12 PICKMAN ST - BUILDING INSPECTION PUBLIC PROPERTY
DEPARTMENT
MAYM `
t20W&Wtt+cltws17WT 0 3_y; Mwttna&st.1'rsot970 Q
M3.978-745-9595 0 FAX'976740-9846
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUI DING
1.0 SITE INFORMATION
Location Name: 8uitdtng:
Property Address:
Properly is located in a; Conservation Area Y94 Historic Diamot Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land /y.
Name: r
Address: r^
Telephone: Z3
3.0 COMPLETE THIS SECTION FOR WORK IN EXtanua BUILDINGS ONLY
Addition Existing
HEEE$_�� Number of Stories Renovated� New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
&d Description of Proposed Work:
i
--- -----_ ----
Mail Permit to. -- - —
What is the current use of the Building? ��=`` ��
Material of Building? if dwelling. how many units?__ _---
Will the Building Conform Law?
Asbestos?
Architect's Name
Address and Phone
Mechanic's Name � � ' �� �7/��7
Address and Phone 3 HIC Registration to /L9 7
Construction Supervisors License# Calculation
��/ppermill Fee
Estimated Coat of Project$yf7 —/
Estimated Co
st X$7/$1000 Residential
Permit Fee$
Estimated Cost X$111$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
Sig
ned under penalty of perjury X
specifications. 9
D to Fj
�I
r
Y F
d CCC
r» Q s o
H o
Llag—
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KL4BERfEY DRLSCOLL
MAYOR 120 WAMe icrON STREET•SALEN,MwsSAcrrt:sfiTis 01970
7h:978.745-9595 •FAx:M740.9t146
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/plumbers
Apiplicant information Please n Le
elbly
Name(Business/OrganirauontIndiddividual): T 6X 6 Z Z
Address:_
City/State/Zip.—IV, Phone#:9 7 t- — / / 7 /-:;z CJ' 7
Are y an employer?Cheek�s aPP Pete : Type of project(required):
1. I am a employer with i 4. El I am a genera(connector and I
employees(fUll and/or part-time).• have hired the sub-connactora 6 New
2.❑ I am a sole proprietor or partner. listed on the attached sheet. t 7. lE
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. Building addition
[No workers'comp.insurance 5. We are a corporation and its
required.] officer have exercised their 10.❑Electrical repair or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No worker' comp. c. 152,§1(4),and we have no
iur nsance required.)t employees.[No workers' 12.❑Roof repair
comp.innrrance required.) 13.❑Other
fAaY aPPtlnet tt�t chedu boa el mat also fill am the section bales shorans their wake'eomPmyrfo I Ongey infamadm
Homeowness who submit tbit dndava mdieatfaa tMy an doiet aU wok ad thm him outside coaeatera mat aubma a row atlWavk =,rcoatraeten that shalt th4 boor moat ruched m additioml sheet shm nal the aams of the nubsoanaaon and their wakma•aomI POW infnnuadoe.
lam an employer that/a providing workers'compensation intaranee for my employees. Below if the policy and fob site Informadora
Insurance Company Name:
Policy#or Self-ins.Lic.#: / Expiration Dated
Job Site Address:/-:2— is� 417 f`T City/State/Zip
Attach a copy of the worker'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 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER anda ties of
of up 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
I do hereby certify nder rake pains and penaJdes ury that the Informadon provided above Ybw and correct
Signature@ //
Offlelal use only. Do not write In this area,to be completed by city or town o,Q7ciaL
City or Town: PermiNLlcense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person• Phone#
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employe a
Pursuant to this statute,an employee is defined as ...every person in the smite of another under any contract of bite,
,
express or implied,oral or written."
An empooyrs is defined as"an individual,partnership.association,corporatton or orbs legal entity,of say two or more
of the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased employer.or the
of an indiviohtal,partnership,association other legal entity,employing employees' However the
receiver er trustee not more than three apartments and who resides therein,off the occupant of the
owner of a dwelling horse having construction er repair work such dwelling horns
dwelling hamse of another who employs Persons to do maintenance` be deemed to h w Ming house
or on the grounds or building appurtenant thereto shall not because of such employment
MGL chapter 152,125C(6)also states that"every state or local lloensleg agency stall withhold the Issuance or
renewal of a license or permit to operate a busbies or to eonshruer buiidlags i•the commonwealth for say
applicant who has not produced aceeptable evience of eompilanee with the Insurance coverage required.
Additionany,MGL chapter 152,§25CM states"Neither the commonwealth not any of its Political subdivisions shall
e performance of public work until acceptable evidence of compliance with the insurance
requirementsients off this d for th
enter into any his chapter have been Presented to the contracting autbority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessaof
ry.supply wbconttsctor(s)came(°),address(es)and phone numbec(s)along with their certificates other
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
are not requireid to carry workers'compensation insnrance. if an LLC or LLP does have
members on partners. advised that this affidavit may be submitted to the Department of Industrial
emPloyeea t policy is regmfed Be
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be nturaed n the city or town that the application for the permit or license is being requested,not the Department of
u have any questions regarding the law of if You are required to obtain a workers'
Industrial Accidents. Should you a<the number lined below. Self-insured companies should enter their
compensation Policy.Please call the Department
9elf inamance license number on.the a
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 fill in the permitllicense number which will be used as a reference number. In addition,an applicant
that moat submit multiple permivlicenw 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 on
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be Provided to the
new ar,,&vlg must be filled each
applicant as proof that a valid affidavit is on file for
li�pernt or�t of lated to any business"C mmercial venture
year.Where a home owner or citizen is obtaining
(i.e. a dog license or permit to bum 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 Departmen's address,telephone and fax number-
The Commonwealth of Massachusetts
Depot omen of Industrial Accidents
081ce of Invatlgado" .
600 Washington street
Boston MA 02111
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
[revised 5-26.05 W WW331ass.gOW"
CrrY of SALEM
' PUBLIC PROPERTY
DEPARTMENT
Construction Debris Disposal Affidavit
(ee wrgd 8x an daaalidaa and ratovadan wart)
In accotdana with the ditch adtdoa of dw Stri LtttildiM Coder 780 CMR section l l l.!
oat*and dw peovialGM otUGL.a 40.S St
8uldbs pamb 0 is bond with the oonMon that dw deMa mulths Ave
dds,tart shall be disposed of is a Doi)►iteecsd waste dtspasa/6dlttlt ara dsdtnad by MGL a
tu.sison.
TM debds wit be transposted Or..
(aa arervfdd
The debris will be disposed otin:
(a hkels of ruatily)
si o(Pamit 00kad