10 RAWLINS ST - BUILDING INSPECTION EI`I'Y--OF-S-AI;E -
PUBLIC PROPERTY
Ile) DEPARTMENT
KI.%MFRI.EY DRISCOLL �1
MAYOR I2o WASHINGTON S1 mEr• J AIJ7i1,.AS5ACHl:Shl'IS 01970
TEL,978-755-9595 4 FAX 978-740-9946
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: Z7a Building:
Property Address:
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ��ef C✓/y_C(/%
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 Area per floor (sn Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of the Buildi g?
If dwelling, how many units? "
Material of Building? ;
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License#
HIC Registration#
Estimated Cost of Project$ GG Permit Fee Calculation
Permit Fee$ Z2 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
specifications. Signed under penalty of perjury X
Date ��
of
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CITY OF SALF.M
PUBLIC PROPERTY
DEPARTMENT
N.roa 135VABURC Uspar*tKw,MAU&OR3ZMGtgM
71 :97W?4S4M•F.ua MU GAM
Construction Debris Disposal Affidavit
(required tot an demolition mod renovation walk)
got accordance with the sixth edition of dw State Building Code.780 CMR section 111.5
Debris,and dw provisions of UM o 4%S.%
Building Penn&d is issued with dw=WWon drat dw dalm is mauking tom
LhU wmlt d ll be disposed of in a property lie nad waste disposal beility as defined by MGL o
I L 1.S 11t1A.
The debris will be transported bq:
a7 (asmm of tsfal.�
i
The debris will be disposed of in:
(nun of fmait»
(aldmu of fmili y)
sisnaWta Pasuutapplicaat
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'rhriw7.Jus
CITY OF SALEM
r PUBLIC PROPRERTY
DEPARTMENT
tc¢uaeat Fv otuscou
MAYOR 120 WAsHmTON STREET a SAtEM.MASSACHUSEM 01970
TEL.9M745.9595 a FAx:979-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le
eibly
Name (Bus6uss/Organimtion/bidividual):
Address: — � �41cz--
/,,
City/State/Zip: �.� i //L Phone #: �� �✓��G'3�
Are you an employer?Check t appropriate box: Type of project(required):
YI am a employer with 4. ❑ 6. ❑New construction
employees(full and/or part-time)-* have hired the sub-contactors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance.
[No workers' comp.insurance S. ❑ We are a corporation and its 9' ❑ Building addition
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11. Plumbing
myself. � ❑ 8 repairs or additions
y [No workers comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.0 Other
-Any applicant that cheeks box#1 must also fill out the section below'showing their wodsms'cempmwion policy information.
t Homeownen who submit this affileft t dieaung they an doing ad weds and the him outside contractors must submit a ame affidavit mitigating such,
tContracton that check this bmr must attached an additions!sheet showing the name of the sub onmwtors end Cher workers'comp.policy inib matioo.
lam an employer that Is providing workers'compensation insurance jar my employees. Below is the policy and Job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
_ Job Site Address: City/State/Zip:
- Attach a copy-ofthe-workarii�tompentiation policy declaration page(showing the poti�umber 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.
1 do hereby certify under the pains and penalties ofperjury that the fnformatdon provided above Is tare and coned
Signature:
Dat
Phone#:
00kial are only. Do not write in this area,to be completed by city or town ojJteiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for
ear emP hire,
Pursuant to this statute,an employee is defined as"...every person in the service of another under any e n
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a 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 therein 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,MGL 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 of compliance 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)name(s),addm*cs)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 confirmation of insurance coverage. Also be sure to sign and date the aIDdaviL The affidavit should
be returned 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 a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the a line•
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 permit/license number which will be used as a reference number in addition,an applicant
that must submit multiple permittlicense 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
id
affidavit is on file for- rture,permilts or.licenses. A new af„davit must be filled out each
applicant as proof that a val
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(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 Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-03 www.mass.gov/dia