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PLANS MUST BE FILED AND APPROVED BY THE
� SPECTOR PRIOR TO A PERMIT BEING GRANTED I
LocationofBuilding RFD AC�£f LN
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Siding,CotrttCt Deck,Shed,Pool
Addition, Alteration, Reps /Replace,Fourtdation Only, Wreclting
Other.
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
M owner;Name: AR('zb PALtmL2 C�ojncor: m oF _
Strat r-) RED AJQ- LA)cityStreet) lX"�ENWt70� Seem 6�. s�2
State Phone 17 C{- �jR)C, State Phone(q79) 'J -7(9 (o
Architect: City of Salem LicA
Street City State Lick HIP k
State Phone ( ) Homeuwoers Esempt Form__yes X no
Stn cture: (please circle) Single Family, Multi Family k Other
Estimated Cost of job S
Will buildiog confirm to law!!
e: no 7�
Asbestosi�n ao
Description of work to be
42LALE
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Dnwi Submitted: s no Mail Permit to:
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Signature of Appliead=,S GNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BOMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
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Department use Only: PermjNk Zoning Map/Lot
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Permit fee S
COMMENTS:
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CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
00.
120.WASHINGTON STREET, 3RD FLOOR
SALEM,MA 01970
TEL. (979)745-9595 EXT. 360
FAX (976) 740-9646
STANLEY J. USOVICZ. JR.
MAYOR
DISPOSAL OF D EBRiS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34, I aclmowledge that as a condition
of Building Permit# ,all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,S150A.
The debris will be disposed of at: Ocre Eq- F
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Lj O e-cy S?E, 2
Address,City& State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL ca S 150A, and the building permits or licenses am to
indicate the location of the facility.
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office oflnvestigatdons
600 Washington Street
Boston,MA 02111
www massgov/dda
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 I _ Please Print LeziblY
Name(Businessiorganization/lndividwo:
Address: LIST —Refn�won� S-r
City/State/Zip: \ADcZC f west. Phan#:
Are you an employer?Check the-appropriate box: Type of project(required):
1.® I am a employer with kkD 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-cantractors
2.❑ lam a sole proprietor or partner- . listed on the attached sheet t 7. Q Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Buildm' g addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repays or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.) t employees. [No work' 13.❑ Other
comp.insurance required.)
Any applicant that checks box#1 must also fill out Poe section below showmg tbev workers'oom ensaboo policy iuformetiom
Homeowners who submit this affidavit indicating they me doing an work and ffien him outside conbadors must autmir a new affidavit indicating such -
:onbactors Bret check this box must attached m additional sheet shD%*the nerne oftbe sulroonaaetors and their workas'comp.policy information. . ..
am an employer that ispronding workers'compensation insurance formy employees. Below isAepolity andjob site
formation. /n�
usraance Company Name: 1.tS . C n . O-P
olicy#or Self-ins.Lic.M A a a 4'7 R Expiration Date: 3 — (-0
lb Site Address: City/State2ip:
ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
H'hue to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
me up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
`up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to lire Office of
Lvestigations of the DIA for insurance coverage verification
do hereby ce►Vy' under the pains and peeakm ofperdwy dart the informadon provided above Is none and cornett
t?�attae: QIAI Date:L
cone#:
QBklal use only. Do not write in this area,to be completed by tl y or town giieiai
City or Town: PermitlUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector S.Plumbing Inspector
C Other
Contact Person: Phone M
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to Ibis statute, an employee is defined as"...every person in the service of another under any contract of hire,
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 thereto shall not because of such employment be deemed to be an employer."
MGL chapter 15Z §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 sball
enter into any contract for the performance ofpublic 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),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 confirmation of insurance coverage. Also be sure to sign and date the aflidaviL 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 then
self-insurance license number on The appropriate line.
Ilh 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 permit/license 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 file for future permits or licenses. A new affidavit most 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
(ie.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
wised 5-26-05 www.mass.gov/dia