71 SCHOOL ST - BUILDING INSPECTION E=OFSALE --
PUBLIC PROPERTY
DEPARTMENT
KISMOU DIUSCOLL yy��
MAYOR t-V W&WNGTON S7REEr
SAttm,MtScnaiLsErrs 01970 Q
lei 978-745-9S9S*FAx:978.7i0-98J6
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: Building:
Property Address: i 1
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.4 Owner of Land a
Name: '71 Scar,zot LLC
Address: So ��
_ Sat-,,,, KKA O kR-to
Telephone: CI,-fc -Z tZ
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demoiition Existing
Approximate year of Area per floor (so Renovated
construction or renovation IGcw
of existing building So New
Brief Description of Proposed Work:
12_c Pa,2 Sao 42L-- V oot= GAa)*trc-
za tAEW GAnA G-C-
S 14(- etF �ao,3 of GAAA Ct c
Mail Permit to: i t=.a so 3rzc R 4 s Sa�� n x�lr.
O�JT�R�
What is the current use of the Building? 1zes c /
Material of Building? Woota If dwelling, how many units? 3
Will the Building Conform to Law?
Asbestos? f.9n.t
Architect's Name
Address and Phone
Mechanic's Name Piz C_ P"p
Address and Phone `j' S n-OAO S t %AAA
Construction Supervisors License# 01 Z HIC Registration#
Estimated Cost of jct$ /o 0 00 .o� Permit Fee Cak ulation
Permit Fee$yip Estimated Cost X$7/$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 to build to the above stated
specifications. Signed under penalty of perjury
Date 4' �cJ - Zco6
J
O
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:1 N
F °off V v ••0
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CTTY OF SALEM
' PUBLIC PROPERTY
DEPARTMENT
t9rOa 130 V/wmw�ow Sff�aT a livau�)f�uoc�r7s 01!'rs
Construction Debris Disposal AtAdavit
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In am we ma with the sittdt edition of dw Stm Building Coda67W C30 seedae I IS
Debri%and dw provisions otlM o 44 g A
Building Puffla t N is ismad wild dw condidoa dtst dw daMs malking atom
tMa wads shall be disposed of in a popwly iicansed WNW dispad&dlit)t as darted by MCI.a
t t t,s lsa►.
Ttte debris wiD be transported W.
(�rzH�a�.• �J�s-cam sus��S
(acres a[hwlar)
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The
/daWs will be disposed*(in:
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(oases of FmWt»
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(aJdsara of fhciliry)
sisaas�ao(pesp spplkaat
G �oJ - 2006
date
i
whn.a"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
K mBERLEY DRLSCOLL
MAYOR 120 WASHNVGTON STREET•SALEM,MASSACHUSEM 01970
TE1:979-745-9595 •FAxk 979-740-98"
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual): 1'p E%E 2 L` �lcMl7
Address: S-0 Z2eAr�b S:
City/State/Zip: SoN.-uf--.+. Mpr o u4 iu Phone#: CnV - 7`(`k - 271 ( 'i_
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. JP 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 required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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'
Other-
comp. insurance required.] l3.❑Other
*Any applicant that checks bon NI must also w ow the secdoa below showing their worsma•e,e peasatloo policy Wasenedoa.
f Homeowners who submit this atAdava mNeming they an doing all work and then hire outside cooftwgars must aubmu a now affidavit attrb
rComtreeton that check this box newt attached an eddidomal sheet ehoaiug the name of the sub-eomtne m ww their woken'camp.policy informado e.
lam an employer that Is providing workers'compensadan insurance for my employees. Below is the policy and Job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
_ lob Site Address: City/State/Zip:
Attach a copy of the workerslermapensatioo 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 S 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 S250.00 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 nder the pains and penalties ofperfury that the informadan provided above is true and correct
Sionaturce Date C( ty u J Z o 0 6
Phone#: ct 1S Z�4 Z� t2
OJJicial use only. Do not write in this area,to be completed by city or town o,Q7cial,
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/rown Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#
Information and Instructions J
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fort their
semploYem
t of hits,
Pursuant to this statute,an employee is defined as"...every person in the service of another under any
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 stub-contractors)name(s),address(es)and phone number(s)along with their cerdficate(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 IndusbrW
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 D 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±;snire-permit.°or-licenses. A new afSduvir 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 bum 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
Offfee of Investlgattona
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 wwwmm.gov/dia