29 SETTLERS WAY - BUILDING INSPECTION )
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A.
AAPPLICATION FOR PLAN EXAMINATION AND 11UIL1)1NG PEIIIVIt"1'
LL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page
SITE INFORMATION r /
Location Name L 6, Building
Properry Address
Map p_
Located in: Conservation Area YM Historic district Y/N
Use Groups
(check one)
Residential(3 or more Units) R2
Type of improvement Residential(hotel/motel RI
(check one) Assembly(churches) AI _
New Building_ Assembly(nightclubs etc) AZ_
Addition Assembly(restaurants, recreation) A3_
Alteration / Business B_
Repair/Replacement ✓ Educational E_
Demolition_ Factory(moderate hazard) Fl _
Move/Relocate Factory (low hazard) F'2_
Foundation Only_ High Hazard 11_
Accessory Building_ Institutional (residential care) 11 _
Other(describe) Institutional(incapacitated) 12_
Institutional(restrained) 13
Mercantile M_
Storage(moderate hazard) S 1 _
Storage(low hazard) S2_
OW NERSIIIP INFORMATION(Please type or Print Clearly) -
OWNER Name &-C � otJ
Address 2`i se 61'(,eAf 41 cti Nq
Telephone
DESCRIPTION OF WORK'1'0 BE PERFORMED
wry 6-uov -4 MA s 6,4-Fk ►Lt. elk L� k
1
s �cS_
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ES'I'1M.11'IiD CONSTRUCTION COST
CONTRACTOR INFORMATION
Name
Address 52 IA'61r S -,A Aye-4'kv IKA OtAHY
Telephone lail4b9-11724
Construction Supervisor's Lic # S`f S�
Home Improvement Contractor# / 3 S 0 9
ARCHITECTIENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 - -70, �`(
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signed
Date C/
t
r. )
CITY OF SALEM
PUBLIC PROPRERTY
' ii elf V DEPARTMENT
J\1n;Hf Il'UBIS(I\n l
\{.\`,+d lK WASHING IU\5'I:tElif 6 S.\l1iN,M.\\.\.\(:I II iP.'1'1\G197.^ _
Ti-i.:978-745-951)5 • 1'.\x. 97g-740 9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/El c cage Print umberLepib v
\ ) illcant Inforination
Nlelna tnucinc vOrganiralinNlnJrvuluall:
City,Stater%ip: Phone
+I Are yours employer! Check the appropriate box:
'Type of project(required):
1.❑ I am a employer with 4. ❑ I um a general contractor and t 6. ❑ New construction
have hired the sub-contracture Remodeling
employees(full sntor r partner- � listed on the attached sheet. 7.
2.E1 I :un a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance. 9, ❑ Building addition
INo workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
I required] officers have exercised their
right of exemption per MGL 1 L❑ plumbing repairs or additions
3.❑ I ant a homeowner doing all work c 152,§1(3),and we have no 12.0 Roof repairs
myself. e resire .workers' comp. employees. LKo workers'
insurance required.) } 13.❑ Other
comp. insurance required]
•nny:�l+phcaut dw[checks box dt must also till out the lecliau below showing their w•orkesi cumpensaliws policy infurmatioa
' l i,)n rwfra who submit this affidavit indicating lhcy are doing all,York and then him uutside cuntmetors must luhmit a new al'fdavit indicating loch.
.( t 0101 divult this box mull aoxhod an additional sheet 1h wing tho na is of the sub onlmclors and their workers'.comp.policy information.
/nun err employer that is providin,,workers'c•m»pensntion uh.aarance fur uty employees. Below is die puhcy undBob vile
infurututiun.
In,Llfallee Company Name: ... --.----...._...------'---
Policv 8 or Sclf-irts. Lic. *: ----- -
. ..____ ExpirationDatC:
CityrStaleiZip: .tJ.
Job Site Address: ---
Attach a copy of the workers' compensation policy declaration page (showing;the policy number and expiration date).
Failure Lo secure coverage as required under Section 25A of>IGL c. 152 cast lead to the imposition of criminal penalties of a
tiny up ro S1.500.00 and/or one-year imprisonment, as\veil as civil penalties in the form of a STOP WORK ORDER and a fine
of up at S250.00 it day against the violator. He advi.scd that a copy of this smlcmcnt may be lum arded to the Office of
I m'e,t l,junns of the DIA for i1)sur:uxc c,ry crag c verification.
l du hereby certify nuder the puitts and penalties of perjury that the utfurnnution provided above is true and correct.
])Ate-
official _—
use rudy. Do not write in this area, to be cuuipleted by city or forvn'Wiciu/.
Gtv or fovrn: --- .. Permit/License h._ _-
Issuin, .%uthority (circle one):
I. Iloard of Ilcallb 2. Ilullding Dcparunent 3. Cit),form Clerk J. Electrical Inspector i, Plumbing; Inspector
6. 01her _ -- -
Contact Person: -- - .-_ Phone ll:
Information and Instructions
,,Vassachusetts 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,
cypress 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 toregoing engaged in a Joint enterprise, and Including the legal representatives of a deceased employer,or the
receiver or trustee of an individual, parmership,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 )it the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.%1GL 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, �2542(7)states"Neither the commonwealth nor any of its political subdivisions shall
cuter 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
Phase rill out the workers' compensation affidavit completely,by checking time boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s)along with their cerri6cate(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 of davit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The aff idavit 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 arc 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 ut the bottom
of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be Sine to till in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple penmiUlicense 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he ()1I Ice of 111Ye%ligations would line to thank you in advance fur your cooperation and should you have:my questions,
Please do not hesitate to give us a call
The D:paruncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offtce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
(tovscd 5-zti-u5 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
A , . PUBLIC PROPRERTY
DEPARTMENT
••I .�; oaSrar.ir • SnuM. \I.\„ _ra _
Il - V'S.-4; );gig • If\S: 'i'% 'a:'as Jig
Construction Debris Disposal Affidavit
(retluired li r all demolition and renovation work)
In accordance Kith the simh edition of the State Building Code, 7S0 CNIR section 111.5
Debris, and the provisions otAIGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debt isbe hansporte/dd by: e'
�I name u(hauler)
I he debris will be disposed of"in
� 4?If )C—. �
(name of facility)
�ll � al'lllt —
¢uaturcp>f Immit .applic�afntt
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