1A STILLWELL DR - BUILDING INSPECTION CITY"-OF
' PUBLIC PROPERTY
DEPARTMENT
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MAYM �J
1t7.:978-745-959S*Fex:97a•740-9b16
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTLF OR BUILDING
e
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
1/2 / Or
Property Is located in a;Conserve don Area Y/N Histarle District YIN
i
t
2.0 OWNERSHIP INFORMATION
r 2.1 Owner of Land `
t — n
Name:
r
Address:
a Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN 7VStone
NGS ONLY
Addition ng
Renovation Number ated
Change in Use Demolition gApproximate year of Area per atedconstruction or renovationof existing building
Beet Description of Proposed Work:
611L yl e,^i t,v w,`hs�ouig
Mail Permit to: V'� � - -"
P -
What is the current use of the Building?
Material of Building? If dwelling.how many unds?_---
Will the Building Conform to Law?
Asbestos?
Architect's Name
Address and Phone `
MechanldsName trSo� v�
i
Address and Phone HIC Registration#
Construction Supervisors License#
Estimated Cost of Project$
it Fee Calculation
P errn
Permit Fee$ Estimated Cost X$7/i1000 Residential
Estimated Cost X$111$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date fL�D�o�
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
Wvaa 130 WAMONGr w STUW•SMZK MAUACFr:-WM a197a
Consimcdon Debris Disposal Aff1davit
(required fa all demolidon and renovadon work)
la aceordancs with the sixth edition of the State Building Code.780 CM section 111.5
Debr*and the provisions o(MQ.a 40.8 A
Buddies Per. 0 is issued with the condition that the debris resulting from
this wort shall be disposed of in a properly licensed waste disposal Ateility as dented by MCM a
111.S 130A.
The debris will be transported by:
The debris will be disposed of in:
(name of facility)
(addrsaa of facility)
G
Sipame of punt applicant
dus
•'s6nW7Jus i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KLMSERIEY DRLSCOLL
MAYOR
120 WASHNGTON STREET•SALEM,MASSACtiUSEM 01970
Workers' Compensation Insurance ARidavit: Builders/Contractors/Electricians/plumbers
Applicant Informatio
/� Please nt Le
Name (Business/OrganontioMndividual): J ` t uw-
n �
Address: �j i 1 2 YZf�O n U Q,
City/State/Zip: fc���rn 41 9 7 0 Phone#: 9 79'
Fam
ployer?Check the appropriate box:
ployer with 4. 0 I am a general coWractor and IType of project(required):
es(full and/orpart-time).• have hired thesub-contractors 6. ❑New coustmction
le proprietor or partner- listed on the attached sheet t 7. �odeling
have no employees These sub-contractors have
for me in any capacity. workers,co 8. 0 Demolition
[No workers, COMP. insurance 5. rpo• insurance. 9. 0 Building addition
P ❑ We an a corporation and its
required.] officers have exercised their 10.❑Electrical 3.❑ I am a homeowner doing all work right of exemption nP or additions
myself. [No workers'co emp Per MGL 11.0 Plumbing repairs or additions
insurance comp. c. 152. §1(4),and we have no
ng d)t employees. [No workers, 12 0 Roof repairs
comp. insurance required.) 13.0 Other
faPm�Pwa�nut checks box el mutt s4o fill om the tertian below showing their who"bait this °'arks•
tContnctms that must gu h d", they an doing all wing rod rhea him outside must
s� aa'
check this box mutt st4ched to edditiowi sheet showing the otme of the ��muq submit s 00w afl9davit indicating rush.
I am an employer that it providing workers'campensadon insurancehe s M a� Belohew w comp.policy inib matloa sonconcions
informatlan / P y p 4 ani sate
Insurance Company Name: i' 6,e r y do f- Oct I
Policy#or Self-ins. Lic.#:_jAC
Expiration Date: '7 — O — D `7
Job Site Address:
�L the workers'
Attach acop City/State/Zir-
y-bf compensation policy declaration page(showing the policy number and a:phraH0 date)
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal
fine up to S1,500.00 and/or one-Year imprisonment,as well as civil penalties ofa
orm of a STOP WORK ORDER and
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the O�� a fine
Investigations of the DIA for insurance coverage verification.
