18 PUTNAM - BUILDING INSPECTION CITY C)FSALEM
PUBLIC PROPS-M'Y
DERAR-17TAENT
AfnvoR
I 10WAM I INGR?N ti'M I Ir I #SAJJ:V.M 1. +t I
7 APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT] AND 2 FAMILY DWELLINGS
IMPORTAKI':Applicants must complete all items on this page
SITE INFOUAT
AT'0 1 '
Location Name Building
Property Address a
Map A
Located in; Conservation Area YIN Historic district Y/N
Use Groups
(check one)
Residential(3 or more Units) R2
Type of improvement Residential(hotelhnouell III
(check one) Assembly(churches) Al
New Building Assembly' (nightclubs etc) A2—
Addilion Assembly(restaurants,recreation) A3
Alteration Business B
Repair/Replacement Educational E
Demolition— Factory(nioderate hazard) FI
Move/Relocite Factory(low hazard) F2
Foundation Only High Hazard If
Accessory Building_ Institutional (residential care) If—
Other(describe) Institutional (incapacitated) 12
Institutional(restrained) 13
Mercantile m
Storage(moderate hazard) SI
—--------- Storage(low hazard) S2
OWNERSHIP INFORMATION(Please type or Print Clearly)
OWNER Name Afe Al Szrwh-eA-6
Address Aff 0 4-",901 Al, S, 45,0 SAA"-Om
Telephone
[)&SCRIP'riONOP MURK'fOBEPI-.R[-'ORI%lt-.'.1)
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�'N CITY OF SALEM
1, ; PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation insurance Affidavit. Builders/Contractors/Electricians/Plumbers
3 3licdnt Informalion Please Print Le ihly
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City,State,Zip / / 16
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Are you an employer? Check the appropriate box: 'Type orproject (required):
1.❑ I :tin a employer with 4. ❑ 1 :tin a general contractor and I 6. 'ew construction
loyccs(full and,ur p art-unic).' have hired the sub-cuntracturs
! listed on the anachcd sheet. 7. ❑ Remodeling
2,2511 um a sole proprietor or partnrn
ship and have no employees These sub-contractors have K. ElDmnolition
working for me in any capacity. workers' comp. insurance. 9. ❑ building addition
Ko workers' cum insurance 5. ❑ We are a corporation and its
I p 10.❑ Electrical repairs or additions
I required.] officers have exercised their
right of . h1C7L 11.0 Plumbing repairs or additions
3.El am a homeowner doing all w exent tiork S Pon Pa'r
Myself, [No workers' comp. c. 152,j 1(4),and we have no 12.❑ Ruof repairs
insurance required.] t crnpluyces, [No workers' U.❑ Other
comp. insurance required.]
•4ny s,pl�t'mll that checks box fit mull;&u fill out the VSCnen Iwluw,bowioa their wurkus'cumpensmiun puli y iu6lrmatium
' Ilumwtw ncn who submil this alTdavit indicaims they am doing all work mW then hire outside cwurxlom must.utmlit a new alCdavif indiuung..wh.
-f'oniristor.(hot chock this box,must aaachcd.m addiriooal.-[silt whuwiny the panic of rN sub- oniraciors and their wurkors'ttmlp.policy information.
l run an employer that is pro vidigq workers'c'ourpenstetion insurancefor ray employees. Below is the pulicy acid job.site
ltrforinatiam
Imurance Company Mitre: .
Policy B or Sclf-ins. Lie. *: ___..... Expiration Date:
Job Site Address: - Cuy,SlaLclZip:
Attach n copy of the workers' compensation policy declaration page(showing; the policy number and expiration date).
failure to secure coverage as required under Swiun 25A uf>IGL c. 152 can lead to the imposition of criminal penalties of a
floc lip to 51,500.00 and/ur one-year nllpriSOinnlnt,ai wc11 as Civil pelialtICs in the form of a STOP WORK ORDER and a fine
of up to 5250.00 if day against lite violator. lie advi.acd that a copy of this stutcment may be lurwarded to the Olhce ut
Iuw c..u,aunm ul'the DIA :or inwcrarcc coscrage icritic.lnon.
/du hereby c ell ,rr r ar t pains avid Pena/lies of perjury that the i iforinallon provided above is true,and correct.
Date-
v• :cnttt,: N"/ / // Y/
Official ase wily. Do tent write in this area, to he ruuipleted by city or town aJjicial.
('itv or Town: ---- Permit/License p_
issuing .iluthurily (circle tine):
1. Ituurd of llvallh Z. Building Department 3. Cit3r'fowsu Clerk 4. L•'Icctrical Inspector 5, Plumbing Inspector
6. Other
Contact felon; __ _ Phone th
Information and Instructions
.Iassachusetts GcncraI Laws chapter 152 t'equires a I I einplo)ers to provide workers' compensation for their employees.
Pursu:u)t to this statute, an empfuree is defined as"...every person in the service of another under any contract of hire,
cypress or implied, oral or written."
An employer is defined as"an individual, partnership,association, corporation or tither legal entity, or any two or more
of the lorogoing engaged in ahomt enterprise. and including the legal representatives of a deceased employer, or the
'receiver or trustee of ail 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.rounds or building appurtenant.thereto shall not because of such employment be deemed to be an employer."
MGL 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. NlGL 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 ot'cumpliance 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)namc(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 con fimhation of insurance coverage. Also be sure to sign and date the •affidavit. The affidavit should
be retuned 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_u workers'
compensation policy,please call the Department at the nunber listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or'rown 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.
i'laasc be sure to fill in the pennit/license number which will be used as a reference number. In addition, an applicant
iliat must submit multiple permitilicemw 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 rile for future permits or licenses. A new affidavit must be filled 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I ha of ticc oI Inve\rigatmns would-like to bank )'ou in advance fur your cooperation and should you have any questions,
please du no hesitate to give us a call.
The Department's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Otflce of Investigations
600 Washington Street
Boston, MA 02111
Tel, k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
"l 1` PUBLIC PROPRERTY
DEP AR'I'vTENT
construction Debris Disposal Affidavit
(required for all demolilion and Ivno\'uliun \\'ork)
In accordance \\ill] (Ile sixth edtttoll of the State Building Code, 7S0 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building 1 ermit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
111, S 1 50A.
The debris Will be transported by:
(name (it hauler)
he debris will be disposed ot•in
(namr ul Iacilny) -
(:I,ttlfeSK u( IaCIIIIVI
H L'1latuic it�penn t upphcunl
Mate
CONTRACTOR INFORMATION ,pp
Nam l �� C�UcPANO
Address o2 / R/ tiC A6 h1 1-z—
Telephone 11irl V-0 3
Construction Supervisor's Lic#
Home Improvement Contractor# /� 7�
ARCHITECT/ENGINEER INFOILMATIOPp ,
Name lJA
Address ND J✓ 9l ear- J
Telephone 49'7 7S-01
Mass. Registration # A f S
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000+ $5.00=
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all infonnation stated above is true to the best
of my knowledge under the penalties of perjury
Sig /
Date ZL
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