3 SPRINGSIDE AVE - BUILDING INSPECTION (3) aCITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposat Affidavit
(required for all demolition mul renovation work)
In accordance w ith the sixth edition of the State Building Code, 7S0 CNIR section 111.E
Debris,and the provisions of vtCL c 40,S 54;
Building Permit p _ _ 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 MOL e
I I L. 3 130A.
The debris will be transported by:
o(17mme t hauler
me cbn sw' l bedis osedofin :
(11ame Uf fu
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w % CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
SIN6F RIF.Y DRMA:011
MAYoR 12C WAshali COtySTREbT 4 SAIEM,MASSAUn.%A-18. 01971
ThL—978-743.9595 •FAX:9M74C9846
Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers
Apulicant Information Please Print Leeibly
Nametl3uainc.worganizatioNlnLlivtfiwal: �NOL, \ltDLvVL
Address:
City/Stare/Zip: 1:�A_vr Phone ft: 779 ? KOS2 z L
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. Q I am a general contractor and 1
6. New construction
• have hired the sub-contractors ❑
employees(full antYur part-time). t. rs .
P
7
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : Q Remodeling
ship and have no employees 'these sub-contractors have S. Q Demolition
workingfor me in an capacity, workers' comp. insurance.
Y9. Q Building addition
i N workers'comp. insurance 5. El We are a corporation and its
gored.) otficen 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.Q Roof repairs
insurance required.) t employees. [No workers' 13.Q Other
comp. insurance required.]
•Ally applicant else clucks box el man also lilt con the section lanow stowiay th6ir wwkm compensation pulicy infiarrWlian,
'l luaaarwnars who submit this affidavit indicating they are china ell work and then Aire outride eonnractas mast•uhmG a new amdavil indicating mach.
Contnxuws that check this box must attached an additional Jtect showing the naae of the sub•eontranon and their workan'carp.policy information.
l um on employer that Lc providing workers'compencadon Insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy q or SnlGins. Lic. #: _.-- _._— Expiration Date:
Job Site Address: Cityistat /zip:
Artach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
fuilurc to secure coverage as required under Section 25A act•.%,IGL c. 152 can lead to the imposition of criminal penalties of a
tine up in 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. He advised that a copy of this statement may be forwarded to the Office of
6n csngaiions of tht: DIA for insurance coverage verification.
Jac hereby cert mJe(��(he ppi 'ns and penu/tiec ujperjury rout the information provided above is true and
correm
tii,•nantrc: ._ _. t` l&__ Datc• JS / ` !/
u••7' C,
Official use only, no not write in this area,lobe completed by city or town ajjiciml
City or Town: __ Pcrmit/l.iccnse N
Issuing Authority(circle one):
1. Doard of llealth 2. Building Department 3. Cityfrotrn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _- . _ --- Phonc p:
Information and Instructions
Ntassachusetts 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.
e%press or implied,oral or written."
An enrplo3wr is defined as"an individual,partnership.association.corporation or other legal entity,of 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 Icgal 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."
bfGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of alicense 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 till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and if
necessary.supply sub-contractor(s)narne(s),addresses)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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
1116:ase 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 permMicease 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 or4icenses. 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. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
fhe 0(iice of lavesrganons would like to thank you in advance fur 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
O®ee of Investt=ations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revi.sed 5-26-05 www.mass.gov/dia
01 -
PUBLIC PROPERTY
DEPAR"I'1bIENT
XM03FA nr 011SCM.
Nwvot 130 WAS"C"W S'MWr•1M&W.MAMAU Sk-17 s 01970
T L•M743-9"S•FAZ VW740-9646
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXIS 4
STR OR B
UC'TIJRE UILDIN -
1.0 SITE INFOR
MATION'
Location Name: 5�r S c Building:
Property Address - -- -- ----- - - -- - - -
Property kt located in a;Conservatbn Area Y/N Hatoric District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 7MiA b vv
Address: 3 J'f>Y`1 w9 S lcic f vc.
Telephone: 7Y 7 YC)
3.0 COMPLETE THIS SECTION FOR WORK IN MUSnNG BUILDINGS ONLY
Addition oNew
Renovation Number of Stories
Change in Use Now
Demolition
Approximate year of Area per floor (sf)
construction or renovation
of existing building
Brief Description of Proposed Work:
/7a 65r
—- ---Mail Permit to: 3 S r' w�S, �' - --
what is the current use of the Building? t a� ` -e
Material of Building?
if dwelling.how many units?
�'� � -
will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( ) -
Mechanles Name �oDV is W v e
Address and Phone
Consbucdm Supervisors License 0 HIC Registration#
Estimated Cost Pr
S � Permit Farr Calwlatlon
Permit Fee Estimated Cost X$7/57000 Residential
Estimated Cost X$11/51000 Commercia--------- _.. .- -
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 Perm to build to the above stated
specifications. Signed under penalty of perjury X `
Date ff- 7" 07
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