182 NORTH ST - BUILDING INSPECTION w
1 /
APPI ICAIION FOR BUILDING PERMIT
ALESTRUCTURFS EYCEPT=_I 4NU 2 FA/1111,Y Dff'EL! [iVG.S
,z IMPOR I AN I':Applicants must com dice all items an this ra•e
SI IT INFORMATION / /)
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Location Name [.�-_.�._ �dinu Q/�I
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Property Address s
\Imp 4 -
--
Lmuted in: Conservation Area YI isluric district Y'N
i
Use croups
(check one)
Residential(I or more Units) 142
Type of improvement Residential (hotel/motel RI _
(check one) Assembly (churches) Al
New Building Assembly(nightclubs etc) A2
Addition Assembly(restaurants, recreation) A3_
Alteration_ _ Ilusiness B
Repair/Replacement_ Educational E
Uemol it ion— Factory(moderate hazard) FI
{ . .- ...' F2ylcve Rclocatp- Factory hazard)
1' I ll"hHazard'
am� y
Accessory Building_____ . Institutional (residential care) I I
{`.. a` .' Institutional mua autatcd)
Other(describe) ( P
�n-`pw�_�'O` Institutional (restrained) - 13NI_
Storage(moderate hazard) S I _
Storage(low hazard) S2_
O\\NI:Iis l l I 1NFOILPI:\I ION(Please lylx or 1'rinI Clearly) (� .—
OWNI:R Name LO 0 Ot
\ hlress
telephone — r
DESCRIIII`'I'If)NOF„'OI IOnE\{4: 1OR:N :ram
e II� ►1 ll
L: H>L\7T.0 CONs'l'Itl.
CONTRACTOR INFORMATION `
Name L�TL1Z''1 a IsmA,,nl C,
Address (. U'u*f6L'Y' ST H44YOXHICU
Telephone 97 gi " 9,s3 !("I o
Construction Supervisor's Lic # 06 ZZ.
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Re,-istration #
1ERN11'I'FEE CALCULATION
Residential cst. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $1 1/$1,000 + $5.00= _
COMMENTS ty
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
.Signed
Date
L`�- 0°o
CITY OF SALEM
3 �, ' PUBLIC PROPRERTY
DEPARTMENT
MA? ,g mrl • S.v : \L \I.N".,, !r
Workers' Compensation Insurance :V7idaNit: Builders/Contractors/Electricians/Plumbers
mlitant Information Please Print Legibly
\;11Iis: i 9u>uu. i hgant[:won.Inds\Iatl al n r r 1 ��—
/� C ^ v
Address: l 7f J 6 y 4 D�
City, sulteiZip: Phone :
Are you an employer? Check the appropriate box: Type of project (required):
I ❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
ey1ploy'ees(full and-or part-time),` have hired the sub-contractors 7. ❑ Remodeling
- I .uu a sole proprietor or partner- listed on the attached sheet.
ship and have.no employees These sub-contractors have 3. ❑ Demolition
working for me in any capacity. workers' comp. insurance. y. ❑ Building addition
\o workers' cum insurance 5. ❑ We are a corporation and its
I ' P
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.El 1 am a homeowner doing all work S P
right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Rif repairs
insurance required.] f employees. [No workers'
comp. insurance required.] 1
13. /Other
•:\ny applicant that checks box NI must also till out the section below showing their workers'compensation policy information.
r I lomeowncrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:(%wi,actora that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l um till employer that is providing workers'compensation insurance for uty employees. Below is the policy and job site
information. -
Insurance Company Name:,
Policy #or Self-ins. Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure ro secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 and/or one-year imprisonment. as well as civil penalties in the firm of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
111%Q ti,,anons of the DIA lix insurance co\crtge ccrification.
i do hereby t'ern1jr under the pains wt 'naldet-ol perju •that the injirritaution provided aaabo a is true lid care
Si_n:aura: Date: / O
Pkot,c
tl//icial use only. Do not write in this area, to he contpleted by city or town ajjicial
('its or Town: _ --__._-- -----_ _ Permitil.icense #-- —__---
Issuing Authority (circle one):
I. Board of Heallh 2. Building Department 3. Citp fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Conlact Person: --------_-- -- .— Phone #:-- --
Information and Instructions
\Iasaac l Wsetts OencraI Laws chapter 15' requtr'es all anployers to pro%ide workers' compensation Ior (heir employees.
Pursuant to this statute. in einlyloree is defined .Is ". e\ery person in the scry ice of:mother under any contract of hirv7
C\press or implied..oral or written."
.\n enrpLirer is defined as ":m iudi\;dual. p.unlership, association, corporation or other legal entity. or any Iwo or more
of the foregoing engaged in a joint eutCrpr;sC. and including the legal rrprcscntati%es of a deceased employer. or the
re Cci\cr or trustee of an indk idual, partnership, association or other legal entity, employing employees. f lowever the
,,w ner of a Ll%vClling house having not more than three apartments and vvho resides therein. or the occupant of the
dvv ,elling house of another who emplovs 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 o be an employee"
\161- Chapter I52, q_'SCf b) 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. s IGL chapter 152, �25C(%) states"Neither the conunon\vealth nor any of its political subdivisions shall
enter into any contract for tine perlonnance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter pace been presented to the contracting authority.
Applicants
Please till 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 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of dte affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pemnit/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 affidavit must be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.c. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The ()17ice of Investigations would like Io thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
the Dcpartntent's address, telephone and fix 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
Ktticed
Fax # 617-727-7749
5-_b-U5
www.mass.gov/dia
• ' CITY OF SALEM
-r — 11
a '4 PUBLIC PROPRERTY
DEPAR"I'MENT
III V'\ 'J i. + i4 I �C. 'i'.Y-'3= •'i Ji,
Construction Debris Disposal Affidavit
(teclimed lirr all demolition and rcnov:aion work)
In accordance \\itll the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Dcbris, and the provisions of''v1GL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
�0 alebrr S
(name oY hauler)
I he debris will be disposed uf•in : �
�/n Ole lie pi
(name oI Iacility) a. 0 v '�v�
,mnatmc of p:r�ut ,q?pllcant
.late