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9A RUSSELL DR - BUILDING INSPECTION v (<.P.�>•e �i.� `tom �i as What is the current use of the Building? / Material of Building? L.fJ�>r L N dwelling.how many units? Win the Building Conform to Law? Y > Asbestos? I A!�5 Architect's Name Address and Phone ! ( ) Mechanic's Name 1\44 / Address and Phone � i 1� l-t� v Construction Supervisors License# - S ©i 8 HIC Registration# — Estimated Cost of Project= 3: GGG Pam&Fee Cala Wori Permit Fes i Estimated Cost X$7/$1000 Residential — Estimated Cost X ill/411000 Commerclsl-- ------ -- -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 sPeo ifloations. Signed under penally of perjury Date y N � � M F �aa G7 i EI'I'�tGJF - - PUBLIC PROPERTY DEPARTMENT uwvoa 130 WMMNG W S VELT YLLtiK yAtSAOil4Ti5 01970 TEL 97e-74S-gS9S•FAX:976740.90" APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR DUEL—DING 1.0 SITE INFORMATION Location Narra: Building: Property Addrear -- --- Property Is located in a;Conservation Area Y/N Historic District YM 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: 117 53 'k %SG:-. D1e r , CIA Telephone: . J_ 73,7 ._ 1 7(� 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 Brie[Description of Proposed Work: CPO --- ---Mail Permit to: E u x -- CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT i:INm'RIF.Y DAMI)l MArtss IY'\VA.%tL%:roteSUM 4 SALMA.MASSAVft V.1"MOltM ThL.97S.745-9595 4 FAx:97x-710-9946 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers -►nnlicant Information Please Print Leeibiv Name tausinus/Organizationtindivtdual): ��tl -� . ' l r i♦ r r.s_ri.- Addrea%: ] 75, CityiState/Zip: "it 415 2/1 Phone q: `i 7.Q- Tel .ire you an employer'Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general coulractor and 1 6. ❑ new construction employees(full and/ur part-tine).• have hired the sub-contractors 2 i am a sole proprietor or partner- listed on the attached sheet 1 7• ❑ Remodeling hip and have no cmployuoa These sub-contractors have S. ❑ Demolition- working for me in any capacity. workers'comp. insurance. 9. Build/ ng(No workers'comp. insurance S. ❑ We am a corporation and its ❑ addition required.] officers have exercised their !0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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' 13.MOther Eepet comp. insurance required.] 'Any applicata IIW chmka tot NI must also fill oa the mclioa Iwluw diowiag that wmktns'cantpumatiaa policy infimltatioM 'I to ,wrwa who subttltl mta arrldavit indicating*wy am doiaa all work and thin hire outswe camnacims mwt•ulanil a mw a ndavil indiwling wch. �C itaatxs that chink this brat met atf I 'm aldilki W Am showing tar name ordw subeomtamon and(heir warkm,comp.policy informadm lain an employer that is providing workers'coinpeitradon insurance for my employees. Below it the policy and Job site i)rfarmadon. insurance Company Name: ..- ..... . . ._ .. -_ -- Policy Al or Self--ins. Lic. 0: _.- ... ...._ Expiration Date: Job Site Address: City/StatuZip: 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.IGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment, as well ass civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against flit violator. lie advised that a copy of this statement may be forwarded to the 011icc of I IIPC.11hall Ulla Jf the DIA for Insurance covArhe verlhcation. l do hereby certify under die pains an)d1rpenallieess ujperjury)That he information provided above is irme and correct, �A . 4-f/ Date' JT ) V PMn'ea' / OJJlci it use unly. Do not write in this area to be cowWrIed by dry or town ofjlriaL City or Town: _.. Permitll.icense p____ Issuing Authority(circle one): 1. lluard of health 2. Building Department J.City/foan Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: — - _ Phone M: i Information and'.Instructions Nfassachusetts General Laws chapter 152 requites all employers to provide workers' compensation for their employees. pursuant to this statute.an e=jP&.vw is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." Art NA*yor is defined as"aa individual,partnenbip.awociadM corporation or other Ito 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 receive or trustee of as individual,patmershtp,assoc gal iation of other Ic entity,employing employees. However the owner of a dwelling house having not more them 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 agemey shall withhold the issuance or renewal of a license or permit to operant a business or to construct buHdlmga to the commonwealth for any appUeatet who hes not produced acceptable evidence of compliance with the insurance coverage required." Additionally.MGL chapter 152,§25C(7)states"Neither the commonwealth not any of its political subdivisions arid) enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of ibis chapter have been presented to the contracting authority." Applieamts Please rill out the workers'compensation affielavircompletefy,by checking the boxes that.apply to your situation and,if necessary.supply sub.conwwor(s)nan*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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Aho lse sure to sign and date the affidavit. Ilia affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of lndustrial Accidents. Should you have any questions regarding the low or if you am required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their .elf insurance license number on the appropriate line. City or Tows Offkbb 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 roll out in the event the Office of Investigations has to contact you regarding the applicant Meuse be sure to till in the pormit/liccuse number which will be used as a reference number. In addition,an applicant that must subunit 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 house owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license"permit to burn leaves etc.)said person is NOT required to complete this affidavit. 1'he 0171cw of Investigations would lice 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 O®ee of llavestlpNoos 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY II DEPARTMENT \t„gat 11CVt•uIIN::aniaetT0SAUM.A%'Q!LK:ht*11S, 9 r h Tn.9724454M •F.MY 97L705.1 , Construction Debris Dispossf Affidavit (required foe all demolition and renovation work) In accordance with the sixth edition*(the State Building Code,DSO CAIR section 111.5 Debris,and the provisions of MtGL c 40. S S4. Building{ Permit N _ . _ is issued with the condition that the debris resulting BtoM this work shall be disposed of in a properly licensed waste disposal facility as defined by.%1GL c l 11. S 150A. The debris will be transported by: — — umma of hwlar—) fiie debris will be disposed of in : N cad G� Si cL¢, c.., mama of inanity) ..darti, ar't'a:il,tyt , .,_...tnr.ail,: •t t.0.pp.tci.t