37 SUMMIT AVE - BUILDING INSPECTION EITYY-OF SA ---
�/U-07 PUBLIC PROPERTY �1
DEPARTMENT p
KINIHM-FY DRISCOLL
MAYOR 120 WAWINaMN s REEr*JAI.lJ{' O�fA�SACJll:561'R 0197e
TEL-978-745-959S♦FAY:976-740-9846
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: j(2) Building: S, N
Property Address:
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 5 A nl
Address:
_J
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use GK New
Demolition Existing j SJ 0
Approximate year of Area per floor (sf) Renovated l7
construction or renovation
of existing building New
Brief Description of Proposed Work: �PMo� 2 xi 5! i n 1�cGK
NQ--) x
- — Mail Permit to: St(-),J `3 -7 SvM�AI� Ave 5�1IeM M� 01770
� a
What is the current use of the Building?
Material of Building? t,.J UG
If dwelling, how many units?
Will the Building Conform to Law? _ Asbestos? A D
Architect's Name �—
Address and Phone
Mechanic's Name Q '� �✓ ��� //
Address and Phone < No l I � � � n � ��ovc�ANcl /`\.A Of �3
Construction Supervisors License# `L S 70 ! HIC Registration#
Estimated Cost of P o'act$ Calculation2 Permit Fee Calculation
Permit Fee$ D� Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date---iT l-r b
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4 u Q G 4
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KLNBERIEY DRISCOL L
MAYOR
120 WASHMTON STREET a SALEM,MASSACHUSEtrs 01970
Workers' Compensation Insurance Affidavit: Builders/contractors/Electricians/Plumbers
A Hcant Information
Please nt Le
Name (Business/Organimtion/Individual): el— L .� C
Address: c-A N d i _ 6
City/SLateJZip:_ G t t e /A n/A AA-A al Phone #:_t7 5{—3 7$'�/�
Fyoumployer?Check the appropriate box:
mployer with 4. ❑ I am a general contractor and I Type of project(required)•
es(full and/or part-time).• have hired the subcontractors 6. ❑New construction
le proprietor or partner- listed on the attached sheet t 7. Remodeling
have no employees These sub-contractors have for me in any capacity. workers'co 8. ❑Demolition
workers' comp. insurance 5. ❑ We are a corporation and its � g addition
mquired.) officers have exercised their 10.❑Electrical repairs 3.❑ I am a homeowner doing all work right of exemption or additions
myself.[No workers,comp. c. 152 1 4 Per MGL 11.❑Plumbing repairs or additions
insurance t ' § ( )•and we have no 12.0 Roof
ngd1 employees. [No workers' repairs
comp. insurance requu*v&j 13.[7 Other Gam_
�AnY eP Homeowners
that cheeks boa NI must alto flU ous the scrim below Aowiva they wmkars•�Pensatioa 11 ataasim
t
Hameowoma who submit this affidavit' omgall polity ibf
=Contractors that check this box must attw additlonsl sheet eho awm the aWork and dimoe"' em town must submit a sous atp policy
indicating�,
sub-conttsetas and their workan'wmP•PaieY infamatim
am an employer that Isproviding workers'compensa
information.
don insurance for my employee.. Below is tbs policy andJob site
Insurance Company Name;
Policy#or Self-ins.Lic.#;
Expiration Date:
Job Site Address-
Attach
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 MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 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. Be advised that a copy of this statement may be forwarded
Investigations of the DIA for insurance coverage verification to the Office of
'r do hereby certify un the pains and penalties o jperJury that the information provided above it due and correct
Si a r
Phone
& 31
OJJTeial Use only. Do not write in this area, to be completed by city or town oJjfciaL
City or Town:
PermitAUcense#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person:
Phone#:
information and Instructions .
