24 SHILLABER ST - BUILDING INSPECTION Crn -OF S-XCE, - --
PUBLIC PROPERTY
DEPARTMETNT--2-2Z--V
KI.%MFJU.EY DNISCULL
MAYOR to W..AsHINGLUN SrzEEr•SA WA,A1A11ACHLSEM 01970
TEL 978-745-9595•FAX:979-740-9816
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:
ay r ST
Property is located in a.Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: _ Tu
Address:
_may Syr 2 5r
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 (so Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
--- -- —Mail Permit to: 2-1 I'acAl�c��tAS 1��. I fnl3c)Dy 0-74. 0/ xo
What is the current use of the Building?
Material of Building? [Moon If dwelling, how many units? f
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name C Oi-ze►,-�( <
Address and Phone V E)OC.57/-roAvfPs I'S
Construction Supervisors License# 3 HIC Registration# yd 5 7 G
Estimated Cost of Project$ 25O=, o Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury i
Date 2T'o
\� N` µ 1
Q
V
a
rr.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MAYOR TWA croNdlRCa� 4 SAU04MASSACIRAFTt01970
TEL.974745.9595 a PAX:978-740.9946
Workers' Compensation Insurance Affidavit: BalldenlContractor$Mectr(dans/Plumbera
Applicant Information Please Print r �tv
Name(Busineworsaoiat onthwividual): C u,117 ia,s—( �,3 M 7`2t1 C
Address:-__ l 15v n /eo —t4s YS�
Ci /StzWz : I�E�?1� [� y�,c�
h' p Phone#:�9?d�
Are oa an employer?Check the appropriate best F[]Remo&Nng
project(req�).
1. I am a employer with 4. ❑ I am a general contractor and I
employees(fill and/or part time).• have hired the subcontractors pction
2. I am a sole proprietor a parmer. listed on the attached shear,t gship and have no employees These mbcontractors have working for me is any capacity. workers'comp,insurance, ddition
(No works='comp.insurance 5. ❑ We are A corporation and its
required.) officers have exercised their 10.0 Electricai repairs or addhiasu
3.❑ I am a homeowner doing all work right of exemption per MOL I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4}and we have no
insurance required.)t employees.(No workers' 12.0 Roof repairs
comp.insurame required.) 13.❑Other
-Any appdom nut checb boa e1 mwt abo su am dw action below&owby dwtr waknu
ltoauossams who sv2mb tlW affidavit ieNuma Amy son defy=wodc and rhm bins aaWds rmtraetan ambit abmtt awns aiminvY temntle8 tor>.
t-OnuKemathat cbwk dds boa map smmbw m a"doa l shot sbmb 8 rho rims of dw adr camsetas and dwtr-oI ==P P�'Y intbtnntlaw.
lam an employer tliat/r providln;worker'compensation Insurance for my employees Below 41 Mrs
informatioa. poS and job sffa
Insurance Company Name: GQ AA if7 4 F z-,qtE_
Policy N or Self-ins.Lic.M Expiration Date:
_. Job Site Address:_V SJ/r!! or?ram g City/Ststamp::.n
Attack a copy of the workers'compensation pe policy declaration page(showing the pulley Hamper sad aapiratba dab}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal a
of free up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties is the form penalties 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.
l do hereby csroiJy undo the pains and penalder of pefjwy that the information provided above Is Vue and correct
-O
Phone Ns
3
OJJlelal are only, Do not write in this area,to be completed by cUy or town oQleia4
City or Town: Permlt/Lkense N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone M
Information and Insfruttions
to provide
workers' compensation fee their emPleye"'
Massachusem General Laws chapter 152 requires all employersa in the service of another under any contract of hire.
Pursuant to this stetute.an e-'yleYts is defined as ...every perso
express or implied.oral oc omatm."
assoeiadM Corporation or other legal entity,or any two or nine
An Qaspfoyer is defined as"an individual,partnership, vet of a deceased employer,or the
Of the foregoing engaged in a joint enterpr;sak and including the legal m esentarr empbyeea However the
receiver er trustee of an ind(viduai.parme:shrP.association or other o resides&grain.or occupant of the
owner of a dwelling hate having not nacre than three apautn"Is construction or mpair we&en such dwelling bona
dwelling house of smother who QmpbYa th�aretomshall not becauss of such employment be deemed to be an employer."
or on the grounds Or budding appurtenant
MGL chapter 152.425C(6)also states that"every stag rt beat acessconstruct
buildings
in the eommenweahtY far say
to opera"a business er"eonstrtet wiry the baseranee coverage required'"
applicareuwat of a e has
se er p produced
acceptable evidence of eompguee
Additionally,
ly, has ch W,15eed Neither the commonwealth nor any of ire political subdivisions shall
Additionally.MGL Chapter e performance forma )erase"
04 he work until acceptable evidence of compliance with the insurance
inter is of this Chapter��y presented to the contracting authority."
requirements
Applicants
affidavit Comptetaly,by checking the boxes that apply to YeUr ani'tiO°and,it
Please fill out the workers' coor(s)n n°n es Phone numbc(s)along with their certificate(a)of
necessary.supply sub-cow"tor(s)nanm(s).address(es) abo ��Ps(�)with no employee other than the
Limited Liability Companies(LLC)or Limited Liability If en LLC or LLP don have
insurance. are not required to carry workers'compensation
insurance.
Bemem
advised that thin affidavit maybe aubmimed"the Departmenr of industrial
IOYen`or` tegn coverage. Abe be sure to sign and date the anldavtL The affidavit should
Accidents for confirmation of insurance er license is being regue8ted,not the Department of
be returned to the city or town that this application for the permit to obtain a workers'
the law or if You are required
Industrial Aecidetite Should You have any goes regardinglisted below. Self-mined companies should enter their
compensation policy.please call the Departmaj at tbo number lima
self-insurance license number on the a
City or Town Oftblale a at the bottom
Please be sure that the affidavit is complete and printed legibly. The Department has provided a spat egarding the _
of the affidavit for you to fill out mkt event office
will be used as aahreference number.to contact you addition.an applicant
Please be sure to fill in the peroti lieations in any given year,need only submit one affidavit indicating current
that must submit multiple permwacmm app titre applicant should write"all locations in__(City of
policy information(if neeessary)and under"Job Site Address" PP the city or town may be provided te the
Of the affidavit that ban been officially stamped or marked se ty
town)."A copy or licensee Anew afidrvu must be filled out each
applicant as proof that a valid affidavit is on file for ices e O rp it
year.Where a home owner or Citizen is obtaining a license tic permit not rotated to any business or commercial venture
to bona leaves etc.)said person is NOT required"complete this affidavit
(i.e. a dog license or Permit
ou in advance for your cooperation and shook!you have any questions,
The Office of investigations would like to thank y
please do not hesitate to give us a ealL
The Department's address,telephone and fax number.
The COmmOnwealth of Massachusetts
Depa tmeat of lndtast W Aeclldents
Offles Of InvestlPtlons
600 washing Street
Boston,MA 02111
Tel. N 617-727-4900 eU 406 or 1-977-MASSAFE
Fax N 617-727-7749
Revised 5-26-05 WWW.Ma3&VV/"
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