4 SPRUANCE WAY - BUILDING INSPECTION iu
' PUBLIC PROPERTY
OXl-�' DEPARTMENT
I:I�WERI.EY DRIS(:OLL
MAYOR i-V WASHINGrON STREET•S 1
Ate,M,vcAa,t;sE,,s 01970
14t 978-74S-9595 4- FAx:978-730-9U6
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: ' �%_�,� i Building:
Property Address: q
'�iC IN
Property is located in 'a;
Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FYls-rwG 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
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building?
Material of Building? If dwelling,how many units?
Will the Building Conform to L"?
Asbestos?
Architect's Name II�\ /
Address and Phone
Mechanic's Name
Address and Phone O
Construction Supervisors License# D 10 e� 5 HIC Registration#
Estimated Cost of Project$ V� OU 0a 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 BuildingPeermit to build to the above stated
specifications. Signed under penalty of perjury X ' �
Date
\S'I
o
N
ate+ a
1_I C
u `L � . " 6. u
u L. O,
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ICnlafinlEY DRISCOLL
MAYOR 120 WAain` TONSTRUT e SALLY,MASSACFRJgTC501970
TIM-9M74S9595 a FAX 9M740-96"
Workers' Compensation Insurance Affidavit: Builden/Contractors/Electricians/Plumbers
ADDlicant Information Please Print Letibiv
Name(BusineawOrsmiatiodindividuat): .
Address: )ti 1/0' 44& C/
City/State/Zip: �-�a u� Phone#: g Id' - 7 Y-j'- s �-
Are you an employer?Check the appropriate box: Type of project(required):
1.[TI am a employer with 4. 111 am a general contractor and I ❑
employees(full and/or past-time).• have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance,[No workers'comp. insurance S. ❑ We are a corporation and its 9, ❑Building addition
regwred.j officers have exercised their 10.0 Electrical repairs or addition:
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or addition@
myself.[No workers'comp. C. 152. §1(4),and we have no 12.❑Roof repairs
insurance required)t employees.[No workers'
Comp.in�nce rsgui�j 13.❑Other -
f�Y apptidet Mat thanks box el eutst a4o @a ad the sxdoa blow ahowing dm&wairm,eompenaadoI poliny iniWoodioet Honnowms who suMoit dde"Ikkvk mdludn@ Woy an doing a@ work and rhea hW @Wide eonkacto I must nbroft a now a V&*mdkatlot OWL
rCoetrachm that cheek this box most sttwW ore additiaoet sheet A"Mit din dine of do VA-ontr and dmk works'comp,policy 0dartnatloa.
I am an employer that is providing workers compensation insarencefor my employees Below/s the policy and fob site
lnformadow. n Insurance Company Name:_ f
Policy#or Self-ins.Lic.ll:_ 'w// C Expiration Date: 3 02 ejo
_ Job Site Address: 41�1
r ""'`` City/State/Zip:
Attach a copy of the workers'compensation policy declaradou page(showingthe Policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 50.00a d and/or one-year imprisonment,as well as civil Penalties in the form of a STOP WORK ORDER and a fine
of up to 3250.00 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.
I do hereby terrify under the pains and penalties ofperfary that the information provided above is due and correct
MENEENNE
Si Date. / /3 Q 6
�
FAuthority
Do not write in this area,to be completed by city or town oJJielaL
PermMUcense p
(circle one):
h 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person• Phone*
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their ernpl®yess.
pursuant to this statute.an easploYes is defined as"...every person in the service of another under any contract of hire.
express or implied,oral or written."
r is defined as"an individual,parmetshnp,association,corporation or other legal entity.or eny two er more
An aatQloye and including the legal representatives of a deceased employer,or the
of the foregoing engaged in s joint enterprise. or other legal entity,employing employees. However the
receiver or trustee of an individual,partnership• and who resides therein.or the occupant of the
owner of a dwelling house having not mere than daft apartment Lion st repair worst on such dwelling house
w
dwelling house of another who employs persons to do maintenance.co to ent be deemed to been employer."
or on the grounds or building appurtenant thereto shall not because of such emp yin
MGL chapter 152,12SC(6)also states that"every state or local licensing agency shell withhold the issu e=*or
renewal of a lleesse or permit to operate a busing"or to constr ct buildings is the eommoaweakh for gay
applicant who has not produced acceptable evidence of comptlaaee with the insurance coverage required.
MGL chapter 152,$25C(7)stares"Neither the commonwealth not any of its political subdivisions shall
enter into any contract Additionally. for the performance of public work until acceptable evidence of compliance with the innuanee
requirements of this chapter have been presented to the contracting authority."
Applicants
• on affidavit completely,by checking the boxes that apply to Your situation and,if
please fill out the worker compensate and phone number(s)along with their certificates)of
necessary,supply stub-cont (")
actot(s)name .address(es) with no employees other than the
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)
uired to carry workers'compensation insurance• if an LLC or LLP does have
members or Partners,ere not advised that this affidavit may be submitted to the Department of Industrial
employees,a policy is required Also be sere to sign and date the affidsvit. The affidavit should
Accident for confirmation of insurance coverage.
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accident. 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 liaemse number on the mziaw •
City or Tows Otdciab
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 affidavit
be sure m fill in to 11 ittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple petmimicense applications in any given year,need only submit oat affidavit indicating current
policy information(if necessary)and under"job Site Address"the applicant should writs"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped err marked by the city or town may be provided to the
it applicant dsvu must be fined out escis
as proof that a valid affidavit is on file for future permit or 1permit icenses.relatedA new to any business commercial venture
year.Where a home owner or citizen is obtaining a license NOT required to complete this affidavit
(i.e. a dog license or permit to burn leaves etc.)said person
The Office of investigations would litre to thank you in advance for 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:
Thor Commonwealth of Massachusetts
Department of Industrial Accidents
O®ea of Investigations
600 Washington street
Boston,MA 02111
Tel. #617-727-4900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26.05 Wwwanass.gov/dig
LAG
CrrY OF SAmm
' PUBLIC PROPERTY
:j
DEPARTMENT
,o.,roa tSww■Nctarassut.SaLSKNe.mawnnsolve
I'm M74645al.FNe rn7404M
Construedom Debris Disposal Affidavit
(regttired fix all demolition and<mrados work)
in xootdm a with the si:ctti edidoa e[dw Stdo BuiWas Code,780 OM seedas l l l.S
peb *and dw p wAdons otUM a 40.8 34
Bnilldin0leetttit 0 to issued wilt the oondWos that dw dews muldna 0oa1
the wo t shag be disposed of is a p109011►lick wasp disposal BdUW me Mined by MM a
1 l 1.s tsa►.
The dews wiU be et=Vood by:
(asma dbrW
The debris will be disposed of in:
si1{wa�[.of tPojc-o
I dl-3106
due '