as General Laws chapter 152 requires all employers to provide workers' compensation for rhea emPI contract of hire,
pursuant to this statute,an employee
Massachu,se is defined as"...every person in the service of another under any
express or implied,oral or written" two or more
individual,Parmers6,P,association,corporation or other legal entity,or any
and including the legal representatives of a deceased employer,or the
An emPloyer is defined as"an employing employees However the
of the foregoing engaged in a joint enterprise, association er other legal entity,e:mP
trustee of an individual,Partnership. three apartmenis and who resides therein,or the occupant of the
receiver or hat,;ng not more than work on such dwelling house
owner of a dwelling horse who employs persons to do maintenance,consbucaon or repair »
dwelling house of another thereto shall not because of such employment be deemed to be an employer.
or on the grounds or building appurtenant
MGL chapter 152,$25C(6)also states that"every state or local
licensing agency shag commonwealth
withhold the thforlasua any
or
renewal of a iteenss or permit to operate a business or to eonstract burildings fa the commonwealth for any
roduced acceptable evidence of compliance with the insurance coverage mb���s»shall
applicant who Gas not P 152,§accept states"Neither the commonwealth nor any of its Political
MGL chapter evidence of compliance with the insurance
Additionally. for the performance of public work wail acceptable
enter into any contras resented to the contracting authority."
requirements of this chapter have been p
Applicanb checking the boxes that apply to Your situation and,if
Please fill out the workers' compensation affidavit completely,by s along with their certificate(s)of
name(s),address(es)and phone Our nbcr( ) other than the
necessary.supply sub-cons actors) or Limited Liability Partnerships(LLP)with no employees
Insurance. Limited Liability Companies(LLC) non insurance If an LLC or LLP does have
are not required to carry workers' compensation of Industrial
members or parmers, required Be advised that this affidavit may be submitted to the Department
employees,a policy insurance coverage. Also be sure to sign and date the uffi ,n �Dep��of d
Accidents for confirmation of thathet or license is being 4
be returned to the city or town that the application for the permit you are required to obtain a workers'
Should ou have any questions regarding the law or if y es should enter their
Industrial Accidents. Y Department at the number listed below. Self-insured companies
compensation policy,Please call the Dep riate line.
self-insurance license number sin the a
City or Town Officials Department has provided a space at the bottom
that the affidavit is complete and printed legibly. The ions has
you regarding the applicant
Please be sure in non,an applicant
of the affidavit for you to fill°rmidlicense number which will be used as as reference number. In addi
Please be sure to fill in the Pe dlicense applications in any given Year.need only submit one affidavit indicating cctsrsenr
that must submit multiple Perrot and under"Job Site Address"the applicant should write"all locations in ( tY
on if necessary) stamped or marked by the city or town may be provided to the
policy informal
town):' A copy of the affidavit that has been officially tamp permits or licenses. Anew at ,dovir must be filled out each
applicant as proof that a valid affidavit is t file for future o t not related to any business or commercial venture
year.Where a home owner or citizen is obtaining a license or petrol complete this affidavit.
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to
The Office of Investigations would li to thank yo
u in advance for your cooperation and should you have any questions,
do not hesitate to give
The Departmem's address,telephone and fax number
'Ihe Commonwealth of Massachusetts
DepaMMA of Industrial Accidents
Office of Investigations
Epp Wwbington Stjeet
Boston,MA 02111
Tel. Al 617-727 Fax
900 6 7 0 0C 1-877-MASSAFE
Revised 5-26-05 www.nim.gov/dia
CrrY OF SALEm
PUBLIC PROPERTY
DEPARTMENT
KIMMA n cancan
vAroa ►m wA"NCMN S1wFs[•SA=:wssAO Sern a1970
Constmcdon Debris Disposal Affidavit
(required ter all demolition and renovation work)
In accordance with the sixth edition of the Shoe Building Code.780 CMR section t 11.3
Debris,and the provisions of MCM a 40.S A
Building Permit M is issued with the condition that the debris resulting floor
this work shall be disposed of in a properly licensed waste disposal dainty as defined by MGL a
111.S 130A.
The debris will be transported by:
Gary 6L
(ssms dt+wise)
The debris will be disposed of in:
("ams of facility
(addrns of facility) I
I
of pemut ant
to L L Z04
.;eeri,r7two