69 ORCHARD ST - BUILDING INSPECTION -
-- _ — I-he (',alunnntt C.tlth ul %I.n,uJuuCu, --- — - ``
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� .. . Building I'Crmit :\Pplic.ttiun To c'unarurl. Repair. Rcntt\utC 01 I)Cnn:li,h .I � 11, , ,• .l A........,
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fhu Srcuun Fur Otllclal l',r Onlv ----__---- - �J
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Ifw,1d, }('nlnlnl.a-•nut Lrye,I'll ill llu I lJ lue, D.ur
L - SECTION I: SI 1'E INFORMA HON
ttu opay�a•) d ress--�L 1.2 Assessors \ S. Parcel Numbers
x (�Ve,h
\la
I luhlhl, in ICccpl J . ❑'ut. sr,___— nl'____� P
ZnnutK O:+trice I'ngw,rJ t'x• -- I Lul :\rcu I,y III Fn,:n ,ee I Ili
LS Building Setbacks (f )
Front Yard tilJr Yards Rrar Y:.:d
I RryuurJ ! Pn:uJrJ _ ReGul:'CJ pr:s:eicJ Rryuu eJ PI. ,n:cl _ .
1.6 Water Supply: IMG L C. .J. 3`11 1.7 Flood Zone Information: 1.8 Sewage Disposal System: _
Zone. _ Outside FI:wJ Zone" 'tunic: sl ❑ On ,tie Jls 311sal ,,,ICm ❑
FuhliC ❑ Pnvale❑ Check it ye,❑ p 1
SECTION ?: PROPERTY OWNEERRSFIIIPt_ -
X z o,.pe� Reeogd—1 CIO -
:I'nnl 1 :1JJre,s litr Ser t:re'.
! �Slgnrtire m-I relc h Pone
-- SECTION 3: DF.S 'RIPTION OF PROPOSED WORK'(check all that apply)
New Cnrotn!ctiun ❑ I Existing 9wlding ❑ TOts tier-Occupied Rep:ursU) ❑ Aherauunl,) ❑ :W_nn+n ❑�
Demolition Ll Accessory Bldg. ❑ 1 Number ur Unns Othe, ❑ SpCnty._
F1ret DCx:lpuun of Pnrpusrd W,)rk
x ..
--- —_,— SECTION a:.EST 1MATED CONSTRUCTION COSTS
E,umuled Cuts:
Item ILabur.mdNiaterwls) official Use Only - ----_- -
�. -
I iiwlJnre S 1. Building Penns FCe. S InJlcale h:�,� (Cc I. �.le1Cl uunCJ.
❑ Standard City/Town Appllcatwn Fee
_'. Electrical S ❑ Total Pngect Cust' them G) \ multiplier x
). Plumbing S t. Other lees: S
4 Slechamcal MAC) S
I i }ki hamc.tl li'Ire 5 -
r �u , trCsa,lnl i r'a.d All Fees S
('heA No _ l'lie,k Amount C.:,h \m.nutl
`x h rotal Project Cost �,6-0 00. oV ❑ P.ud to FIII ---- ❑ Oul>t'jild�inyyg li.11.ln.e [)tie
C 1c -T-Y
SECTION 5: CONSTRUC rION SLR% ICES 4,
5.1 Licensed Construction Supers iwJr ICSL1 7e 4Q P.-- --- _/r _ �Oq
•��,,, �_rr-enQa
Si. Ilolgir --- --- ---- — —
6V I Li,l l'SI. [Nile nri h:lrra i
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\I \I d,oan Ihrs
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- if Ki.iJ:in r.rl SnIiJTiil liunuu�ALLrL.0
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52 Registered Ilume Irnpruvement Contractor fill(-') qqlrbw
�;
� SignoW re telephone
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT IM.G.L. c. 152. § 250611
WV )rkers Cornpensatilm Insurance affidavit nJust be completed ❑nd ,ubmhted with this appllc:uiun. FaJure In pen,ide -
this affidavit will result in the denial of(he Issuance of the building permit.
Signed Affidavit Attached" Yes .......... ❑ No _._ O -
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR/�CONTRACTOR APPLIES FOR BUILDING PERMIT
IX / rlbw-e ` as Owner of the subject property herebv I -
:mthorize to act on my behalf. mail maven
relative to writ k authorized by this building permit application. y _
----- — --/—?—(:�> ---------- . .
