7 ROPE ST - BUILDING INSPECTION CITY-OFSALEM
PUBLIC PROPERTY
DEPARTMENT
KI\R1FRI.EY DRISCO/IlL ,7
MAYOR,T/�J J /�j/ 120 WASHINGTON S7REEr*SAIEM,MA�SACHI:SE IS 01970
- TEL-978-745-9595*FAx:978-740-98"
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: Rope ;uilding:
Property Address:
t e S�1
Property is located in a; Conservation Area Y/N Historic District YIN /t d
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: & e N Id ! S ie L CT_ G
Address:
-- {�
TeleP hone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition go Existing
Renovation Number of Stories Renova
ted
Change in Use IV New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation 1 oa
of existing building New
Brief Description of Proposed Work: pp
0'
Mail Permit to: 3 e T
What is the current use of the Building? 1Z U 5�2
Material of Building? wilo d If dwelling, how many units?-2 —
Will the Building Conform to Law? Asbestos?
Architect's Name A/o AI E
Address and Phone j
Mechanic's Name i ay�^� r re-A,
Address and Phone c�zz �3i!
Construction Supervisors Licens # Ld b HIC Registration #
Estimated Cost of Project$ /Q Permit Fee Calculation
Permit Fee $ '40 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
C
specifications. Signed under penalty of perjury
Date
NI
w r
a
4 u GO
�k C \ y L O
� 'O Y
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
F-WRERLEY DRISCOLL
MAYOR
120 WASHINGTON STREET•SAI EM,MAssACHUSEM 01970
TEL 978.743-9595 a FAX:979-740-9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (� ( Please Print Leeibly
Name(Business/Organixaaon/Individual):_ D AV I D
Address: :2 Z o
City/State/Zip: e U L
Are you an employer?Check the appropriate box:
1.❑ I am a employer T
yperoject(required):
mp yet with—� 4. � I am a general contractor and Iconstruction
employees(full and/or partltime).' have hired the sub-contractors
2.01 am a sole proprietor or partner- listed on the attached sheet. i modeling
ship and have no employees ese sub-contractors have molition
working for me in any capacity. orkers'comp. insurance,[No workers' cone , insuran lding addition
p insurance 5. We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11-El Plumbing repairs or additions
insurance( o workers'comp. c. 152,§1(4),and we have no 12. Roof repairs
required]t employees. (No workers'
comp. insurance required.] 13.❑Other.
'Any applicants that chocks box N1 must d w ISO one the section below showing their waken'eomPm+stioa polity infamadoa,Homeowners who submit this affidavit indicating they am doing all work ad then him onside cannactom must submit a miss aRidevit
imU
tContrectors fist cheek this box must attached an a"tiomst sheet showing the mane of the sub-coo �f •ttaetors aM their waken'come•pasty itefosrnatico.
I am an employer that Is providing workers'compensation insurance for my employees Below it the paltry and job site
information
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:_ %0—jZ—2pG 7
Job Site Address: 7 iC 0 p C S City/State/Zip: .5,L LE M A9A
Attach a copy of the workers'compensation policy declaration page(showing 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 31,500.00 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.
do hereby certify
under
��the pains
ppand penak&s of perjury that the information provided above is true and coned
Si atu • �en+�er GG � � Dat /0 2-
Phone /OL
---------------
Ojjleial use only. Do not write in this area, to be completed by city or town ojJlciaL
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
6.Other
Contact Person• Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant to this statute,an employes 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
house having not more than thin apartments and who resides therein,or the occupant of the
owner of a dwelling to persons to do maintenance,d stntcdon or repair work on such dwelling house
dwelling house of another who employs PersO be deemed to be an employer."
or on the grounds or building appurtenant thereto shall not because of such employment
ce
MGL chapter 152,§25C(6)also states that"every state or loons licensing agencdings ash oithhold the mmonweealth for any Of
renewal of a license or permit to operate a business or to construct bttisdings
applicant who has chaProd S acceptable57 tates Neither the opliance with the IRsurna
mmonwealth nor any of political cc gsubdivisions"shall
Additionally, p table evidence of compliance with the insurance
enter into any contract for the performance of public work until acceptable
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
supply sub contractors)name(s).addresses)and Phone numbers)along with their certificates)of
necessary, upP Y Companies (s),(LL or Limited Liability Partnerships(LLP)with no employees other than the
insurance. Limited Liability mp
members or partners,are not required to carry workers' compensstion 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 Industrialhe affidavit. The affidavit_
Accidents for confirmation of insurance co for die permit or license is being o be sure to sign and date trequested, t the Department of d
be returned to the city or town that the applicationstiona regarding the law or if you are required to obtain a workers'
Industrial Accidents. Should you have any quo should enter their
compensation policy,Please call the Department at the number listed below. Self-insured companies
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 applica
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
applicant as proof that a valid affidavit is on file for future permits or licenses. A new of ,&vic 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. 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 5-26-05 www.mas&gOv/dia
CITY OF SALE.M
PUBLIC PROPERTY
DEPARTMENT
NArat 130 WAUGU.MOM STU=•S"JEW6 MMACW-VWM GIVIG
Construction Debris Disposal .Af idavit M
(required tw all deoolition and rawvadon wodc)
In accordance with the sixth edition of the Sties Building Cods.7W C M secdom 111.5
Debr*and dw provisions of MGM a A S St
Building ft. is issued with the condition that the debris cead&g fte
this welt shell be diapoasd of in a propely lieaosed waste disposd hdlity as ded and by MM e
1 11.s 150A.
The debris will be transported by:
(e.m.ottrtaar)
The debris will be disposed of in:
LL!�
(Hams 0(&dityy
(addrem or rYitiry)
sitaamm otpsrmir apptiaaat
a z 6 Q�
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