193 1-2 NORTH ST - BUILDING INSPECTION What is the current use of the Building? �PS
Material of Building? ✓n p If dwelling.tow many units?
Win the Building Conform to Law? Asbestos? -
Architect's Name a
Address and Phone
Mechanic's Name
Address and Phone
Constriction Supervisors License S Q_�—HIC Registration tt
Estimated Cost f PrOk Permit Fee Calculation
Permit Fes$ Estimated Cost X$7Ii1000 Residential
Esfimated CoatX$`I11$1000 Commercial—An Additional$6.00 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(
Date (o a i
o
N
2L J ^ �,V �
0
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OF � \ °'
/la 7-eI7
CITY OF SALEM
V
) PUBLIC PROPRERTY
r DEPARTMENT
ri LU n::R[liY URIICULL
MAYOR 120 WASHING ION STRELT •SAusx4,MASSACI H AH T,6197.
Thl. 978-745-9595 •FAX:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Arittilicant Information Please Print Legibly
t
Name(BusineWOrganizatini in N divid`uul): _ 1 f -
Address:�l 1A Jw,- t t I(1 71 ill
City lStatciZip:GRt_)\/•P 152s I09one it: Q_7�?
Are you an employer? Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6- ❑ New construction
e and/or part-time).* have hired the sub-contractors
mployees(full
am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling
skip and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ a I m a homeowner doing all work right of exemption per MGL I L❑ I lambing repairs or additions
myself. (No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. LNo workers' 13.0 Other
comp. insurance required.]
'Any applicant that checks box it] must also lilt out the section ln:low showing their w'orkesy cumpensulion policy information.
'I lOmenwWrS who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/nor air employer that is pro riding workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:-----,,-,.............
Policy 4 or Self-ins.Lie.M —------- Expiration Date:
Job Site Address: City/State/Zip:
Attach it copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25 A of MGL c. 152 can lead to the imposition.of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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.
/do hereby certify under the pains and penaltie.•of perjury that the information provided above is rue and correct
Sienautre: � � Date: GL /a -7
Phone 4:
Official use only. Do not write in this area,to be completed by city or town official.
City orTow•n: --__---------- Permit/I.iccnse.tt_______ -
Issuing Authority(circle one):
1. Board of health 2. Building Department 3.City/foe'n Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.other
Contact Person: -------------- Phone t#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplgvee is defined as"...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 foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the I(
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
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."
MGL 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 the insurance coverage required."
Additionally,b1GL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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 nunber(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 continnation 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 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/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.e. it 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 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
CITY OF SALEM
I 1 PUBLIC PROPRERTY
DEPARTMENT
\tAYOK
I30 W.\9 0 S.\t:\t,Sf.K5.\1:2K iL l'li 7:9/:
Tn.:979-745.9595 •FAx:979.74C.9M
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ . __ 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 c
111, S 150A.
The debris will be transported by:
(name of hauler)
I'lie debris�will
,betdisposed of in : `
(name of facility)
l alktf S� Jf fac:lay) _
:1IC
✓�e LarxirrziNiueea o�✓��.a � it
Board of Building Regulations and Standards
0 HOME IMPROVEMENTCONTRACTOR- 'I
r; Registration 142157
Eip radon 3/t8/2008
SA li
CMS CONST
LGROVE�LANID.
SANTO$, - ` ,,,yf�r
INGTON'STREET' ,,,#
i s MA 0M4, Administrator
�. z.-n.__ --.:. s.�.n.....,e 1 __•,,_..........:.gym«.::-: , �j
rd of Building Regulations and Standards. .
- Construction Supervisor License
Llcer a' CS 85905,
' BIrthdste `1n7/1970
Explratloi� 1/27/2009 Tr@ 7841,
ReetrlCBO,,nr Oo'1`
i.... ' . �e V41'L _i.
CARLOS M SANTO
157 WASHINGTON STT., �-' -
GROVELAND,MA 01834 Commissioner
r.
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I
CITY-OF
PUBLIC PROPERTY
DEPARTMENT ,
w�.MFJLI,Y D�ISCUl1
MAVM 130 WAf1UYKir *bMEEr•`.iMOI.wttACKst„s0197o
1E7:M745-9M•FA3e 97i.74o4W
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:
Properly le krcated In a;Conearva*m Area Y/N Historlo 0kVkd Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: O 6,-P
Address:
Telephone: C6 —
3.0 COMPLETE THIS SECTION FOR WORK IN EXI8LAIp BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sO Renovated
construction or renovation
of existing building New
Bde!Description of Proposed Work: L
Roo
--Mail Permit to: do I - --- - _--