5 UGO RD - BUILDING INSPECTION (2) CITY OF SALEM
4D �y p� PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposat .Affidavit
(required for all demolition and renovation work)
In=ordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris. and the provisions of MGL a 40. S 54;
Building Permit 0 _ _ is issued with the condition that the debris resulting !torn
this work shall be disposed of in a property licensed waste disposal facility as defined by VIGL c
111, S 130A.
The debris will be transported by:
l?PO f,q�<- r/ Y /t o 1
— — umau of hauler)
me debris will be disposed of in :
(name of iacdrty)
.d.:rcx. at'ixiLty) .
CITY OF SALEM
PUBLIC PROPRERTY
' DEPARTMENT
8 t'Stru'atfy DILMAX-1.
MAY(* I2C V7Avuw70ty SMW a SAt EM,WASSACl n..u:-I-Is 019T`
'CELL--97f745-9595 •FAX:97e-740.9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aoniicant Information Please Print Leeibly
flame tdu'4ACUlOrganiz,1600Vlndiv,duui):- C6�or4 e /t/9 r f /
Address: I ptlr__? /J �'L ti r 2t1
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City/Srateizip3J /mi^t, I o IshoneP L9 7- 9Y5- 229 0
Are you an employer'Check the appropriate box: 'Type of project(required):
III 1.❑ I am a employer with 4. Q I am a general contractor and 1 6. Q New construction
.�( employees(full mullor part-time). have hired the sub-contractors
2�ESI,1 am a sole proprietor or partner- listed on the attached sheet. : 7. ❑Remodeling
ship and have no employees These subcomcactom have 8. Q Demolition
working for me in any capacity, workers' comp. insurance. 9. Q Building addition
lKo workers'comp. insurance S. Q We are a corporation and its !0.❑Electrical repairs or additions
required) officers have exercised their
3.Q 1 am 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 12.0 Roof repairs
insurance required.) t employees.[A'o Workers' 13.❑Other
comp. insurance required.]
•nay 4pplicaW the ch cits box al mess asap all sun the faclios below dwwiag their wurka to cumproaWiyn ptdiay infitmma/ioa
'I l., ,wrma who submit this antdwit i ndicating t hay ass doing all watt and thtm Aita omaide cawrataon meal aul+mk a now afRdavit�C indialins Huh.umtxvn that Check this box muq anachmd at 7'mldt wool attest Jwwing the nmpo of ale subeomrsctara and chair Wuhan Policyinrdm anus.
�0•W wY
i um an employer that 1s•providing workers'compensation Lrsarance for my employees, Below is the pa/icy and job slti
information.
Insurance Company Name: _..--
Policy p or Sclf•ins. Lie. 0: .. .._._ Expiration Date:
Job Site Address: Cityislatuzip:
Artach a copy of the workers'compensation policy declaratioa paste(showing the policy number and expiration date).
Failure w secure coverage as required under Section 25A uf.MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
.if on m S250.00 a day aguinst the violator. lie advised that a copy of this statement may be forwarded to the Office of
luv"ngauotu uh•Ihc DIA rot insurance coverage veriticatiun.
i da hereby certify ad the pains d enalties of perjury that the information provided above is true and correct
tii�•aawra' _.. �'�— Date• 13 — zo — 0 /
O/Jlciaf ore mrly. Da nor write in dhis arra,to be completed by city or town ofJiciaL
City or Town: PermitiL(cense M
Issuing Authurity(circle one):I. hoard of ilealth 2. Building Department 3.City/fosvn Clerk •i. Electrical Inspector 5. Plumbing Inspector
6.Other
C 4,11taet Person: ___ I'hone p:
Cm
PUBLIC PROPERTY
DEPARTbIENT F
ximsEM ry DRISCULL
MAYOR 130 WARUNGnM MELT*
&MbM.W.ISSAQILSkTiS 01970
TEL-97474S-9S9S•F=M740.98"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY VaSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Is located in a:Conservation Area YM Historic Oftid YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: d- A Lq
Address:
Telephone: 7$ _ L/ 7 V
3.0 COMPLETE THIS SECTION FOR WORK IN EnA M BUILDINGS ONLY
I
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sn Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
Re- oPvr4 -ti0-n 0 --
�X IS1�� h `c Tc-
--------Mail Permit to: --
C
What is the current use of the Building?
fir , �� C
Material of Building? L120 CL If dwelling.how many units?T—
"I the Building Conform to Law? -P S' — Asbestos? -
Architeas Name
Address and Phone ( )
Mechanles Name
Address and Phone
Construcdw Supervisors License#(D6 Z Z 3 -( HIC Registration#
Estimated O O o o Permit as CalwWon
Permit Fee 3 Estimated Cost X$71$1000 Residential
Estimated Cost X$11/51000 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 penally of pedury /�
Date 2 D—
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