28 SHORE AVE - BUILDING INSPECTION (2) What is the current use of the Building? D w2I I N
Material of Building? W 00d If dwelling.how many unitaT
Asbestos?
Will the Building Confom►to Law? N
ArchiteaS Name
Address and Phone ( 1
Med►artids Name
Address and Phone
�„t udion Supervisors License �1 ti70� HlC ReglsUation
Estimated Cost
Permit Fee i— 0 UU. 00 Permit FeeCaloulatlort
Estimated Cost X$7/$1000 Residential
Estirnsw cost $I I/: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 Suilding�P[smitit to build to the above stated
specifications. Signed under penalty of perjury
Date ?-o 9-O?
el
s\
i96 ~
EI;I'Y gXLEb
PUBLIC PROPERTY
DEPARTMENT
u.a�xsr D.Isaxw / b
MAYOR I3DWARUNGt Mbl� *sALXK WA,sAau:se„s 01970
A_pPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DILMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
IIA SITE INFORMATION
Location Name: o,re a Building:
Property sw- — -
Propsrty is located in a;Consarvatlon Arse Y Hisfoft Dhtrlot Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name•. oe Tci Ck e
Address: AS S I _�1v fe A Vl--
ne:Telepho
3.0 COMPLETE THIS SECTION FOR WORK IN DINGS ONLY
Addition Existing �7
Renovation V� Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building I I INew
Suet Description of Proposed Work:
G)eck (-�2pq 1 r
-- Mail Permit i 'e 7 , - - -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
$AU:.M. ` -%Si.%01L SLI1Sp191C
TFt:973-74i-9595 *F.%X:97d-74G9946
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section t 11.5
Debris, and the provisions of MGL a 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 MGL e
111. S 1.50A.
The debris will be transported by:
U�s (59G 1
(name of hauler)
fhe debris will be disposed of in
` (oumeOrfICility)
Or
9� D7
CITY OF SALEM
� 1r PUBLIC PROPRERTY
,�� DEPARTMENT
SIm Ill(RIXY InrK LL
MAYOR 12C WASHI.\GfOKSTRELT • SALLs4,MASSACIIILSICI7S01970
TeL 978-743.9593 • FAX:978-74v^-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lecibly
1 L ,
Name(Buciiiess/Organizatioivindividuul): PI r l�l O/V S7 f Ll��� �✓u
Address: -�-2 R1Ve_n/e f k_) A- ye
City/Stare/Zip: ()�,-Nyef 5 ri" - L 113 Phone 4: �'9 7�- 3 as 7 3
Are you an employer? Check the appropriate box: 'Type of project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6 ❑ New construction
employees(full and/or part-time).` have hired the sub-contractors
2.� 1 am a sole proprietor or partner- listed on the attached sheet. : ?• Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
Ito workers'comp. insurance 5. ❑ 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 11.❑ Plumbing repairs or additions
myself. (No workers comp. C. 152,§1(4),and we have no 12.❑ Ru if repairs
insurance required.] t employees. [No workers 13.® Other Qe.C_ m1 q\�
comp. insurance required.)
•Airy applicant that chucks box tl most also lilt out the section Wow showing{their workuri compensation policy inhtrnmtion.
'I lomuuwnett who submit this affidavit indicating they,are doing all work and thm him outside contractors must submit anew affidavit indicaing such.
�Commcmrs that check this box most attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/our an employer that is providing workers'compensadon insurance for try employees. Below is the policy and job site
imfornation.
Insurance Company Name: .__ -
Policy 4 or Self-ins. Lie.#: ------- 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 wcure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tint up «t S1.500.00 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 Ilse violator. lie adviu:d that a copy of this statement may be forwarded to the Office of
hn'esligatiuns of the DIA for insurance coverage verification.
/do hereby certify under the poiti d enaluec of perjury that the information provided above is true and correct.
Sie:rnl r : t?t Datc' 7 _On_D7
Phone 3t
Ofjic-iul use only. Do tint turite if:this area,to be completed by city or town ojjiiciuL
City or Town: _. _.. __._ Pcrmit/License#__.__ __
Issuing Authority(circle one):
1. Board of llcalth 2. Building Department 3. City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
contact Person: Phone#:
Information and Instructions
Massachusetts 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,
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,associatic a 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 rill 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 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 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 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 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 permitilicense 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Otiicc of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a calla
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgations
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