2 1-2 ROPES ST - BUILDING INSPECTION (2) CTTY OF SALDA
40 �D D PUBLIC PROPRERTY
DEPARTNEM
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Construction Debris Disposat Affidavit
("quired ror all dMudidon and Snot atioa wont)
Ia mantartce with the a%&edition of ow Sam Bull ng Coda.730 LAIR section It 1.5
Debris,wA the provisions o(MGL a 44 S Sk
Suilill"S Pon N _ is iswaad with the coed don lass the debris resulting It m
,his woek shall be disposed of in a properly liceetsed waste disposal facility as definod by%lGL a
lI1.S15"
The debris will be transported by:
todow al home)
fhb&--bris will be disposed of in :
(n:assr of f29111ry
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e
r� The Conmtottwealth of 112assacltttsetts
Department ofbidustrial Aceidents
J2 Office of Investigations
600 Washington Street
Boston, MA 02111
mi minass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
NaII7C(Business/Organization/individual):
Address: --
City(State/7.ip: J r _ Phone#f: ci0� (oc�
Are you an employer?Check the appropriate box: Type of project(required):
1.91 am a employer with 10 4. [Q I am a general contractor and I
' employees(full and/or Part-time).*
have hired the sub-contractors G. New construction -
2_❑ t ant a sole proprietor or partner- listed on the attached sheet. 7. gRemodeling
'llrese sub-contractors ship and have no employees 8. n Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp. insurance comp. insurance.t
required.] - 5. We are a corporation and its 10.0 Electrical repairs or additions
3111 am a homeowner doing all work officers have exercised their 1 LQ Plumbing repairs or additions
myself. [No workers'comp. right of exemption per V1GL 12 ❑ Roof repairs
insurance required.] i c. 152, §I(4), and we have no I3.❑ Other
employees. [No workers' .,..__
comp.insurance required.]
-Any applicant that checks box 41-must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work mid then hire outside contractors most submit a new affidavit indicating such.
his 1Contractors that check t box most attached an additional sheet showing the name of ilre sub-cnntrxtors and state whether or nor those entities have
employem Irthe sub-contractors have employees,they most provide their workers'comp.policy number. -
I am an employer that is providing workers'eanepensation irtsnratece for aty employees. Below is tbepolicy and job site
inforination.
insurance Company Name: �^�tt�` � C 0
:Policy [[.or Self iris:Lie.it. - a[! _ Expiration Date:_— t�—D
Job Site Address: _ CitylState!Gtp,
Attach it copy of the workers' compensation policy declaration page(slioiving the policy number-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$1,500.00 and/or one-year imprisonment,as well as civil penalties in tire 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.
I do hereby certify wader the pains an/d,fQenalties afperjury that the information provided above is trite and correct.
Signature: i A Date:
Phone#: '(,262
Official use only. Do not write in this area, lobe completed by city or town offeciaL
City or Town: Permit/License#
.Issuing Authority (circle one):
1.Board.of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5�Plumbing Inspector -
G.'Othcr _
Contact Person: Phone#:
CrrrOF
:PUBLIC PROPERTY
DEPARTMENT
Hume 120 WAMUNCr w Sinow•SAtK NUSIACHLU-M 01970
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTIOM,
DE,rIOL =N. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 317E INFORMATION
Location Name: Bumno:
-- -- -----Sa 1+ 12 — —--- - --- - --- - --
Property In located In a:Conservation Ares YIN Hlatorlo Dtstrtct YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address: Same
Telephone: 9 - - 7U
&0 COMPLETE THIS SECTION FOR WORK IN 9ne<Tilura BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use NO New.
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Soef Description of Proposed Work:
4
--- —- ---Mail Permit to: VO occc-,A-2 C , "xA, 0
use of the Building?
What is the Current s . „
Material oll Buddit? t• I �we Iing,how many units?
Will the Building Conform to Law? Asbestos?
Architects Name
Address and Phone l
Medranic'sNart+e pn�% �D 11P, rc3S�Qr
Address and Phone �� �lo� � �o
Construction Supervisors License 0 _ HIC Registration is \ $�l
Estimated�s � f�D Permit Fes CalculationPermlt Fee Estimatad Cost X$7/$1000 Residential
Est$natedCosLXS41/=1000C nvnwcist----------- -
An Additional $5.00 Is added as an
Administrative Charge.
Make sure that all fleids are properly and legibly written to avoid delays In processing.
The undersigned dose hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of padury
Date
N