I do hereby certify an er the paint and it en iris w afperfary that the in/ormodan provided above is true and correct.
SigEahtre-
D t
Ph _
OfJ9cial ass only. Do not write In this area to be completed by city or town oJjlc1
al
City or Town•
Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town own Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person•
Phone#:
Information and Instructions
ter 152 requires all employers to provide workers compensation for their employees.
is defused as all
person in the service of another under any contract of b€re.
M Pursuant
eth General Lawn chap
pursuant to this statute,an employed
express or implied,oral or written." two or more
is defined as"an individual,partnership'association'
corporation or other legal entity-ot 1oY er.
An employerm a joint enterprise.and including the legal rcpresentatives of a deceased employer,
Of the
ual,Partnership-association or other legal entity,employing employees However the
of the foregoing engaged ) or the occupant of the
receiver or trustee of an wing not more than three apartments and who resides therein, on such dwelling house
owner of a dwelling who employs persons to do maintenartM construction or repair m be an employer•»
dwelling house of another thereto shall not because of such employment be deemed
or on the grounds or building appurtenant
MGL chapter 152,§25C(6)also states that"every state or local licensing u agency shah withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings fa the commonwealth for any
produced acceptable evidence of compliance with the insurance political subdivisions shall
applleanerage required-"
t who has not p with the insurance
Additionally.MGL chapter 152,§25C(7)states"Neither the commonwealth le evidence of compliance
enter into any contract for the performance of public work until acceptable
resented to the contracting authority."
requirements of this chapter have ban p
Applicant checking the boxes that apply to your situation and.if
Please fill out the workers' CO�nsamon affidavit completely,by
necessary.supply workers'
sub-contract, name(s),addresses)and phone numbers)along with their certificates)of
insurance Limited Liability Companies(LLC)or Limited Liability Parnterships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an ep or LLP does Have
is required Be advised that this affidavit may be submitted to the Department of Industrial
employees a Policy
be sure to sign and date the sfffdavk. The affidavit should
Accidents for confirmation of insurance coverage• Also or license is being requested,not.the Department of
be returned to the city or town that the application for the permityou are required to obtain a workers'
Accidents. Should you have any questions regarding the law or if y should enter their
Industrial mem at the number listed below. Self-insured companies
compensation policy,Please call the Departriate line.
self-insurance license number on the a
City or Town Officials ent has provided a space at the bottom
be sure that the affidavit is complete and printed legibly. The Deparam the applicant-
Please
rmidlicense number which will be used as a reference number. in addition, i applicant
of the affidavit for you to fill out in the event the Office of Investigations has to contact youinaregarding
Please be sure to fill in the Pe dlicense applications in any given year need only submit one affidavit indicating city
that must submit multiple Pernti and under"Job Site Address"the applicant should write"all locations in ( tY
policy information(if necessary) stamped or marked by the city or town may be provided to the
out each
tower)•» A copy of the affidavit that has been officially tamp
applicant as proof that a valid affidavit is on file far furor: i,etmi a t not related to any business ii or ccommercciial venture
year.Where a home owner or citizen is obtaining a license or permit to complete this affidavit.
to burn leaves etc.)said person is NOT required
(i.e. a dog license or Permit nip
and should you have any questions,
The Office of investigations would a to thank Yo
u in advance for your cooperation
please do not hesitate to gi
The Department's address,telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofnee of InvestlPtiOns
600 Washington Street
Boston,MA 02111
Tel. #617-727F 900 e�or 1-877-MASSAFE
Revised 5-26-05 www.mm.gov/dia
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