2 RIVERVIEW AVE - BUILDING INSPECTION (3) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposat Aft1davit
(required for all demolition aril renovation work)
In accordance with the sixth edition of the State Building Code. 730 CNIR section I I I.5
Debris, and the provisions of MGL c 40, S 54;
Building{ Permit N . ._ is issued with the condition that the debris resulting &orn
this work shall be disposed of in a properly licensed waste disposal facility as defined by.1GL c
f 111. S 150A.
The debris will be transported by:
j (1181R6 ur hau1K) ,
I
me debris will be disposed of in
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
nrN it ItIF.Y UaLWOLL
MAY(ra 12C\VAsw.%(:T0N SrsrEr 4 SALW.WASSACI R.'*A-ls 0197,^.
Tel 9711*745-959S a FAX:979-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridens/Plumbers
Annlicant Information Please Print Leeibly
NaMe tou.icwsstOrpniruiorvindivnluul): jc� tf
Address: L1S 7-'�"Lo`-. fly .
City/StareiZip: t I at e/t'�W 4A4 0-4172 !'hone N: 7_2f S ' 7�-.65
%rc you an employer?Check the appropriate box- 'type of project(required):
L2J am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(rule amVur part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
ship and have no employees Them sub-contractors have S. ❑ Demolition
working for tree in any capacity. workers'comp. insurance. 9. ❑ Building addition
f no workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.❑ Ruof repairs
insurance required.) t employees.(1\o workers' 13.❑Other
comp. insurance required.]
'Ally applieam that cheeks boa el man also Till out the xc1w Lwluw showing elicit wurke s'ewnperud"pdicy iniii,ne, o,
'I I•mrrarwnwa who submit this affidavit indicating thry,are Jcine oft work and thce hoc awside emtrxrors mess submit a maw amdavit wicaing such.
�C.mnrxlers that chsk this box mar arl l an additimral ANN Jmwing the nwa of the sub-cmnrxrors sad their workots'comp.policy inriwmanua,
o fain on etnplayer that Is providing workers'coarpenradon Ltsurance for wry employees. Below is the policy and/ob site
information r/
Insurance Company Name:Eel
_-( —
folic q or Self-its. Lie.ti: Q(l/LS7`lZ 1_7 6
Y n __.._ ... .____ Expiration Date:
Job Site Address� 1�~1lM{V 7 2yJ ( � j
CityiStatetZip:
i Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Scctiun 25A uf.NIGL c. 152 can lead to the imposition of criminal penalties of a
hill up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in The form of a STOP WORK ORDER and a fine
of up m S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the 011ice of
In\-Catlgations uI the D r in .cc cos rage verification.
I do he y cerl' order the a' red penahirx ofperju that floe infarrnallon provided above is true and correct
si- nauer Date-
Phurnc#: 72,s 5
OJJlcial use o,dy. no not write in this area,to be cuapleted by dry or town oJjkiaL
City or Town: PermiV1.1cense M
Issuing Authority (circle one): -- -
1. Iloard of licalth 2. Building Department J.Cit)lfotan Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _ Phone p:
Information and Instructions
t,lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employed is defined as"...every person in the service of another under any contract of hires
eapress or implied,oral or written"
An aopioyer is defined as"an individual,partnership.association corporation or other legal entity,of any two or more
of the foregoing engaged in a joint enterprise,and including the legal reprewntadves of a deceased employer,or the
receiver of trustee Gran individual,parmeral ip.association or other legal entity,employing employees. However the
owner of a dwelling houo s 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 ties issuance or
renewal of a license or permit to operate a business or to construct buildings In the commoaweam for any
applicant wbo has not prodttced accept"evhtsnee of compliance with the insurance coverage required."
.additionally.MGL chapter 152,$23C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any convact 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."
Applieants
please fill out the workers'compensation affidavit completely,by checking the boxes that apPly_to your situation and,if
necessary.supply srrb c°nhactor(s)name(+).addtess(es)and Phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Parma (LLP)with no employees other rhan the
members or partners,are not required to cant'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 aMdaviL 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 of if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter thew
self-insurance license number on the appropriate line.
City or Town Officlab
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 fait out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to rill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 now affidavit must be tilled out each
year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
r i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
fhc Of tix 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 lavestiptlom
600 Washington Street
Boston, MA 02111
Tel. p 617-7274900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26-05 www.mass.gov/dia
PUBLIC PROPERTY
DEPARII�IENT
uwvae 120 WARU G"W sMT
&MAiK VASiA01LStTis Ot970
1ti 978-715-9S93♦FA3c 9M740.96M
APPLICATION FOR THE REPAIR. RENOYATIOM CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property AA:MMSS:---
---
2 (2-w%
Property Is located In a;Conservation Arse Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: 2—
Rl�ery eye y{„�
Telephone: 9 fie• 66C> - 5-
f
3.0 COMPLETE THIS SECTION FOR WORK IN EXULTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovate
d
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
grief Description of Proposed Work:
Mail Permit tO; - e l
What is the current use of the Building?
Material of Building? if dwelling.how many units?�—
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name 17
M� � 6 l8J 2
Address and Phone
Supervisors License 0 ��f�3 % HIC Registration S
Construction Supary 2-( 9 f
Estimated Cost Of 'ect Permit Fee Cak ulatbm
Permit Fee i Estimated Cost X$71$1000 Residential
Estimated Cost X$11/111000 Ccmmsrcia4----------
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 a above stated
specifications. Signed under penalty of pedu
Date -�
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