to give us a can.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Inds strial Accidents
Offles 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•mass.gov/dia