10 NIGHTINGALE LN - BUILDING INSPECTION "' PUBLIC PROPERTY
� '��' DEPr1RTMENT
KISIBM EY DRISCOLL
MAYOR df�n� //i 120 WASHINGTON STREET SAL4.'..0 .MmmcrosLITS 01970
TEi.:97&735-9595* FAx 978.740-99"
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: / ,\ tlI J kI g3olc / pi
Property is located in a: Conservvatlon Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: �q� 1 m�j lc✓
Address:
Telephone: /57S-- -7W- �;2 I/
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to:
n �/r�
What is the current use of the Building? X P Si
Material of Building? If dwelling, how many units?
n.
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone 57�f�i (� /Ji I/x J66 S� 2f ?GlCP S i`
Construction Supervisors License# HIC Registration# �� 9
Estimated Cost of Prqojectsi2,azLPermit Fee Calculation
Permit Fee$C-;: =6 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 X7 _
Date
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
Kl�mta�Y ouxou. - 120wASMWcrM Sr Err•c.^,. M. A5SACHLSEM 01970
�1AYOl
'tit:978-74S-959S 0 FAX:976740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code.780 CMR section 111.5
Debris,and the provisions of MGL c 40,S 54;
Building Permit M 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 MGL o
1 11.S 150A.
The debris will be transported by:
(usme o1'hsuler)
The debris will be disposed of in
�
(name 6GPaTlityr)
(address of faeility)
sisvnla a of petntit plieam
date
.Ichnsa174rc
The Commonwealth of Massachusetts
Department oflndush'ial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www massgov/dia
Workers'Compensation Insurance Affidavit: Binders/Contractors/Electricians/Plumbers
Applicant Information Please Print Uezibly
Name(B,umessiorganizationandividwD:
Address: �3 V 7�
City/StateMp: Phone#
Are you an employer?Check the-appropriate box: Type of project(required):
1.® I am a employer with 4. ❑ 1 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. ® Rtmmdeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repass or additions
requ�,] officers have exercised their
m
3. I am a all work tight of exemption per MGL 11.❑ Plumbing repairs or additro
❑ homeowner doing
c. 152 1 4 and we have
.§ ( ). 12. Roof
myself [No workers comp. ❑ repairs
[No workers
insurance required.] t employees- 13.❑ O&et
comp.insurance required.]
`Any applicant that checks box#1 mast also fill sit the section below showing their worked'w m mpeasation policy inforation:
t Horkeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most sti writ anew affidavit indicating sack
tConl wwm that check this box must attached an additional sheet showing the mmme ofthe subcontractors and their workae comp.potiry information
ram an employer that is providing workers'compensation baurancefor my employeim Below Is dwpoUcyand hob site
information.
Insurance Company Name: A IN ea.
Policy#or Self-ins.Lia M 1,2q Expiration Date:
lob Site Address: City/State/zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and exphattion date)-
"ailme to secure coverage as required under Section 25A of MGL c. 152 can lead to fie imposition of criminal penalties of a
me up to$1,500.00 and/or one-year imprisionment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to die Office of
nvestigations of the DIA for insurance coverage verification.
'do hereby cer*fyy under the palm andpenaMes ofperjwy that the lnfonnmion provided above Is free aad cotreex
9Qnati e' Date-
'hone#- /�7�— Z;17,
O,(jrcid use only. Do not write in this area,to be completed by eily or town o. eW
City or Town: Permit/i.icense#
Issuing Authority(circle one):
1.Board of Health Z.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
C Other
Contact Person. Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their emplayZM.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
xpress or implied,oral or written
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
rf 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
!welling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
rr on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
AGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
•cnewal 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."
Wditionally;MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
rater into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
equirements of this chapter have been presented to the contracting authority."
►pplicants
'lease fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
ecessary,supply sub-contractor(s)nameK address(es)and phone number(s)along with their certificate(s)of
ist rance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the
zemliers or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
unploy6e a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
.ccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
e returned to,the city or town that the application for the permit or license is being requested,not the Department of
adustrial`Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
ompeusation policy,please call the Department at the number listed below. Self-insuued companies should enter their
elf-insurance license number on the appropriate line.
ity or Town Officials
'lease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
f the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant
'lease be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
eat must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
olicy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
own)."A copy ofthe affidavit that has been officially stamped or marked by the city or town may beprovided to the
pplicant as proof that a valid affidavit is on fide for future permits or licenses. A new affidavit must be Med out each
'ear.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 bum leaves etc.)said person is NOT required to complete this affidavit
'he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
lease do not hesitate to give us a call.
he 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
ised 5 26 OS wwwmum.gov/dia