63 PALMER - BUILDING INSPECTION CITY OF SALEM
4,9 PUBLIC PROPERTY
DEPARTMENT .
nIMBERIEY DRISCOLL
MAYOR 120 WASHINCTON STREET•SALEM,MASSACHLSEI S 01970
TEL,978-745-9595♦ FAX:978-740-9846
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:
Property Address: 'VC'AVL"AC
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: S 'Oef ) 'c _
Address: �Q
l� olL
Telephone: —7 Z Z
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation L,,-" 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
Brief Description of Proposed Work: Vev-Le—
Mail Permit to: l IAALQFr� {M A d at-CY
What is the current use of the Building?
Material of Building? If dwelling, how many units?�
Will the Building Conform (,
form to Law? Asbestos?
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Architect's Name t I -7wof
Address and Phone 115 S D U,"klkn
Mechanic's Name e� A'k),
Address and Phone av1 C-
Construction Supervisors License# O(:;a I HIC Registration # + ��
Estimated Cost
of
Project$q Permit Fee Calculation
Permit Fee $ Estimated Cost X$7/$1000 Residential
Estimated Cost•X$11/$1000-Commercial
'An Additional $5.00 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 Pe it to build to the above stated
specifications. Signed under penalty of perjury
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CITY OF SALEM
j� PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET♦SAt.EM,MA.CSACHUSEf1S 01970
TEL 978-745-9595 ♦ FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4 1 licant Information rr Please Print Le ibl
Name (Busincssiorganization/lndividmp: O S LL C
Address:
City/State/Zip- Phone :
Are you an employer?Check the appropriate box: 'lype of project(required):
I.�1 am a employer with-_s^� 4. ❑ 1 am a general contractor and I b ❑New construction
employees full and/or art-tine).' have hired the sub-contractors
( P' 7. 0 [remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.:
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
jNo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right exemption t of per MGL I LE] Plumbing repairs or additions
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myself.(No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
ployees. [No workers' 13.❑ Other
insurance required.] r cm
comp. insurance required.]
-Any applicant ow checks box ff1 must also till out the section Wow showing their worktai compensation policy infurmatim
'Ilomeowners who submit this affidavit indicating Ihey are doing all work and then hire outside cmimctors mmi submit a new affidavit indicating such.
�Contracuus unit check this box must attached an additional sheet showing the name of the suWcontraetots and their workets'comp.policy inPormation.
l ate un employer that is providing ivorhers'compensation insurance for my employees. Below is die puhcy and job site
iwforaration. f D�
Insurance Company Name:
Policy#or Self-ins.Lic. Expiration Date: DQ
Job Site .Address: (-) '1,t^ _ s 6 City/Stale/Zip: 51
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
tine LIP In 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 LIP 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.
1 do hereb ce ify mtderydrr,p�and penalties of perjury that the information provided above is true and correct.
U � / v I/�
'iLmIluN: I / I)a re:
41 Phonc:i: I� `
Official use only. Do not Ivrite in this area, to be completed by city or town official
City or'fown: - Permit/License
Issuing Authority(circle one):
1. Board of Ilealth 2. Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other —
Contact Person: Phone#:
Information and Instructions
1%4assachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee 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 a joint enterprise,and including the legal representatives of a deceased employer,or the
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."
b1GL 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 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 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 pennitllicense 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.a 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
0111ce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPERTY
r
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WA.SHINGTON MREET♦ SALEM,MASSACHUSEITS 01970
TE :978-745-9595 ♦ FAx:978-740-9846
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 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
_.W Vow ti
(name of facility-
(ad ress of facility)
signature of perny t applicant
date
debnsaff.doc
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