56 TREMONT ST - BUILDING INSPECTION (2) What is the aunt use of the gWk*V9• tftknlLY HQIPE 3
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L4schwW*Name I 1 T2P�Ft2 RD D
Addreall d Phorw
an S n�4Dl L�HIC Rephtretton sY
Co wvucwn&Vwviaars LianN s
Coat at PraIact s 2L 0 P«�FN Calms
Es*naod Em* m 'Coat X$11$1000 ResiderMial
PumR Fes= E,�atb Coat X=11/:1000 CanrnardM ---An AddWwW f6.00 in added as an a l�
AdrnWjdm i o ahe q&
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sun that all ttalds are property and isyibly written to avoid delays in p�"a
Maw a-
The undwsbned does Eby apply f r a euuduv permit to build to the above stated
�pacifigtlona. signed undo►penally of paiury
Date "- ° 7
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ETPY'"OF
PUBLIC PROPERTY
DEPARTMENT
w.a
DEKOLITI IN,OR CHANGE OF USE OR OCC[t*,Lrtr•y
coign RE ORB In.nrntn
1.0 WM INFORMATION
Location Name &"rq: 3 F T�5,
-- -.
Property Address:---
5b -1?knr,Wt S-ri T _ -
F%Ww Iy Y locabd in i;Cww vs0w Arne Y/N t4 Q _Hbbrlo okW t Y/PI
2.0 OWNERSHIP INFORMATION
2.1 Owrw of Land
Names LSI-EPOEN FfAttY
Addrssm 'f5 MA50N ST
€SA k AAA DI 70
TwWww. 5V@_qqq_0q, j Eu- �g1 -a58-'78 QS"
3 COMPLETE THIS SECTION FOR WORK IN Muomm BUILDINGS ONLY
Addition fisting
Renovation ✓ Number of Stories Renovated
Change in Use New
Oemoution fisting
Approximate year of Area per now jsi9 Renovated
construction or renovation
of existing buildirq New
Boef Description of Proposed Work:
Rtm.om-rE KrrcEto4 AND DAvi
RMACi✓ -54igV77Z00c
REPAIR POP-0 tT=Fs
--- -- ---Mail Permit t0; ST;✓iiE 1 ALEY (iMi M ADS `f5 I�AS®N SDI' SAt�h• - -
` CITY OF SALEM
PUBLIC PROPRERTY
DEPARTmENT
lme. L.
\Ll�.a I3C'n.�lrv::�iatst�iu:f1.Navcv:�a..tc11s.:�1
'ha:t17�7K's9ts �f.�hC 97N�69{I�
Construction Debris Disposal affidavit
(required for all demolition and renovation work)
in accordance with the sixtb edition o[dw State Building Cods.790 C1►iR section 111.5 {
Debris,and the provisions of%fGL c 40.9 S*
Bust %Permit A _ _ is issued with dw condition that the debris resnitins has
w 1 be disposed of in a licensed waste di tbcitity as dented by�iGL e
this work shad po DroV�Y ��
I i 1.9110A.
The debris will be transported by:
1`L . SOLI C> (,J-s-rF -'rNC.
Ina=a haulu)
rho&-bds will be disposed of in :
Macnit ut't'acd,ty)
(Fowl-ey l�A
I - .3"40-1-4A
lO 17
-AW
"'aCITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MWWRtr.Y UlltnaXL
�ttYtta 120 VASM.V.To4t Sneer a$Mast,WASAU n aa:•rIx 01970
Thu 97$.745.9S93 a F.ax:9MY40.9946
Workers' Compensation Insurance Affidavit: Builder/Contractors/ElectridsoWPIumben
Analicant Information Please Print Legibly
Name lweainesfrOraaninliowltahvtduotl: cl)wk ADS
Address:-l45 lM 50R ST
CitylStatcJZip: SA LLB Ilion#. +1-10QiI
Are you an employer?Cheek the appropriate beta
'hPe of IueOiect(required):
I.,ff I am a employer with V) 4. ❑ 1 am a gcru al contractor and 1 6. ❑New conrtructiott
etnpluyees(rull and/or part-time).• have hired the sub-cumractora
2.❑ 1 am a sole proprietor or partner- listed on the attached sheer. : 7. ®Remodeling
ship and have no employtea These sub•eonotserora have V. JR Demolition
working for me in any capacity. workers'comp. insurance. 9.
