14 OAK VIEW AVE - BUILDING INSPECTION EI`I'Y-OF3=
PUBLIC PROPERTY
DEPARTMENT
KI%Q .RLEY ORLSWAL
MAYM 120 WlSMNGwW SrREn 0 '
1t1-97e-745-9595♦FAX 97&740.95"
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:
Propertykddress— — -- --.- —
l I/ 0a11fu,'eGLJ -C.-
Property Is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: o n
Address: ! ,-f
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXIS11 UG 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
Mel!Description of Proposed Work: ff
--- --Mail Permit to: - ------
What is the current use of the Building? f C2S
Material of Building? l l/rig If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# y 5 s k l(o HIC Registration#
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee$ Estimated Cost X$71$1000 Residential
----- — - - - -- — — -- - — --- Estimated Cost X$t1/$100o Commercial
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit t build th stated
specifications. Signed under penalty of perjury
Date /0 C)
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Kn-most Sy Dalscw,.
MAYOR IM WA20GTONSTIM a SAtrtt,MASSAattmiT[s01970
TW w s-745-9s9s a FAx-97a•7o9a4
Workers' Compensation Insurance Affidavit: Sanders/Contmtor$Mec r(clana/plumbers
Applicant Information ( Please Print i edilt•
Name(BusweworpafadeNtndiv&W)' V Pcv;re- alv�,z • ` 'C1/N
/ a
Address' / i/ Al� J n P r CA _
City/statemp: all AL. nl9l n Phone#: cJ`/3 -S3
ype
Amyl�a employer?Check the appropriate bent ot
1.[� I am a employer with 4. [3 I am a gmaal contractor and I T New project( oquir :
employees(IWl and/or part-time).• have hired the sub-conaaass a
onstruction
2.0 I am a sole propaiaoor«parmeN listed on the attached sheet, t 7. 0 Remodeling
ship and have no employees These sub contractors have 8. ❑Demolition
working for me in any cmadry. workas'comp.mamance. 9.
q workers.comp. insurance s. 13 We am have and its ❑Ong addition
exaeised their 10.0 Electrical repairs or adMans
3.0 1 am a homeowner doing all work right of exemption per MOL 11.(]Plumbing repair or additions
Myself.(No workers'comp. c. 152,§1(4),and we have no
insurance required]t employees.(No workers' 12.0 Roof repairs
gyp,insumuce requirefl 13.0 Other.
-AxyWVdmwa an mAsdaba1metvanatlastheWe"111 slowing disk , -os•
ltomttoente•rho ntbmk this tdddWh they tm deiaa ell ttodt and Om bin ewdde eao mtit abaft aw sMdadt hdk+lfoa rreL
tcoaet don tht chock d&bmt mm atuched as sdd dmd abet shm%g des name of the attb�eotmemn and thdr waelaea• g pot?in tkeft sw
tim
f ass an anapbryar that L providlnf wodtsrs'"A'A" esdon lnsarafor my exaPioyeea Below le&*Po&7 drd fotrslp in/orstaalotr -
Insurance Company Name--Zr "9;2 1n t C&4-�
Policy#or Self-ins.Lie.# l-K lJ t� - 9 7 </O-/- C3 �7 Expiration Date-_=n oR
Job site Addreaa
ciry/satNZip: Ol c) 7�7
Attack a copy of ttr worker'compensatloa poaey declaratloa page(showing the policy number and expiradea da")6
Failure to secure coverage as required under section 25A of MGL c. 152 can lead m die imposition of criminal
fee up to S 1,500.00 and/or one-year imptiaonmemy as well as civil penalties
ota
of up to$250.00 a day a penalties in the form of a STOP WORK ORDER and a fine
gain?the violemr. Be advised that a copy of this statement may be forwarded to the Oflfce of
Investigations of the DIA for insurance coverage verification
/do Atreby cardA und4r do Palms and penaiNes o/Per/aq'that the Informadoa provided oboes is low and correcs
Sttmature , Z-- -0,7
Date
Phone 4• - q 21f:5: ?l
O,Q?elet use onl t Do not write bs this area;to be conrp/Hed by city of town oJylekL
City or Town: Permkt/Idcense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Ckryfrowe Clerk 4.Electrical Inspector S.Plumbing Inspector
&Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 mgWma all employers to Provide the service
workers�compensation y theft employees'
hung
Purwant to this statute.an easplew is defined as ...every person
ther un der an connect of bite+
express or implied,oral or written"
� on or other legal entity,a any two a more
An saeployer is defined as"aa individual.parmerabtR ves of a deceased employer,or the
Of the foregoing engaged in a joitot eOterP[ise,and includingthe legal representatives loyees. finer the
of an individual.partnership,asancanon or other legal entitY.employing enW of the
receiver or trustee hotter hart not mom than dues and who VIddas Win'or the occupant
owner of a dwelling who, persons to do maintenance'construction Of repair work on such dwelling houa
dwelling boase of another ibteeto shall not because of such employment be deemed to be an rmployer."
