28 PURITAN RD - BUILDING INSPECTION (2) " s
CITY-OF SXCE --
' PUBLIC PROPERTY
� DEPART INIENT
KMMF. LEV ORLSWU
NAvoR 120 WASIUNGrON hMEEr•Sutar,MASSACHM-1-501970
TIEL,978-74S-9S95•FAX 97&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: G QP. of ,,G� Building: SA,,A
Property Address: d faym)lal
a PiYrl
Property is located in a; Conservation Area Y/N-,&— Historic District Y/N W _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of / �� q Area per floor (sf Renovated
construction or renovation / (� f f
of existing building Q New
grief Description of Proposed Work: 9c e
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-- Mail Permit to:
ft
What is the current use of the Building?
Material of Building? Od4 /`-j-e2jjjL If elling, how many units?
Will the Building Conform tqq Law? �f Asbestos?
Architect's Name
Address and Phone ( 1
Mechank's Name
Address and Phone
Construction Supervisors License#�/ ��0�3��� HIC Registration# A K?
Estimated Cost
��ofpp.Project$ 00(9 — Permit Fee Calculation
Permit Fee$LLB,—_ 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 property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build a above s ted
specifications. Signed under penalty of perjury X
n
Date
i
o
Yr � n
y `
u
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ttntaERl�r nRtscou
MAYOR
Ito WA4DWM STREET a SAI 4,MAXACM;U S 01970
TEL•M743.9595 a FAX 976.740.9$46
Workers' Compensation Insurance Affidavit: Bullden/ContractorsmecMcianwph mbera
Applicant
Name(Businese/orguoae • 'dual);
Address: &-we X //��
Owstate/Zip: S Phone#:�t7�- ��� - 2,,?7
Are you as employer?Check the approprlah M
1.❑ I am a LL4 general wnseactoc and I �of pro1�(ro9dred):
employer with 4. I am a 0__
employees(full and/or part-time).• have hired the sub�conhactas 6 evtr
2.❑ I am a sole proprietor or partner- Hated on the attached sheet. t 7. Remodeling
ship and have no employees These sutb eonttactars have S. O Demolition
working for me in any capacity. workers'comp inntrance.
[No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition
required.] 0i7tcars have alt9mised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.[]Plumbing repairs or additions
myself.[No workers,comp. c. 152,$1(41 and we have no 12.(]Roof repairs
insurance required.]t employees.[No workers'c 13.❑Other
comp insurance required]
;Anyeppilmot trot dwdm boa e1 mar also a0 art the teens below thotvina tldr warkrs•
r oI[—
Hameowouvncwwho a aftdds thibox
st w vitsac ie w=a thaw w doles aE ttadt sect the tyke aemida aonit wbeJt eons alpdtvtl
ComeeOma chat cheek Was bar mat aesehd a sdditiaal thtot dwvk�tlr Deer of floe ab.aonpamom sad dab nahm•gyp,Polk7leibtmstlae.
1011 am employer that Is provldbwg workers'compensadon Warance for my ernpleyees Below is the poney andlob slh
information.
Insurance Company Name:
l��si1
Policy#or Self-ins.Lie.# Expiration Date:
Job site Address
ci /stawz• .
h r�.
Attach a copy of the workers'compensation policy declaration page(show
ing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to due
fine up to S 1,500.00 and/or one-year imprisonment ns weU as civil Penalties in the form of STOP WOion ofcriminRK ORDER�of s
of up to$250.00 a day against the violato fine
r. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
/do hereby Gerd er/ p en of per/ary that dM informadon provided a�bove b and correct
Si
Phone#:
OJl?claf au only Do not write Gs this Dreg to be coneplsfsd by cltp or tows o11k1aL
City or Town: Permitucense#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts ceneral tar 152 requires all employers b provide workers' othatundrcompensation for their contract
PIOYCM
of bin.
Pursuant to this stetum.Lan acme is defined as"...every person in the service of another undo any
express or impitiA oral or written."
partnership,-an iudividual, associatiM corporation er other legal entity.or any two or more
An tsPteYa is engaged
enm a joint entesprisa.and tnclttding the k 0 representatives of a deceased employer,err the
of the locagoiat engaged J asaoeiapon or other legal entity.emPlOYita�ployeas However the
receiver or uuustee of an individtul,partnership, and who resides thaein•or the otxttpo t of the
owner of a dwelling house bavmfi not mom than to domaime+ n Or repair work as such dwelling boom
dwelling bottle of anther who eraPloYa to shall not became of such employment be deemed to be an erapleyer"
or on the grounds or building appurtenant
that"every stab er h►ea1 Seining sgency spat;withhold the issuance�
MGL chapter i ss $tor permit also states buildings b the commonwealth for any
b operate a business or b construct with the insurance coverage required'"
naewsl of a e hase et Permit acceptable evidence of eomptlanee shall
who has net per 152d25C states of its subdivisions
appnesnt 152,$ (71 "Neither the commonwealth nor a� poh�with the insurance
Addiumu,l .MGL clupbt contract ft the paftmance of public work until acceptable evidence of compliance
enter ft of this chapter,have bim presented to the contracting audwcitY•»
requitareari
Applicants the boxes that apply to Your situation and'if
affidavit completely.by cnumbeg ale with their catificaa(s)of
please fill out the aswb coo�mr(s a).ad�ese(ut and Phone n uftels )along ees other than the
rtecassary,supply or Limited Liability partaerahips(LLih with no employ
insurance. Limited Liability Compan are not required ies carry workers•co on insurance. If an LLC or LLP does have
member$of he Department Of lodn'trid
emP s.a��c Be advised that Abe be sueto sib dab the da&vlt may be submitted to I he a6tdavrt should
Accidents for confirmation of insurance coverage. of
be retested to the airy or town that the application for the permit or license is being requested,not the
Industrial AccidentL Should you have any questions regarding the law er if you are required ro obtein�tvoa era'oM thus
compensation Policy.Please call the Department lam do e. number listed below. Self-insured companies
self-insurance license ramtber on.the
City or Town Ofsdsk a at the bottom
and printed legibly. The Department has provided a spat
Please be antic that the affidavit is complete ffice of bons has to contact you regarding the applicant.
of the affidavit for you to fill out in the event the mber which will be used ss a reference number. In addition.an applicant
Please be stun to fill in the pasmit/licease applications in any given year,need only submit one affidavit indicating cunesst
that must submit multiple per"Uhcense apP should write"ail locations in�(citY Of
policy information(if necessary)and under"Job Site Address the applicant ci or town may be provided to the
of the affidavit that has been officially stamped or marked by city sown A copy u on file for fisems Permits or licenses. A new afudrvit must be 611ed out each
applicant as proof that a valid affidavit a license or permit not related to any business or commercial venture
year.Wbere a home owner or citizen is obtaining is NOT required to complete this affidavit.
(i.e. a dog license or permit to ben leaves etc.)said Person
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 Departmeat's address•telephone and fax mtmber:
'Chia Cmmnwealth of Massachusetts
Department of lndtistdal Accidents
Ofike of Investlgatlotfs
600 Washington Sht d
Boston,MA 02111
Tel. #617-7274900 on 406 of 1-977-MASSAFE
Fax M 617-727-7749
Revised 5-26.05 wglw.nlaSa.gov/dia
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