(too workers'comp. insurance 3. ❑ We am a corporation and its ❑ Building addition
-quired.) otrcom have examined their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all wont right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No workcra'comp. c. 152,§1(4),and we have no 12.0 Ruof repairs
insurance requited.l t employees. (A'o Workers' 13.❑Other
comp. insurance mquinxi.]
'Any:pphaot der chocks two 01 map abo fill"err aectim la:iaw ding their wwkm'cwopmaadun Policy inam r"6on.
'Ilwwawnas who salon t this anl0svk indleaema dwy m doing all wait sae deer him mddds aeaaraMN man-Ubmil a new amdavit in,licoina such.
•Coaravtarr nia rbock dos boa mull anadw/at additional.beet.bowing the nacre 0(We and their warli m'comp.policy inawmatiar.
l am an employer that 4 providing workers'competaradon hararanee jar/ray employees. Below Is the pu/fay and Job.bpi
information.
Insurance Company Name:
Policy is or Self--ins.Lie.0: _.. Expiration Date: OmQBL X08-
100 Site Address:_ n7 lk-otiDN7 >(. CayiSlaWZip: .54L.Ext. WW
Attach it copy of the workers' compensation Policy declaration page(showing the polity number and expiration date).
Failure lu secure coverage as required under Section 25A of.%tGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1.500.00 and/or one-year imprisomment,.era well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day aguias the violator. lie adviacd that a copy urthix slatcment may be forwarded to the Office of
lue,angatiatus of the DIA for iosurarcc covera.e verification.
!do hereby certify under the pains and penuiiles of perjury that the injormallon provided above is true and correct
tiia:tature:
qJX1�4q__e�1 -1 - .
O/fkAsli art rrnlpt Do not write is thhr area,to ba evA pWird by city or town o,07'a is l
City or Town: _.. PermiV1.1eense M
Iskuing Aulhorily (circle one):
1. Board of Iteaith 2. Building Department 1.Cilyffown Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone p:
I
Information and'Iristructions
%laysachusetts General laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this staaue.an cayloyee is defused as"...every person in the service of another under any contract of hire,
express or implied,oral or written"
An raydayertidefined as"na iadividttal,parinseship,atsociatiaa,corporation or other legd entity,or aay two or ranee
.af the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employee,or the
association or other legal entity.employing employees• However the
owner ofa dweltiug house havingg not rnae than thtea apartmentsreceiver dust°° ao ice having
pertmetshrp. and who resides therein.or the occupant of the
a
dwelling house of another who employs persms to do maintenance.construction or repair work on such dwelling house
enant there shall not because of such employment be deemed to be an employer."
or on the grounds or building spacers in
MGL chapter 152.¢2SC(6)alW states that"every state or total breading ageaey shall withhold the Issuance or
rearwal of a IReaes or permit to operab a business or to construct building In the cemraeaw"M fir any
applicant who has net produced accept"evidence of compliance with the Insurance coverage required"
Additionally.MGL chapter 152,$25C(7)states"Neither the commonwealth nor any of its political subdivisions shill
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of ibis chapter have been presented to the contracting authority--"
Applicants
please fill out the workers' compensators affidavit completely.by checking the boxes that apply to your situation and,if
necessary.supply sub-contractors)namc(s),address(es)and phone number(s)along with their certificates)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 htduscial
Accidents for conffratation of insurance coverage. Also ba sure to sign mad dute the affidavit. 'Ilie affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Iadustrial Aceidcats. Should you have any questions regarding the low or if you ate required to obtain a workers'
compensation policy,please call the Deportment at the number listed below. Seif-insured companies should enter thew
.elf insurance license number on the appropriate line.
City or Town Oftklab
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 felt out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to till in the permit/licettse number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 of
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 licenses. 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
t i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l'hc Ot iicc of lnvestigatiuns would Cue to thank you in advance for your cooperation and should you have any questions,
plcuse du nut hesitate to give us a call.
The Department's address,telephone and fax number.
The Cotntnonwealth of Massachusetts
DepadMcnt of IndtIstrial Accidents
Oak*of Iavestiptleaa
6W WashinSM11 Stied
Boston, MA 02111
Tel. Y 617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
Rev{+cd 5-26-05 www.tn=.gov/dla
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