26 SCENIC AVE - BUILDING INSPECTION (2) CITY OF SALEM
J7 al PUBLIC PROPRERTY
r DEPARTMENT
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W.%Yf* M2 WMHINCION STREET•SAtru,MAssxcncsl:'rrs O1979
Tka�978-743-9595 • FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Leeibiv
Name (Bitsilwss/OrganizatiorVindividual): 0111//e 8201%0
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Address: DZ G _u bas►C.' sZeee-F
Cityr'Stare/Zip: ptQ , /� 1?8ss Phone 0: 978 532- 9.S'Z
Are you an employer! Check the appropriate box: Type of project(required):
I.❑ i am a employer with 4. ❑ I am a general contractor and 1 6 ❑ New construction
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employees(full and/or part-time).` have hired the sub-contractors
2.211 t am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
iNo workers'sump. insurance S. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 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.❑ Rout'repairs
insurance required.] t employees. (No workers' 13.❑ Uther_
comp. insurance required.]
-Any applicma unit checks box#1 must also lilt out the section W,uw showing their wor4ni cumpunsation policy inliunuriun.
'11omcowress who submit this affidavit indicating they are doing all work and then hire outside euntraetors must submit a new afrdavir indiuring stmh.
�C vuracutrs that chuck this box most aaachcd an additional shect showing the name of tho sub<onrrac urs and their workurs'comp.policy information.
l aot an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic.tt: _........_..____-_ 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
tine up m SI.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
Invcsligatiuns ul'Lhc DIA for insurance coverage verification.
/do hereby ccrlij er the pains and peenntd�tieDc of perjury that the information provided above is true aid correct.
Sienalure: !?M/✓✓J ( Datc: July 7 ' 200
Mine.4 97A S32 QS2/
Official use only. Do not write in this area,to be completed by city or town ojjiciul.
City or Town: _ Permit/License#__.____ _----------
Issuing Authority(circle one):
1. Board of llcalth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _._ ___..__ _ Phone #:
Information and Instructions
Nlassachuscus;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 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 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 nuntber(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 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 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 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. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I'hc Off ice 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
1 I PUBLIC PROPRERTY
DEPARTMENT
\l.7Ti g 1?0 W.\91f\I�:JN S:AEET �5.\Li\t, S1.\51\(:.Il Ala 1�019/�
To:978-743-9595 • f.%x:978-74Cr9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 C11*111 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 V1GL c
l 11. S 1.50A.
The debris will be transported by:
1 name of hauler)
The debris will be disposed of in
��.�_ _ t,�puSBC 00 elo
fac(name of ility)
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PLAN OF LAW
IN I CERTIFY THAT THE DWELLING
IS LOCATED AS SHOWN.
SA L EM, MA SS. 0., Al
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REID LAND SURVEYORS RALPH
WILLI At t
365 aM 7FlAA/ Sr., L YML ANSS. „�EE0 )" ,
SCALE 1"--20'. -MARCH 15, 1991
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• S�Ei � ,♦
VISTA HEIGHTS
N/F REALTY TRUST
DORIS A. SIf/}LE"` 717Er' Ll y� .
McCORMICK GRA65 •85
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0 TS 55: d '� I G i o
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T1l�c V RA .rMQ, PROPOSED
SHED
AREA FameG tious
AP4lvrc/� 14 It t � w.
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PnT Io i st&+oP ,�_ aa4a
ffEGGE c� W 1
SPLIT ENTRY G� N/F
C7 V8 GEORGE E.
8�,� = WOOD FRAME WA`( A SMITH
GARAGi S
SbROl3 / s26 UNDER 5
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L.T.S.
Ei78-532-9521
ARKE BROTHERS
ASKI STREET PEABODY MASS
9 CELL-781-838-1415
MRS FOURNIER 26 SCENIE AVE
SALEM MASS 1508-5271473
I] BUILD ADDITION TO SHED 12'X 16 `.
