5 S PINE ST - BUILDING INSPECTION i
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR'Tv1ENT
'All:rtrr, 09M.0IL
I!C *Il)M/'.
To;9mm-is" F.\x:979-74C-"*
Construction Debris Disposaf AMdavit
(required for all demolition atxl renovation work)
In=ordance w ith the sixth edition of the State Blinding Code, 730 CNIR section t 11.3
Debris,and the provisions of MGL c 40.S 34;
` Buildin11 Permit N . _ is issued with the condition that the debris resulting ftom
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 130A.
The debris will be transported by:
l name u[hauler)
fhc debris wi11 be disposed of in :
y
tnamc of la.i(ItY)
i..ddrcs� oltSiiLl;q .
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xmni-Ri F.Y Unit ULL
MAYOR I2t:WASHL\l4roteSUEer a SAMM,MASSACf11.ti:'llS0197'J
Tt1.:978-743-9595 •FAX:97 -740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anr►licant Information �J n 9 fJ Please Print Leetlibly
Name tHucit WOrganizatiorvindiv,duul): f�E A3 (, RQI£� � _� - �J'j{Plci [pf)STiP(1C7/BtJ
Address: /7 Tir9 AeoVz- /.//1✓
City/StatciZip: p&f4eedza ZV,0 6/82/ Phone M: 97J^ 8DS-t/6/
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer wish 4. ❑ 1 am a general contractor and I
h'
employees(full and/or part-time)., have hired the sub-contractors New construction
2.D� I am a sole proprietor or partner- listed on the attached sheet : 7• RJ Remodeling
ship and have no employees These sub contrutors have S. ❑Demolition
workingfor me in an capacity. workers'comp. insurance.
Y9. ❑ Building addition
[Ke workers'comp. insurance 5. ❑ We are a corporation and its 10. Electrical re
required.) officers have cxcrcL%W their ❑ pairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers comp. C. 152,§1(4),and we have no 12.❑ Ructfrepairs
insurance required.] t employees. [No workers' 13 ❑ Other
comp. insurance required.]
'Any�pph"4 aua ducks box al moat alw lilt uw the seclian Iwlow dewing thvit wurktaa'cumpemadon pulicy infurm;uiwi
'1I,o„wownms who submit ibis affidavit indicating they an;,Luny all wort and then hit,outside connatam mmi•uhr it a new affidavit indicting such.
f.nttrxuxa that chuck this box must atlached an additional dteet showing the nsluo of the cob-comractors and their wurken'comp.putiry infarmation.
fain an employer that Lr providing workers'compensadon Lisurance for uty employees. Below is the pulley and job site
iujurnnutiun.
Insurance Company Name: �Ei✓//U�s9 Ti/UAfX/��_ rLrl� T
Policy#or SelGins. Lic. #: �iti)L' — 11?#M_ . _._ Expiration Date:
Job Site Address: f— S P/.tl.c ST CityiState/Zip: A� .N.4
Attach a copy or the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
fine op to 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 the violator. Ile advised that a copy of this statement may be forwarded to the OBice of
his esngations of the DIA for insurance coverage verification.
t do hereby certify nude le I in" nd penalties ofperjury that the information provided above is true and correct
tii•:rnurtll Date, 7
p o..,.
L
se only. Do not write in this urea,to be conspleled by city or town oJJTci,,Z
own: _ Permit/Llcenseuthority (circle one):
of liealth 2. Building Department 3.City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
erson: — Phone #:
Information and Instructions
hfaisachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employee;.
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,ssgociadoo,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
appiicant who has not produced acceptable evidence of compliance with the insurance coverage required."
additionally. MGL chapter 152,§25C(7)states"Neither the commonwealth not any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance w ith 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-conawtor(s)name(&),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 appmpriatc 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 till in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/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 i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l'hu Ottix of lnvestigations would like to thank you in advance for your cooperation and should you have any questions,
pleas du not hesitate to give us a call.
The Dcparnnent's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lnvesdzil ions
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
a
PUBLIC PROPERTY
DEPARTMENT
IG.�WFJL.6Y D�15[ULL
�/wYo11 130 WAQuNG iw snwwr•SAujK L5k-m 01970
TO-97a-71i9M•FAX W&740-M"
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DIF OLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Prop"Address:-..3----- --- -- -- ---- - - - -- -- ----- -
Properly ie boated in a:Conservation Area YIN_dL Histaria Dkwd YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: SAL fJ
Address: s PIAAe- --r
Sl9LF/'�, /ham
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN "ISIING 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
of existing building New
Brief Description of Proposed Work:
IEfPLAC'£ G1i�uDOGv,Tie//''1�00v� Tjjt-pry, T �O.e
�,r1 Kc` BoA.e�S
- Mail Permit to: - 3- s ..-
What is the current use of the Building?
Material of Building? 2X9 np If dwelling,how many units? O r'
WIN the Building Conform to Law? Asbestos?
p rohited's Name
Address and Phone ( )
r-MachanidsNarm 'mod/, e a°BQi-FrU
Address and Phone / , ,
Consbudicn Supervisors License 0 (11R01 -7 HIC Registration#
Estimated Cost of Projed$ .IMF. F" Permit Fee Calculation
Permit Fee$ 6 G Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/51000 Commerdat-----------
An Additional.S5.00 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 a Bove stated
r
specifications. Signed under penalty of perjury
Date
� N
N
s
b �r .
� •� v s i
C I
• a
4 1
1
r