14A RUSSELL DR - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
` \t: YOK 11C W.W IIXG:JNS:BEET •)d[rft,St.\u.\l::LL UII]�.)l,^.
TF.1:979-745.1595 &F.%X:978.74G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Cb1R section 111.5
Debris, and the provisions of M. GL c 40, S 54;
Building Permit # _ .. -_ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by: VA 915icLL � c
--`- 111amc of Hauler)
I'lu debris will be disposed of in :
-- hl:unr oY facility)-
L
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:U 11a:SRL1iY DRISCOLL
)it 120 WASHINGTON STRELT •SALEM,MASSACI llan:I Is 01970
Tal.:978-745-9595 •FAX:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t tlicant Information Please Print Le ibly
Verte (Bucinc%s/Organintion/Individual):
Address: 2 t (2 Lf rJ pp
City/Starc/"L.ip! 01 2 7 y Phone 4: 276 7 -7 f y7 Y
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and I 6 ❑ new construction
employees(full antL'or pan-time).` have hired the sub-contractors ?.,,Remodeling
2.E�4aai a sole proprietor or partner- listed on the attached sheet. r
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
No workers'comp. insurance 5. ❑ We are a corporation and its
l p• 10.❑ Electrical repairs or additions
required.] officers have exercised their
3. I am a homeowner doing all work exemption exem ti right of per MGL i t.❑ Plumbing repairs or additions
❑
myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. LNo workers' 13.❑ Other
comp. insurance required.]
' applicant that checks box 8t must also till out the section Iwlow showing their workeni compenwtioa policy information.
Any
?I lomeuwmxa who submit this affidavit indicating they arc doing all work and then him outside contmelors must euhmil a new of idavil indicating%rich.
Contract rs that check this box must atlachod an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lapis rat employer that is providing workers'compensation iusaratice for uty employees. Below is the policy and job site
information.
Insurance Company Name: .....-------_.-_-_--
Policy x or Self-ins. Lic. V: N.S Expiration Date:
Job Site Address: L �`Cl f SLZL �� CitylStatt/Zip:
Artach it 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
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 S250.00 a day against the violator. Be advised that a Copy of this statement may be forwarded to the Office of
Illy' sthatiol of the j.,
m ranee coverage vcriticalion.
1 tlo hemb cep y u ins and pen(r tics of perjury that the information provided rib a is trip aad correct.
Sienature: �/ !J Date: 6
Phn (. '
Ofjic'ial use only. Do not[,rite in this area,to be completed by city or town ofjlcial.
City or Town: Permit/License --.--_-_--_.---_._--
Issuing Authority(circle one):
1. iloard of health 2. Building Department 3.Cityfrown 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 ernplgvee is defined as"...every person in the service of another tinder 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 ajoint 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 152, §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,b1GL chapter 152, §25C(7)states"Neither the commonwealth nor any of itspolitical subdivisions shall
enter into any contract for the perforntance 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-contractors)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 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
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 their
self-insurance license number on the appropriate line.
City or'fown Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be Sure to till in the permiulicense number which will be used as a reference number. In addition,an applicant
that must Submit multiple pennidlicense 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
towny"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 tilled 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
fhc Office of Investigations would like to drank 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
Of ee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Rc ised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
C1 1 1 O�Jl 1LG�Y _..
PUBLIC PROPERTY
DEPARTMENT
�iw+E�nsr o•�•-•ti
NAVM
147:M74MM•PAZ 97L740.M6
APPLICATION FOR THE REPAIR RENOVATi N CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OC FANCY. FOR , EXISTING
STRUCTURE ORM&RING
1.0 SITE INFORMATION
Location Name: Building:
Property Addreec
Proprrty Is located;In a:ConswvstlOn Aroa YIN Hlstortc o t k*YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land '
Name: Z14AI" -t- G/NA D o/V
Address:
Telephone: 76 7`f e /A
F&OiCOMPLETETHIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Existing
� Number of Stories Renovated
7� New Existing
ar ofArea per floor (sn Renovated
enovationng New
Brief Description of Proposed Work: /
(o K l 2—
Mail Permit W. - —
What is the current use-of the Building? (/� � .
ot� If dwelUng,how many units? 1 t'
Material of Building? {f ASbastOS?
Will the Building Confom+to Law? Y
Architects Name ( j
Address and PhoneI /mil C
Medwnlds Name g 7 B
Address and Phone
U HIC Registration 0Construdlon Supervisors
Estimated Cost of projad i °� Permit Fee Ca lwtallon
.� Estimated Cost X$71:1000 Residential
Permit Fee i
Estimated Cost X f111$1000 Commercial'--An Additional $5.00 is added as an
AdministmOve charge.
Make sure that all flelds are Properly and legibly`Mitten to avoid delays in Processing-
The undersigned does hereby apply for a Building P it to build bove stated
specifications. Signed under penalty of perjury /�
spec .
Date �
aad C6
be
a