53 SUMMIT AVE - BUILDING INSPECTION EI`I'Y--O��AL
PUBLIC PROPERTY �C
DEPARTMENT
IGIUBOU-13Y DRISCOLL
MAYOR I20 WASHING:TON STREET' JAir'ai,MAssncHt;sti-rs 01970
'IEi 978-745-9595 0 FAx:97&740.9946
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: S 4-a,� Building:
Property Address:
Property is located in a; Conservation Area Y/N Historic District Y/N ,1 o
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: a
Address:
_3a/{ems A o/ o
Telephone: 7& — ';'Li/ -2os r
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: 0
lie/'00 C
Mail Permit to: "e �wht r
a
What is the current ent use of the Building? s �
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? P S Asbestos? 0
Architect's Name
Address and Phone A
Mechanic's Name 17n In��'�� "� �`� c ` S 6 6 — 3,/7- 0s'E-.3'
Address and Phone S L� ( o/t P�'4 50 ( ° 9 G Y
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ a o 3 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 Building Permit to build to the above
specifications. Signed under penalty of perjury X 7 '
Date
DI
0
N
7t y
V
�p✓f�,aae�c�eu�
e �� + Board at Building Regolagoas�d Standards
HOME IMPROVEMENT CONTRACTOR�
4
Registratim& 138640
ExpUation .7/28/2007
T[ `Type Supplement Card>
Ix ti �r i
INTERLOCK INDUSTRIES INC.G)
KEITH- O'DONOGHLIE`r v
#7-25 WALPOLE PARK_SOUTH .✓_
WALPOLE.MA 02081'. Admidatntou
b4 OR 18
�st � � R
s a �I.
d d d
0
M y ,
1 1'�
g '
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHMtGTON STREET•SAi.Em,MAMCHUSEM 01970
TEL.978.745.959s •FAx:978.740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricianv/Plumbers
AauHcant Information Please Print Leeibly
Name (Business/Organiation/individuak): �4 4 G
Address: g�S_ L✓at, pr Ze- 12G,,-4 se _ 7
City/State/Zip: ,,r 14 Phone #: f - 3/Y`C9
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with -' -5� 4. C1 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ?• ❑ Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity. workers'comp, insurance, 9. Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp. insurance required•]
'Any appkicent that checks box#1 must sho fill on the sectlou below showing their writers'eompeawtion policy infruntlb6
f Hrnoowoen who sWmt this sftidavit mdteating they am doius all wodt and thin hire outside c aincu es must submit a new&il,& k iodicaties such.
tContnuton that check this box must attached an s"tional sheet showing the name of the sub-eontraUots and tick workers'comp.policy infrtnapae.
lam an employer that Is providing,workers'compensadon insurance jar my employees Below is the policy and fob site
information. QQ
Insurance Company Name:_/y/1+15 '� C eik a A
Policy#or Self-ins.Lic.#: G✓G/ - Y3 7/- 0 7 a a 3/ T C- Expiration Date: a /i /O 7
Job Site Address: S 3 S vc s ,f o4-</,2_ City/State/Zip: Sg 4" ef 14
Attach a copy ofthavorkers'eompedsatou policy declaration page(showing the policy number and exptraHon 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$250.00 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 certify under the point an snap' Ofpedary that the information provided above Is true and correct
Signature t� Date
Phone#:
001cial use only. Do not write in this area, to be completed by city or town oJJlclaL
City or Town' Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#'
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their contract
of hire,
Pursuant to this statute.an employee is defined as"...every person in the service of another under any
express or implied.oral or written-"
An employer is defined as"an individual,Partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased eml y ,�«e
Or the
receiver or trustee of an individual,partnership.association or other legal entity,employingemployees.
owner of a dwelling house having not more How
than three apettments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling borne
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings is the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally.MGL chapter 152.§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority.
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),addresa(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. 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 license number on the appropriaM line.
City or Town Officials
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 be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future,permits.or,licepses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CTTY OF SALEm
' PUBLIC PROPERTY
DEPARTMENT
w>aaEa 000=L
H.raa 130w►s�mKaor sswa�suaa<aro�aosot170
Tm M745-OSK•FNe 9M7469M
Consimcdon Debris Disposal Affidavit
(required Lets all dem ffim and tenovatios work)
in aetordaoee with the sixth eMoo of dw Sbft BtWdinf Codes 7W CMlit section 111.5
Debris,and dw provisions of UM a AA 3 SIt
Buildins Been&4 is issued with the Bond doa that the debris m=Wns ikora
this wa&Mall be disposed of in a peoperllr Ueeased write disposal&d tl►as deduM by MM a
I L t.31SO&
The debris will be ttansported by:
(ssms aLtralsel
i
The debris wiU be disposed of in:
(hams of Finait»
(addmn o/&CWW)
siyaaaue olpamsit appliaat
due