198 NORTH ST - BUILDING INSPECTIONr
%w°. CITY OF SALEM
3.1 y PUBLIC PROPRERTY
'� � DEPARTMENT
120 WA91IiVG:0N S-fREET •SALIOt,MASi-%CH1 NLl'ti 3191c
O TGI:979-745-9595 •F.+x:978-7449M
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 # _ _ __ 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 1.50A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(namme of fa�iLt
IaSdress o(Cacili[y)
--__ .,I_caturo of,�anr,it appiiunt
I ne (.ommonweotth of Massachusetts
Department of-Industrial Accidents
Office Of investigations
600 Washington Street
Boston, MA 0211-1
www.massgov/dia Totun Df Arlington
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Le ibl
Name (Business/Organization/Individual): a�L�D 1
Address:_ / w::) — T,.QttAL4,D� 5A—
City/State/Zip:_ A 7Cz!-iQ r P s Phone #:
-
Arrr�ee1 you an employer? Check the appropriate box:
1.�1 7 am a employer with. 4. ❑ I am a general contractor and I -Type of project (required):
employees (full and/or part-time).• have hired the sub-contractors 6. New construction
2.❑ 1 am sole proprietor or parmer- listed on the attached sheet t 7. ❑ Remodeling
ship and have no employees These sub-contractors have -
working for me in any capacity, workers' comp. insurance $' 0 Demolition
[No workers' comp. insurance 5. ❑ We are a corporation and its 9' ❑ Building addition
required.] officers have exercised their 10.E3 Electrical repairs or additions
3. 1 am a homeowner doing all work right of exemption per MGL 11.0 plumbing repairs or additions
myself. No workers' comp. c. 152, §1(4), and we have no
insurance required.] t 12:❑ Roof repairs
eq ] � employees. [No workers'
t comp. insurance required.] 13.0 Other
'Any applicant that checks box A l muss also fill out the section below showing their workers'wmprnsetion policy infomralion:
t Homeowners who submit this affdavit indicating they are doing all work and then hire outside conhacturs must submit a new affidavit indicating sack
1Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'c amp.polity inforn ration.
'am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name:— L�V� \ilt2 ,
Policy#or Self-ins. Lic.
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 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$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250-00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Sigature:
Date
Phone#:
O
fficial use oe/y- Da not write in this area,to be completed b c'
P y city or town official
or Town:
Permit/License#
ing Authority(circle one): -
oard of Health Z. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
ther
Contact Person:
Phone#:
_ KCPRDTNIEi�iT
K,;QAF M cv pRMUw,
NAYM 130 WASMNGTON hntE6r•'AL 0u %L%W CKLShM 01970
TFi TW745-9M•FAX 97F740.98"
APPLICATION FOR THE REPAIR. RKNOWA-U-0ft CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTINGI
STRUCTURE OR BUILDIN
1.0 SITE INFORMATION
Location Name: Building:
-- Prop"Address:---- - --- — - --- -
1G �
Property is located in a;Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone:
v
3.0 COMPLETE THIS SECTION FOR WORK IN UILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Hriet Description of Proposed Work:
"'�ep\o Ck 2J VDtr�c�Ulc�S
---- - -- Mail Permit to: - S C , �� l 190� - -
What is the current use of the Building?
Material of Building? .j&, r If dwelling.how many unibT
Will the Building Conform to Law? at-;, Asbestos?
Architect's Name
Address and Phone
Mechanids Name
Address and Phons
Construction Supervi
sors License 0 HIC Registration 0
Estimated Cost Of�Proojject$' �- Permit Fee Calculation
Permit Fee$—1— Estimated Cost X$71$1000 Residential
Estimated CostX S111411000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property 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 /- e 4 --il-p 4 t
Date-6
of
N
9
a r.
a