85 PROCTOR ST - BUILDING INSPECTION (2) cn OF ALE
PUBLIC PROPERTY
DEPARTMENT
Kisairx6Y DRISCOLL
MAYOR 120 WASHING"S�TREB'r♦SALE MASSACHMI.1S 01970
TtL 978-74S-MS•FAx: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: Building:
Property Address:
Property is located in a; Conservation Area YIN Ala Historic District YIN�1Z
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: P to
Address: �✓� �J��_ n�
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use 3 New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation New
of existing building
Rrief Description of Proposed Work:
�'V dt✓
Mail Permit to:
What is the current use of the Building?
r
Material of Building? t—7) If dwelling, how many units? '
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone act /� �� d o l kl s — ��✓ �Li
Construction Supervisors License# /�,5- /).S y HIC Registration# �
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
U
specifications. Signed under penalty of perjury
Date o
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CITY OF SALEM
PUBLIC PROPRERTY
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�`7l �� DEPARTMENT
xnseeasaY naccou
MAYOR
t20 WAS 04TONSnM a SAtM4 MAXACHt1¢T'Jr;01970
TEU 97t'745.9595 a FAX 978-7409M
Workers' Compensation Insurance Affidavit: Butldera/ContnctorsmectricLna/pinmbers
Applicant Information PIlfew Print Legibly
Name(11usineworganizauoMnmvidual):
Address:-
city/state/MP: Phone
Are you as employer?Check the appropriate boat
1.0 I am A employer with 4. 0 I am a Seneral contractor and IF :81.f pro]eet pYqutred):
employees(fiell and/or part-time),e have hired the sub-connecu" New construction
2.0 1 am a sole proprietor or parmer- listed on the attached sheaf tRemode
ship and have no employees These nib ceatrscmrg have Demolit
wonting for me in a�capacity. workers'comp insurance.
NO workers'comp. insurance 5. 0 We am a corporation and its urequired.] ofllcers have exercised their lal repairs or addidma3.0 1 am a homeowner doing all work right of exemption per MOL lng repairs or additions
myself.(No workers' comp. e. 152,$I(4),and we have no
insun ace req�d]t employees,[No workers' oof repairscomp.insuance required] ther��r wvaoat not daa8u bca NI mme.tso tm cut tee eaetlos bdow thsving rsatr.atw• anaa
HGEMOW0ee2 tvlhs athmlt fats dgdsvn maieadeg may an doing al wcdt and d m m ad
at Wre wows weasetme muse tathmh a am atadsvle todleaWtg sods
tCoenacoms chat dteek ttds hes mugedrd dldaul eked rhavm9 the ems of dw ad their rorkns'canµ ply talhffma"
Ian an employer'bat Is providing workers'compeneadem ursuranee for my employees Below/s tke paU.y and fob rite
informadow
Insurance Company Name:
Policy N or Sell-ins.Lic.N:
Expiration Date:
Job Site Address;
Cary/Statellip:
Attach a copy of the workers'compensation policy declaration page(showingthe
Failure to secure covers as e imp lity number and a:piratloti date}
coverage required under Section 2SA of MGL a l52 can lead m the imposition oPcriminal panel as
of a
fine up to S 1,500.00 and/or one-Year bitty. Be advi as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up m 5250.00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office of
Investigations of the DIA for insurance coverage verification
f do hereby cero&under the pause and penalties of per/ary then the lnformadon provided above is uaa and correct
Simmaturc:
Da
Phone N:
0,pial use only, Do not write in thie area,to be completed by city or town o,Q7eleL
City or Town: Permit Ucense N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cltyfrowu Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone N•
information and instructions
ter 152 requires all employers to provide workers' compensation for their empbyea
ft,siu Massachusetts General Laws chap in the service of another under any contract of bite.
Pursuant c0 dtna stalum.an ewftfoyss its defined as"...every person .
mesa
«implied.oral or written." t
exp or any two«tame
association'corporation or other a d entity.
An sarpfoyo is defined as"an iiadtvidua4 Partnership• ��� mtanves of a deceased employer.or the
Of the foregoidg engaged in a joint enterprise.and includinL entity.empbying employes However the
asaaciatioa or other legal
receiver or trustee of an individuals partO and who resides theeein.Or des'occupant of the
owner of a dwelling douse having not mere than three maintenance.apartmaata censuisctioa or tePau,vim m such dwelling hotter
dwelfing house of=Other who employs thereto ada�ll nor because of such empkWitiett be deemed to be an employer.•
or on the grounds or building appurtenant
MGL chapter 152.4�(6)also states that"every stab or toeal neenselag agemy=hat wlthbold the W°210"or
to operate a business or to eoastrnd buildings Is the eommoaweakh for aq
reaewat of a tltenst or parmlt aeeeptabb evidaset of eomptlaan with the losursaee coveragevisiec"shill
+ Ous
Additionally.Additionally, chaPterPr 1��2SCM stem"Neither the commonwaalth nor any of its po�sol"with the insurance
of public work until acceptable evidencerequireSSICIAS of this chapter of compliance
enter into,
any contract fbr the have ins presented to.the.cont<actinL a!shoft-"
Applkanb aitiadou and,if
Please fill out the wakes•compensadic affidavit completely,by checking the boxes i�IY�Y�s)of
s �e{s),addras(ea)and phone number(d)along employees other than the
LimitedLip Liability�oCompanies(LLC)or Limi co Liability Partnerships(L�an LP)�or LLP doges have
members or Partners,are not required to catty wO*='cones insurance•
A forPolicy u � Be advised that this affidavit may be submittal to the Department of ludoatrlai
employees' Of
o[insurance coverags Abe be ante to sign and dam the affidavit. The affidavit should
IrAccidentse returned o the City mwn that the application for the permit or license is being requested•°°t the Department
re the law a if you are required to obtain a workers'
Industrial Aaidenm. should You have any questions gsrdiai
compensation Policy,please call the Department lilt the
number listed below. self-idaued compadies should enter their
self-h a vance llcenae mrmbec on the
city or Tows Officials at the bottom
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space _
of the affidavit for you to fill out in the
event number which will 1>e used as as has
num to contact Yber regardingou addition, applicant
Please be tam o fill in the permi lications in any given year.need only submit one affidavit indicating current
that must submit multiple portal ccm ap "Job
site Address"the applicant should write"all locations in__(city or
policy information(if neeeaeary) officially stamped or marked by the city or town may be provided to the
own)."A copy of the affidavit-dud has been is or liceases. A new afa-&vit must be filled cut each
applicant as proof that a valid affidavit is on fib for fitnne permits ial venue
year.Where a dome owner a citizen is obtaining a license or Permit not related o any business«commetc
(i.e. a dog license or Permit to bum leaves eta.)said person is NOTrequired to complete this affidavit
its would like o thank you in advance for your cooperation and should you have any questions,
The Office of tnvestigstio please do not hesitate togive us a call.
Departmene's address.telephone and fax number.
Thu CotnmonwWth of Massachusetts
Department of InduseW A=&Mts
OtIIes of INVOId Bong
600 WWdII8t=Strad
Boston,MA 02111
TeL #617-727-4900 eA 406 of 1-877-MASSAFE
Fa Al 617-727-7749
Rcvised 5-26-05 W W W,mass.goV/ilia
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