—t-�— --- —�I
Sienmure of Owner - Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent her Jec l:oc
that the statements and information on the foregoing :application are true and accurate, to the best of my knowledge and
behalf i—
rP"t�
Print Nar e
Sign ure of er or A hon ed Agent Dale
I. In under tide arns and penaloesol (u I
NOTES: _
1. An Owner who obtams a building permit r Jo his/her own tsork, or an ossner who hires :tit unregl,arrnd rrr,Ir.r, for
(nut registered in (he Home Imprusement Contractor 11I0 ProgramJ. will trnf hale acre>, to lne alhitr: iwo j -
program or guaranty fund under M.G.L. c. 142A. Other important intoimation on the HIC Program and
Construction Supervisor Licensing WSL1 can he found in 780 CNIR Regulations I I0.146 and 1 IU 10. re,pciuscly
' When ,uhstamial work Is planned, prosrde the rN�rrmanon helow:
7rual 11mrs area (Sq. Ft Including garage. f ni,hed ha,ernenUairics, deck, or porih,
Grass hvrng area rSq. Ft.) Habitable mart count
Number of prep Laces -- Number of hedroom,
NLltllhCa or hathnuan, _-- Number of h.Jtih,uh, _
L,pe of he.Jute ,s,1em _- --- Numhrr ref Jc.k,r -
�
3_ .:Total Pnyecl Square Footage" Ina) he ,uh,tituted fur rot.d Pnrlert C\r,f
,
s�
CITY OF SALEM
PUBLIC PROPRERTY
'a` r DEPARTMENT
t.PI❑I gi I:Y DIt 1 it: 1.1.
\I Yl.to 12C Wn rli.Ni:ru.NS I K IEL'r* Snu:x4,MASS-%Cln sl%I IS01970
Till;978-.'45-9595 • 1'nx:978-74-1-M46
Workers' Compensation Insurance Affidavit:t Builders/Contractors/Electricians/Plumbers deice Print Leeib v
v licant Information r
4lime (Business(nrganituinNlndividuull:v�_Ts
Addre,;s: 11 A) 0(,gmS C,L_o
Cilyistate,'Zip: > �" OMJ:a t'hone ;': A17 (5�-23
'type of project(required):
Are you an employer! Check the appropriate box:
I.❑ I um a employer with 4. ElI ran a general contractor and I G. ❑.New construction
have hired the sub-contractors7. ❑ Remodeling
enq>luvees(full and/or part-time) laced on rile attached sheet.
2.{�yG7�r I ant a sole proprietor or partner-
' Ship and have no employees These sub-contractors have S. ❑ Demolition
workers' comp. insurance. 9. ❑ Building addition
working for me in any capacity. 5• ❑ We are a corporation and its
lNo workers' comp. insurance 10.❑ Electrical repairs or additions
required.] officersof have exercised their
nigh[of exemptionM
per GL 11.[] Plumbing repairs or additions
3.❑ I am a homeowner doing all work C. 152, §1(4),and we have no 12.❑ Roof repairs
myself. LNo workers' comp. employees. LNo workers'
insurance required.) t 13.❑ other
comp. insurance required.]
'Ally'.1plihcanl Ilan checks box of must also rill out thu action Ixlow showing{their workers cumgsenvuion policy information.
' llomcowm"whu submit this affidavit indic:uing They arc doing all work and then hire outsid<euntmclors must submit a new al'LAavit indiubng such.
that cl 'k this box must auachcd an additional shut 1h wing the name of the
sub-coniracwrs and their workers'comp.policy infurmariun.
1 am un employer tbar is providing rvorkers'cornpen.vation iu.surtutee fur any employees. Below is the policy and)ob site
iufurtnatiutt.
Insurance Company Name: - .... ....._-.._--._.._.-----_----
Pulicv it or Self-ins. Lie. Expiration C ityi State/Zip:
Date:
Job Site Address: —
Attach a copy of tire workers'compensation policy declaration page (showing rile policy ntnnber and expiration date).
Irailurc to secure coverage as required under Section 25A of 11GL c. 152 can lead to the imposition of criminal penalties of a
line up to S1.500.00 and/or one-year imprisonment, as well as civil penaltics in the furor of a STOP WORK ORDER and a fine
of up to S250.00 a day aguinst the violator. Ile advised that a copy of this mutcrnent may be forwarded to the Office of
luvrsti.,alions ol'thu FAA for insurance coverage verilicanun.
/du hereby certify I alter the thins a penal ' s jury that71hejunnulloDate-provided above is to d correct.
Uatc�
Official use only. Do not write in this area, to be completed by city or town o))ichrl
City or Town: Permit/Licenseb.-___...
Issuing Authority (circle one):
1. Board of health 2. Iuilding Departtncnl 3.Citr/'fown Clerk 4. Electrical Inspector 5. plumbing; Inspector
G. Olhcr
Contact Person; Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emphgyee 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
„P the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of .m 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."
`tGL 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, ss'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 nunmber(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 time 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 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 permitilicense 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I be 01113cc of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du nut 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 ext 406 or 1-877-MASSAFE
itcvised i-26-05
Fax #617-727-7749
www.mass.gov/dia