6C RUSSELL DR - BUILDING INSPECTION id`t . PUBLIC PROPERTY
DEPARTMENT
KIMSFRLEY DRISCOL.
MAYOR IMWASHINaroNSIREEr -
SALFIN,MA-1SACHl;56llS 01970
TEL-978-745-9595 4 FAX 978.740-98J6
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: I I A tlk, L. u Building:
Property Address: C U S S L l k-
��I V
Property is located in a: Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION y/( g/y 1-/,q za S
2.4 Owner of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: c
t I,OL v4 c i;
(RtiPL V'�c CL) Irr004U5
�f? � toL ,4c2 5L r, 2 ,2
Mail Permit to:
What is the current use of the Building? N)a
Material of Building? W o c n If dwelling, how many units?
\/1 Asbestos? °y
5 �f
Will the Building Conform to Law? T
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone 9 7 - 7 Y. 6 S S
Construction Supervisors License# t 6 3 HIC Registration#
Estimated Cost of Project$ 6 Permit Fee Calculation
Permit Fee $ Estimated Cost X$71$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 t ild to the above stated
specifications. Signed under penalty of perjury X 1
Date 6
t ,
r
� o
N
V f
F y T
►.
I• CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET •SALEM,MASSACHUSETTS 01970
TEL•978-745-9595 #FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): To d
Address: bZ 1 F .4't rt G o v ns 7—
City/State/Zip: A k- - ti Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2. C] 1 am a sole proprietor or partner- listed on the attached sheet. t ?• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
[No workers' comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself [No workers' comp, c. 152,§1(4), and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.❑ Other
•Any applicant that checks box#1 most also fill out the section below showing their worker,'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hue outside conttsemr,must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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$1,500.00 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 cer^under the pains an enalties ojperjury that the information provided above is true and correct
Si nature• Date: t o 6
Phone#: J -- O,S,O S
Official use only. Do not write in this area,to be completed by city or town official.
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 11
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 employee 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
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
has not produced acceptable evidence of compliance with the insurance coverage required."
applicant who p shall
a 'visions
pp commonwealth nor any-of its political subdivisions Additionally,MGL chapter 152, §25C(7)states"Neither the comet
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-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 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 applicant.
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 permit/license 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
(i.e. a dog license or permit to burn 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.mass.gov/dia
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
VJI.WERL y 005,0LL I20WtiIUNGn>Ny fr CAL E \L%bSACHLsETc501970
SAAYOIt
'I4i 979.74S-959S•FAx:9711'74o'`l846
Construction Debris Disposal Affidavit
(regwred for all dennalitioa and renovati
on work)
with the sixth edition of the State Building Code,780 CMR section 111.5
In accordance resulting
Debris,and the provisions of MGL a 40.3 54;
is issued with the condition th ��by M�m
Building Permit!i 1 licensed waste disposalas
this wort shall be disposed of is a proper y
111.3150A.
The debris will be transported by:
foams of Imulac)
The debris will be disposed of in :
(name of facility)
(addcets of facility)
7� aceofrapplcanti i
.trin++t7.4e
EM
/q✓ " �j PUBLIC PROPERTY .
DEPARTMENT
KI\MEALS!DRISCOLL
MAYOR '120 WASNINaMN N ntEEr Ca\EM..H&%AC1iL;SL'1'iS Ot976
I'M 978-74S;9M OAx:97&740.9&W
"APPLICATION FOR THE"REPAUL RENOYATION CONSTRUCTION
DEMOLITION "OR CHANGE OF USE OR OCCIIPANCY' FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name:_J9r , cam, ' Building:
Property:Address:+
Property is located in a; Gonserva n Area Y/N Historic;District Y/N`
2.0 OWNERSHIP INFORMATION..
1.1 Owner of Land
Name:
Address
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING. BUILDINGS ONLY
Addition Existing
Renovation - Number of Stories ' Renovated
Change in Use: New
Demolition Existing
Approximate year of • Area per floor,(sf) Renovated -
construction or renovation
of existing building New
Brief Description of Proposed Work:IL
pp JJ
Mail Permit to: ,- '
what is the current use of the Building?
Material of Building?
4 If dwelling, Flow many units? .
will the Building Conform to Law?
O S Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
�-) .:. Q4
Address and Phone + Z
Construction Supervisors License# "Z HIC Registration# —
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee$ 3' Estimated Cost X$71$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional$5.00 is added as an
Administrative charga
Make sure that all fields are properly and legibly written to avoid delays in processing. .
The undersigned does hereby apply fora Building�P/errnft to bui to the a ve stated
specifications. Signed under penalty of perjury
Dates +�
s
,r , a
�, of
9
~ n
CITY OF SALEM
�i. PUBLIC PROPERTY
DEPARTMENT
K@a+s61.6Y otuxou '
MAYOR - 120 wtiswNaroN S,xET•S,uEr, Aaiuserrs 01970
147197874S-9595 9 FAY:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,780 CMR section 111.5
Debris.and the provisions of MGL 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
I 11,S 150A.
The debris will be transported by:
".;f _->; ti .
(nam of lwuler)
The debris will be disposed of in:
(name of facility)
1�7F
(address of facility)
ofpemi pplcana
date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL -
MAYOR 120 WAS17O IGTON STREET+SALEM,MASSACHL SETTS 01970
TEL-.978-745-9595-#FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ` Please Print Le¢ibly
Name(Business/Organization/Individual):
Address: ? y 9e f 7e w S
City/State/Zip: Llf r Phone#: 2t-
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or 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 These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
(No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I LM Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. (No workers' 13.❑Other
comp.insurance required.]
-Any applicant that checks box#1 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 and than hive outside contractors must submit a new affidavit indicating such.
tcontractors that check this box must attached an additional sheet showing the came of the sub-contractors and their workers'comps policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name? F I-e
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: ?, /b S_xl lciJ7S9i/ 09 rL&V4 Z City/State/Zip: , S� X f''J
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$1,500.00 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.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Signature: Date:
Phone#•
Official use only. Do not write in this area,to be completed by city or town official,
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 employee 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
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,MGL chapter 152, §25C(7)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 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 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 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 Town Officials
Please be sure that the affidavit r�`omplete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out iri the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 licemises. 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
(i.e.a dog license or permit to bur 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
Revised 5-26 OS Fax#617-727-7749
www.mass.gov/dia