21 FLOOR WILL BE FRAMED WITH 2X8 FLOOR
JOIST EVERY 16" ON CENTER, COVERED WITH 3/4
CDX PLYWOOD,
31 WALLS WILL HAVE 2X4 STUDS EVERY I6" ON
CENTER WITH 2X4 SHOES AND TOP PLETE ,WALLS
WILL BE COVERED WITH %2 PLYWOOD AND
TYVEK.
41 ROOF WILL HAVE 2X8 RAFTERS EVERY 16" ON
CENTER WITH 2X8 RIDGE, COVERED WITH 5/8
PLYWOOD -15 LB FELT PAPER,
51 ADDITION WILL SET ON FOOTINGS [ FOOTING
WILL BE 4' BELOW THE GROUND WITH SONA
TUBES FILLED WITH CEMENT.
6] ADDITION WILL HAVE WINDOWS AND DOOR
FRAMED[ OWNER WILL FURNISH WINDOWS AND,
DOOR,
CLARKE BROTHERS WILL REMOVE ALL RUBBISH
DO TO WORK BEING DONE.
PLEASE MAKE PAYABLE TO DENNIS CLARKE
THANK YOU
WE PftW®SE HEREBY TO FURNISH MATERIAL AND
LABOR COMPLETE IN ACCORDANCE WITH ABOVE
SPECIFICATION FOR THE SUM $10,000 WITH $5000.00
DOWN $2500.00 WHEN FLOOR AND WALLS FRAMED.
$2000.00 WHEN ROOF HAS BEEN FRAMED $500.00 WHEN
WORK HAS BEEN COMPLETED.
ACCEPTARCE OF PROPOSEALTHE ABOVE
PRICES SPECIFICATIONS AND CONDITION ARE
SATISFACTORY AND ARE HEREBY ACCEPTED. YOU ARE
AUTHORIZED TO DO THE WORK AS SPAECIRED ,PAYMENTS BE
MADE AS OUTLINED ABOVE
SIGNATURE------------------------------------SIGNATURE-
-----------------
THA YOU FOR YOUR BUISNESS
LIC"CS 024109 REG" 118936
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t►PPl,ICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
D&MOLMON, OR CHANGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION J
Location Name: Build4l�
fteperty Address;
2 odr /a✓e•
Properly is located in a;Conservation Arse YN d4 Hlskift Dislrld YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 179es - 'ZAe ec
'
Address:
Z SL'e4: e / ,je
Tom: `v �S 2 7 l
3.0 COMPLETE THIS SECTION FOR WORK IN EY1AT1uta 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 New
of existing building ShpGl let 2
9aef Description of Proposed Woric:L7�
1 2 xl6 1-m 68C v 9( A2-
f�or21a�3f °C 3 c,0c< l0L/w00d/• /
ea ells U,�11 QN 2d4 sTnctS !(c o c r, /�trwavc� !1-111,C� Wad CAI
/zc,6 F w,Cc. (3e, y.Z perh 2x8 Qe rTees I r. "oc �8 � •,�a/ a,pd/ (1oaFya 6v(,�
SAcc, will Se a,,4 FauQ i=oor y ` Qelow 5feoun(c( cen,e.iT
oo( lit 1 ET2�2 Qoue•
---- - ---Mail Permit to: - -
What is the Cunt use of the Building?
Material of Building?
L•, n r ✓� It dwelling.how many units?
"a the Building Conform to Law? I=S- Asbestos?
Arch'deds Name
Address and Phone
Mechanic's Name �^� 2b vn�
Address and Phone C
Cor►sbuction Su caors License ss ti /n c( HIC Registration is
perv'
Estimated Cost of Projed: Permit Fee Calauletion
Permit Fee i 7�•o_o Estimated Cost X$7/51000 Residential
Exftatsd CostX 511/:100gCammerda�=--
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned do"hereby apply for a Building Permit to build to the above stated
specifications. Signed under penally of perjury
Date
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