10 SUMMER ST - BUILDING INSPECTION . 03 � F
ao
� O CITY SALEM
PUB IC PROP L RERTY
_ DEPARTMENT
wl.xtar ALEY uanl:uu
1X.V7Asrimt;'rox Srarx7 4 SAtEM,MAanu a ay.I tN 0197'J
'ft•.t:979.745.9595 4 FAX:97V-744D.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Amitlicant Information Please Print Leeibiv
r
VamNamelBuainecslOrgmtizatioNlndl o(Iai1D: T G /fL
Address: Aj &17/'ce-,coc i%U�_
Phone —
Cit lStatdZi � I hone N:
Y P
.ram/ �r �i>zs5 s>r�
,%r_e.,yoou la u r employed Check the appropriate box: Type of projee_t(required):
1.LR'1 .am a employer with 4. ❑ 1 am a general contractor and 1
6. Q New construction
employees(full and/or part-time).' - have hired the sub-contractors
?.❑ I am a sole proprietor or partner- listed on the attached sheet : 7• ❑ Remodeling
ship and have no etnploytxat These sub-contractors;have a. Demolition
workingfor me in an capacity. workers' comp. insurance.
Y9. Q Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its MCI Electrical repairs or additions
required.) officers have exercised thew
3.❑ 1 ant 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.❑ Roof n pairs
insurance required.l t employees. [No workers' 13.❑ Other
comp. insurance rcquired.1
-Any applicant dial checks box NI most also lilt cot the section Letuw showing choir workeni cumpnn atiwl pulicy inrunm aw,
Ilwnw,wnon who submit thin affidavit indicatin I am Jos WI coo o '
1{ hry doing work and hen bin outside contractors most sul+mil a new amdsvil indicaina oak.
Zigac ,rs that check this box muat anached m a"Iki aJ
dssal showing are panto of am mb-contractors and their wurknn'coin .p policy informatitw.
/um un simplayer that Is providing workers'compensadon Insurance jar my employees. Below is the policy and job.site
Insurance Company Vmne; ./t/f 1 r'! 4r1,._ ..
Policy 4 or Self-ins. Lis Expiration Date:
lob Site Address: City/State/Zip:
Attach it 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.VIGL c. 152 can lead to the imposition of criminal penalties of a
fine up tit S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a IIne
of up to 5250.00 a day iguinsl the violator. Ile advised that a copy of this statement may be forwarded to the ODlce u1
Inraangatiuns ufthc DIA for insurance covcragc verification.
film hereby certify it/ er the pains rod u!!'• uj erjury that the injannatlon provided above is rice nd correct
tii•:rnnret _ Dat .
,Inc 7 /
O/j&ial ase uulx. Do not write In dds area,to be coarpleted by city or town ojjlciaz
City or 'rmsn: _. Permit/Llcense q
Issuing Aulhurily (circle out):
1. Board of llealth 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Pcrsoa: ._ - .. ___ Phonc p-
CITY OF SALEM
PUBLIC P 4D ROPRERTY
T
DEPARMENT
t_'C W.%91IV::0NS:1 ET#SACITt,
TYI:vn745-IM • F.M'9MAC-9"
tion Debris Disposal Affidavit
Construe p
(required for nil demolition auxi renovation work)
In accordance
with the sixth edition otthe State Building Code, 730 C IL1R section 111.3
Debris, and the provisions ofM. GL c 40, S 54,
Building Permit N - . ._ is issued with the condition that the debris resulting from
an racili as defined b M. GL c
disposal in a property licensed waste tY Y
this work shall be disposed of p perly Po
Ill. S 150A.
The debris will be transported by:
--'� �1y1ma uY haul
�bris disposed o Pin
will be dis :
fltia�l� p
wa rw of iadlluy)-
W if
S �
s
.1 1
..1t.
Wha
t is the current use of the Building?
M dwelling.,how many units?
in
Materia
l of Building?
Asbestos?
WI,the Building Conform to Law?
Arch iteet's Name
Address and Phone
�
Mechanis s Name
�
l nit vo Cl—
Address and Phone
/ 1
4 Construction Supervisors 0 O 7 HIC Registration it
License - �
Estimated Cost of
Project S Q Permit Fee Calculation
Permit Fee SALL' = Estimated Cost X$7/51000 Residential
Estimated Cost $111$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.
s The undersigned does hereby apply for a Building Permit to build to the abov to
specifications. Signed under penalty of perjury
Date
x N
s v1
� Loh
x °o y
P3 >
.96
EITy"OF
PUBLIC PROPERTY
DEPAR'I1bIENT
f:1�MFFJLLY DUSCOIl
(AVM 130 WARUNGnW SMEEr '. �^aX4 S(wnAawstil'M 01970
Tn.978-74SgS"•FA1C 976.740.98"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STR UCTURE OR BUILDING
1A SITE INFORMATION •
Location Name: -e2 s Building:
-- --. ... - progeny Addresx - -- — — - - -- ------- - - -
6 ZfG
property Is located in a:Conservation Area Y/N Historic Okrtrid Y/N
II
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land �G
Name:
Address:
Telephone: —
I 3.0 COMPLETE THIS SECTION FOR WORK.IN EXISnNG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition
s Existing
Approximate year of Area per floor (sO Renovated
construction or renovation
of existing building New
'3'
Brief Description of Proposed Work:
y
----Mail Permit to:
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