19 PARADISE RD - BUILDING INSPECTION dR cn Y C SALE W
� M ) PUBLIC PROPERTY o�
DEPARTMENT o
KI%IHFM-EY DRISCOLL
MAYOR
i?0 WASHIN4TON S'IREEC*$Art,M.MASSACHt;S6'1'IS 01970
TEL 978-745-9595 4 F=978-740.98"
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING_
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: nylx _ Building:
Property Address:
Property is located in a; Conservation Area Y/N H_ Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: to r 114�-
si�v-4;� (c•(W 13oD
3 C�s 9 lye. 0.2iF3;
Telephone: _ygAff
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
0
Demolition I Existing
Approximate year of /PkS Area per floor (so Renovated (mod
construction or renovation
of existing building New
Brief Description of Proposed Work:
7 ZN HGvf
V rV/ 4lY
Mail Permit to: r z
What is the current use of the Building.9 c6ofA" rVI
Material of Building? /K u+u If dwelling, how many units?
Will the Building Conform to Law? ..y��
Asbestos? MCI
Architect's Name
Address and Phone----------------
Mechanic's /
Name Cad>� `U
Address and Phone
Construction Supervisors Lice nse# C S- '/ 13c2 HIC Registration#
Estimated Cost of Project$SOT Permit Fee Calculation
TT Estimated Cost X$71$1000 Residential
Permit Fee$�U 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 Permit to build to the above stated
specifications. Signed under penalty of perjury
Date v ,Y� o G
�I
0
b
ar-
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
VAvoa I+30 WAUGUGUM SVMW•&Ujok HAOACHL= R 0tf7a
IVA:MUS-9S9S•PAZ M740,964a
Consimcdon Debris Disposal Affidavit
(required fat all demolition and renovation work)
In amrdaaea with the sixth cdidm of the State Building Code.780 CUR secdcal 111.S
Debris.and the provisions of MQ.a 40.8 Sk
Building Pannit N is issnad with the condition that the debris resulting ftm
this worst shall be disposed of in a properly licensed waste disposal ftillty as defined by MCiL a
111.S 130A.
The debris will be transported by:
(ssms a[bsnlsr)
The debris will be disposed'of in:
(naaw of facility)
IT I�cra.li
(addrom of f' •nay)
fi�oiRlre of permit 0 pticam
�O a7 OL
date
.:c6nsY7Jw / !
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xLNHERLEY DRLSCOLL
MAYOR
120 WASHMTON STRM•SALEM,MASSACHUsEM 01970
TF.1_979-745.9595 0 FAX-978.740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leelbly
Name (Business)OrganiaCott/IntSviduai): = /.JrH Gf= OiYSTldur'17rrr
r
Address:_
City/State/Zip: l3os{ o r it Phone#:
Are you an employer?Check the appropriate box:
FM
(required);
I. I am a employer with 4. ❑ I am a general contractor and I
employees(full and/orpart-time).• have hired the subcontractors truction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t g
ship and have no employees These subcontractors have nworking for me in any capacity. workers'comp, insurance,[No workers' comp. insurance 5. 0 We are a co ddition
rporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 114 Plumbing repairs or additions
myself.[No workers'comp. c. 152, §1(4),and we have no 12,0 Roof repairs
insurance required]t employees.[No workers' 0
comp, insurance requirc&I 13. Other.
Any applicant that checks box#1 anus also till out the section below showing their worikms'eompeosation paltry Inforttnnob
I 1{omeowmn who submit this aRidavit iodicuina they ate doing all work and then him wtuide cmtkaetass must submit a new affidavit eneL
tConbactors do cheek this box must attached an additiond sheet showing the name of the nub-contnotots and thetr aorkas'oomp.policy infmnaaad
en
lam an employer that is providing workers'compensation insurance for my employees Below it the policy andJob site
information
Insurance Company Name:. 4�jco
Policy#or Self-ins. Lic.#: l
� / Expiration Date: o 2�/o
Job Site Address: i-a [crrcr F ( City/State/Zip:.SAP�,ir lj/yam,
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 S 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.
l do hereby certify under
rrJthe p !ns and penalties of perjury that the information provided above Is drre and coned
Sijmarum /
D t • /oa� oG
one#: 60 S2 3 -7 t/16,
EafHealth
on!}t Do not write in this area,to be completed by city or town ojjlcial
Town: Permit/License#
ority(circle one):
Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
son' Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empl9Yses pursuant to this statute.an employee is defined as"...every person in the service of another under any contract of hire, ry
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, al represen or other legal entity.or any two r t more
of the foregoing engaged in a joint enterprise,and itxluding the legal representatives to i 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."
d the
ce
MGL chapter 152,§25C(6)also states that"every state or local construct
buildings
agencdings in the ommolnweatth for any
renewal of a license or permit to operate a business or to contract buildings
applicant who has not produced
152,d 25C(7)states `Nle ether the commonwealth nor any of political asurance coverage required-"
ce of compliance with the 1
Additionally,MGL chap $ evidence of compliance with the insurance
• enter into any contract for the performance of public work until acceptable
requirements of this chapter have Bien 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
s name(s),addresses)and Phone numbers)along with their certificates)of
necessary,supply sub-contracted ) Limited or to ees other than the
rtne
insurance. Limited Liability Companies(LL workers- sinsuuraanc s(IfLapn)LLC r LLP does have
members or partners,are not required to carryaffidavit may be submitted to the Departmeut of Industrial
employees,a policy is required' Be advised that this
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,n tain a workers'
of
Industrial Accidents. Should you have any questions regarding the law or if you an requiredes should enter their
compensation policy,please call the Department at the number listed below. Self-insured ompani
self-insurance license number on the a line.
City or Town Officials
Please be sure that the affidavit is comtheplete and event theprinted legibly. The Department has provided a space at the boron
of the affidavit for you to
fill out ttliccense number ffice of Investigations whichwill be used as are Bencenumber regardingt you In addition,an applicant
Please be sure to fill in the Perini given year,need onlysubmit one affidavit indicating current
that must submit multiple permittlicense applications in any gi hcant should write"all locations in (city°T
policy information(if necessary)and under"Job Site Address"the app
of the affidavit that has been officially stamped or marked by the city or town may be Provided to the
town)."A copy emits or licenses A new afiidsvir must be filled out each
applicant as proof that a valid affidavit is on file for future Pe .I
g a license or permit not related to any business or commercial venture
year.Where a home owner or citizen is obtainin
(i.e. a dog license or perm to burn leaves etc.)said Person
re it is NOT required to complete this affidavit
would like to thank you in advance for your cooperation and should you have any questions,
The Office investigations
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 sheet
Boston.MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
[revised 5-26-05 www.mass.gov/"