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17 ROSLYN ST - BUILDING INSPECTION (2) s S s What is the current use of the Building? �S Material of Building? If dwelling.how many units? Witi the Building Conform to Law? Asbestos? N) Architect's Name Address and Phone l 1 Mechanic's Name C G�Nco/r✓ i4-Ve Address and Phone Construction Supervisors License# HIC Registration# Estimated Cost of 1�S �v Pernik Fee Calaulatlon Permit Fee S Estimated Cost X$7IS1000 Residential Estimated CostXSt1/5100000mmemlal--------.. An Additional S5.0o is added as an Administrable 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 ific specations. Signed under penalty of perjury X eto �9 4 o N olj a 4 EITrOFAy PUBLIC PROPERTY DEPARTMENT I:I�NFFJIIsY D�erw �IAYDa 130 WMMN=W JhM= &Md4 1lSt:Y1S 01970 TW-9711.743-9S95•FAX M740.960 APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION DEMOLITION,OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUMDIIN 1.0 SITE INFORMATION Location Name: 0&1 e Nt C1 P t*1 r- Building: --------- - Properly Is located In a.Conservation Area Y/N Historic District WN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Q o e R A- I � Name: Address: / 7 Telephone: 9 y 460 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition lRenovated Renovation Number of StoChange in Use Demolition Approximate year of Area per floor ( construction or renovation. of existing building New Brief Description of Proposed Work:/ Mail Permit to: S - - r CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT wN1aF R[F.Y DAM"1LL VI.Xvcxt 12C WA4u.1a:7ONS1nk7\T•SAlE14.WASACift'W 1'I\01972 Tea.976-743-959S a F.ix:971P740.9946 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicaut Information Please Print Leeibly dame tauaiaess/Organizatiavindivtduun//: Address: 226 ZZECO/G/ City/Srate/Zip: /¢ G ��/NLl �rTi� Phone t Are you an employe?Check the appropriate tax: 'type of project(required): 1.❑ 1 am a employer with 4. (VI am a general coulractor and 1 6. ❑ New construction employees(full and/or part-time).• have hind the sub-contractors 2.© 1 am a sole proprietor or partner- listed on the attached sheet : 7. ❑ Remodeling ship and have no employees These sub watractoa have S. ❑Demolition. working for me in any capacity. workers'comp, insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its n:quiretL] officers have exercised their 10.0 Electrical repairs or additions 3.El am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. (No workers'comp. c. 152,J 1(4),and we have no 12.0 Roof repairs insurance required.) r employees. (No workers' 13.❑Other comp. insurance requirtxl.] •At0 aiPhCaul that dwe"Ens el main also fill out ae welioo beluw slrowiaa their wotlim'eumpeauaton pAiey iaturttaaiYR 'I lumwtwnem wbe submit"af davit indieatine Mry on,Joins all work and then Aim outside eorurav ots mesa awitrnit a new atndsvit inJiclaina a h. lC.mtrwisws thaw cAssk this box must anached as additional.hen Jewinx the nalm of se wb•contraeton and their wotkata'Comp.Pinney information. l um an employer that Is providing workers'compel salon hi-turance for my employees. Below is the pus/fay and job site information. 1, Insurance Company Name: Policy M or Self-ins. Lic./1: Expiration Date: Job Site Address: 12 Roll,(0/t J / CilyrStatuZip: Attach a copy of the workers'compensation pulley declaratioa page(showing the policy number and expiration date). Failure to xcurc coverage as required under Section 25A of.\,IGL c. 152 can lead to the imposition of criminal penalties of a tine 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 to 5250.00 a day against the violator. lie advised that a copy urthis statement may be forwarded to the Office of In\'dlll�aUUna uI the DIA for insurarcc a)vcrage%k:rlhcattun. / /u terra by certify uud die sins altd na k.v of p Jury that the information provided above is i and correct Sir:)oture: Date. . B' 4. 3i 6 OJJlcial use only. no not write/n this area, to be completed by city or town oJ�a iaL City or Town: __. Permiul.lecuse q Issuing Authurily (circle one): 1. 114)ard of Ilealth 2. liuildinu Department 3.Citylroon Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other C"Illact Person: . - - _ -- Phone p• Information and Instructions NJassachwetts General Laws chapter 152 requires all employers to provide workers' compensation for their employem pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hive, depress or implied,oral or written." An employer is defined as"an individual,Wrmaah*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 of 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 building appurtenant thereto dhall not because of such employment be deemed to be an employer." grounds pp or on the grow C AtGL chapter 152.025C(6)also states that"every state or local licensing agency sban withhold the issuance r renewal of a license or permit to operate a business or to construct building is the applicant"be has trot produced acceptable evidence of compliance with the insurance coverage required." Additionally.MGL chapter 153,423CM 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),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or ptnrtoers,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 affidavit. 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 Industriai 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 appropriate 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 file out in the event the Office of Investigations has to contact you regarding the applicant. please be sure to till in the permitflicerue 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 new affidavit 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 t i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. l'ha Otlicc of Investigations would Cue to Chunk 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 Coritmonwealth of Massachusetts Department of Industrial Accidents o®ee of Investiptlons 600 Washington Street Boston, MA 02111 Tel. p 617-7274900 ext 406 or 1-877-MASSAFE Fax M 617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM 4D PUBLIC PROPRERTY DEPARTMENT Tn:WN45.4"s •F.M 9W40-*% Construction Debris Disposst affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code,780 CUR section I I I-S Debris,and the provisions of MGL c 40.S A Building Permit 0 - . _ is issued with the condition that the debris resulting from this work shall be disposed of in a property licensed waste disposal facility as defined by%.AGL c 1 I I.S 150A. The debris will be transported by: lmtoe lit loafer) me:cb6s wilt be disposed of in : (name lit'fa�ihty) +d.:rcx.of ruiLly) •.a4 i