27 STATION RD - BUILDING INSPECTION I
le�X �C7,0 CITY OF SALEM
PUBLIC PROPRERTY
_ DEPARTMENT
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
annlicant Information Please Print Leeibly
Name tiltrunc.wOrganizatioNlndividual)
Address: e17 A4u 60 (Z
city/sweizip: 5�3��� �//>tSS ['hone
Are you mployer7 Check the appropriate box: Type of project(required):
I. um a employer with 5;1— 4. Q I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-tune).' have hired the sub-cuntractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 3• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. Q Building addition
fho workers'comp. insurance 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions
required,) officers have cxcrcLsex!their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.Q 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'
comp. insurance mquiretl.] 13.0 Other
•Any applieata due checks lax et must also fill cats she section tw1ow diowing their workns'compensation pulley in(urna;uiwt.
' iformawrtan who submit this affidavit indicating they are doing all work and then him outside eontmpon mud auhmit a new afridavil indicating saacb.
:ContravLaa that chclt this bon nun attached an additional dsmt%hawing the nano or the ab.comracton and their wurkan'comp.policy in(amariun.
i am tin employer that Is providing workers'comperlsadon Ltrurance for sty employees. Below is the policy and job.rile
iajonnation.
Insurance Company Name: re &O't 7
Policy#or Sclr-ins. Lie.0: G>'/G ' �Sso �._ Expiration Date: -�
lob Site Address: City/State/Zip:
Attach a copy of 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
tine up 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
o(up to S250.00 a day against life violator. 'Ile advised that a copy of this statement may be forwarded to the ODice uP
In\'elihal Pllas ul the DIA ror n1\urance coverage veri llcation.
/da hereby ccrtijy or er(he pains ud air' uj rrjury that the informudon provided above is true nd correct.
Daw
i••7 /
Offl of use only. no not tvrire in Mir area, to be completed by city or town ofjicimL
City or Town: Permitil.1cense
Issuing Authority (circle out):
1. lloard of Ilealth 2. Building Department 3. Cilyaw%n Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person:—__ _ _ Phone #:
CITY OF SALEM
Ir- 4D PUBLIC PROPRERTY
DEPARTMENT
..,Altle U1nY AN-01L
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Construction Debris Disposa[ Affidavit
(required for all demolition slut renovation work)
In accordance with the sixth edition of the State Building Code, 780 CA1R section 111.5
Debris, and the provisions of viGL c 40. S 54;
Building Permit N - . ._ 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 c
l It. S 150A.
The debris will be transported by:
E
tllama of haul
fhe debris will be disposed of in
(/ /
i hlamr of iaddlty) �/
14
•.1IC
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i
plhat is the current use of the Building?
Material of Building? If dwelling. how many units?
Will the Building Conform to Law? Asbestos?
Araiteds Name
Address and Phone I )
Mechanic's Name
Address and Phone ) r'1
Construction Supery�4ors License* O 7 HIC Registration N
/ ��
Estimated Cost of Projed S Permit Fee Calculatbn
Permit Fee i ��� Estimated Cost X$7161000 Residential
Estimated Cost 31141000 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.
I
The undersigned does hereby apply for a Building Permit to build to the abov to
specifloationa. Signed under penalty of perjury
Date
ill
D
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n
S
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1
EITy`OF SALE1G
PUBLIC PROPERTY
: DEPARTMENT
r
130 WwwlNCrnN b"rRF1,T 0 SA-W- SLASSAQrLStrlIS O1970
THL-979-715-9S"♦FAX:979-740.96"
TI N O RE AP LI A P REN VA N P C O FOR THE AIR O TI O CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address --- -- — --- — -
Property Is located Ina;Conservation Area YIN i!/Historic District Y '
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
J �
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK.IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated r
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
-------Mail Permit to: c�C• D• r r'� �� ��v