or on the grounds or building appurtenant
"eY state or local licensing agaaey abar withhold the i/a0anee t r
MGL chapter 152.42K(�Ci°o states that cry i.the eommeeweslth for a"
to oporats a business err to coes�buildings naYatwea rk
revewal of a Recast ea parsaft roduc acceptable ovidew*of eoanptlaam with*a insurance s6a11
Applicant who has not produced states-Neither the commonwealth not any of its Political subdivisions
Additionally,MGL chapter 152,12SQ7) m
evidence of compliance with the insmae
enter into any cmuza for the performance of public wait until acceptable
reqttireettenm of this chapter have been presented to the contacting auttialty'"
Applieaab
affidavit completely,by checking the boxes that apply to Your situation and.if
Please flu out the workers'compensuton a address(es)and phone number(s)along with their cerdfiCAU(a)of
necessary,supply�O°trocii s)creme( ).add<ere( with no employees other than the
Limited Liability Compamea(LLQ or Limited Liability Parteera6i"(LLih
fie' to carry workers'eompmsation insurance' if an LLC er LLP does have
er ate not required iced to the Depatbnwt of Industrial
members P� be subset
vit way Y
Be advised that thin ' should
employees,a policy is tion o d coverage. Also be secs to sip and date the amdavit. The affidavit
Accidents for confirmation of insurance the a a license is being requested,not the Department of
the
application for
Perron
er town that app a worker
city to obtain
be returned to the ty the law err if you am inquired
Industrial Accident& Should you have any questions a num regarding
compensation Pokey,please tail the Dep0rtmeter ° listed below. self-insured compattiea should enter their
self itiavaneg license number on the
City or Town,Omelab
Please be sure that the affidavit te is comple and printed legibly. The Department has provided a space at the bottom
ant
of the affidavit for you to fill out
l the event the license number whiceich
of
be used as aceference to number. in addition, a ou regarding the p
lic
Please be sum to fill in the perms applications
in any given year,need only submit one affidavit mdfcating cuttent
that must submit multiple penmitllicenae the applicant should write"all locations in.__(City or
policy information(if Wccfsuy)and under"Job Site Address" marked
the city er town may be provided to the
of the affidavit that has been officially stamped or marked by ty
town) A copy is on tale for Shure permits of licensee. Anew afudrvir err c m filled out each
applicant as proof that a valid affidavit a license a permit not related to any business a commercial vanmm
year.Where a home owner a citizen is es obtaining is NOT required to complete this affidavit
(i.e. a dog license er Permit to burn leaves ate.)said person
The Office otlnvestigations 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 addresa,telephone and fax number:
The Com onwtglth Of MMUhusetta
Department of Inds: WW Accidents
O®e$of IAVUdgadons
600 Washington strut
Boston,MA 02111
TeL N 617-7274900 cd 406 of 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26-03 WWWmass govi a
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Crry OF SALEM
PUBLIC PROPPXM
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