6 WARNER AVE - BUILDING INSPECTION —C��-0�'
' PUBLIC PROPERTY
DEPARTVIE�1T
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MUYM 130 WAswNGTm SnmEr
"L.EK N(titacxLShTtS 01970
1EL,971-74S-95"*FAX 97&74&9846
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTL 1G
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
property Address -- — -- --- -
. - A i-e
Property is located in a;Conservation Area Y/N_ / Historic District Y/N Al
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: A L
Address:
C
Telephone: j '1
3.0 COMPLETE THIS SECTION FOR WORK IN EXISXING BUILDINGS ONLY
Addition Existing
Renovation Li 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
8def Description of Proposed Work:
E 8
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--- Mail Permit to: MR r AA/ef /� !sj/, /r ,X,,9ive 4e�AlNE iE'
What is the current use of the Building? �' S� �'7A
Material of Building? If dwelling,how many units? o Ay t
Will the Building Conform to Law? c —
Asbestos? Me
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License S HIC Registration
Estimated Cost of Project$ 0 Permit Fee Calculation
Permit Fee$. = Estimated Cost X$7/$1000 Residential
---- Estimated-Cost X$11/51000 -An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to theabove stated
specifications. Signed under penalty of perjury xz�
Date /i e
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
anreEatB,t nascou
MAYOR uo WnsmuerortstnesT a
e.^,Mwsssattx9gt,soi97o
TM-M745•9595 a FAX WS-70984
Workers, Compensadon Insurance Affidavit: Buiidersicantractor$Mectrit anVftmbers
Applicant Information Ilease Paine r edbly
Name l dud): Liz
Address'
CitylState/Zip: 1V1 4L5�/�-,kt , Ky, eyi4ec' Phone#:ZfSi —3�2 7 i
Are you w employer?Cbeek the appropriate be=
1.(] I am a employer with 4. ❑ I am a general contractor and I ape of doled(required):
employees(S+B andlor part-time).• have hired the solo eonhacwn 6' New construction
2.®Tam a soht proprietor or patmer- listed on the attached sheet.t 7. E xamoa H g
ship and have no employees These sub•conhaetors have 8. ❑Demolition
working Cer mein roY capacity. workea'comp,inane, 9.
0 We are A corporation and its
q ' [] Building addition
comp insurance S' officers have exercised their 10.❑Electrical
3.❑ 1 am a homeowner do' all work right of repairs or additions
exemption Per MOL 11.[]Plumbing repairs or additions
myself.(No worker'comp, o. 152,j 1(41 and we have no�N� 12.�Roof repaid
insurance required]t employron(No workers' 13.Q Other comp.insurance mquired,j
fir wv�a dam arm beer rl soot erica der out tlr aaalm bdme dterise a wk.0dWM.
Hameowats.ha a60t Ws aatdwh mdtatlse dry an Mae an.mk sad dr No oaratde matt a6a�t i ake aa[davtl
rCoaaeetme abet cbwk ebb beer now ruehd as■d"=d dart dK We dr name ofthe sub eoaeaetam ad drk erabam'cm* POHM hifimmilaL
1 am as saeployer that itprovi ft worhen'compexradew/ataraacejor my employees Below lathe iajonrodow,- - poBry aadJob.rlar
Insurance Company Name:
Policy N or Self-imL Lie.N Expiration
Date:
Job Site Address: City/ShteiZip:
Attach a copy of the workers'compensation policy declaration page(showingthe
pedcy number said ez*aWn date).
Failure to secure coverage as required under Section 25A of MOL 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 penult es in the form of a STOP WORK ORDER and a tine
of up 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Oineg of
Investigations of the DU for insurance coverage verification.
/do hereby cerdJjr wader the pabu and penahles o rimy that the iajofaradoa provided a
bove Is Amer and correct
Phone ZTI— 3::21
o,Qfew use onlA Do not write In thir area,to be completed by c4 or town oJJfelaL
City or Town: Permit/License N
Issuing Authority(circle one):
1. Board of Healtb 2.Building Department 3.Clty/rowo Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person
Phone N•
Information and Instructions
m General Laws chapter 152 requires all employers to provide workers' compensation for their amploeeL y
giant to this statute.an employee is defined as".'.every patron in the service of another under any contract of hit%
express or implied.oral Or written
aswciatioq eorporatiob or other legal entity,o any two or more
An esspfOYer is defined as"an individual,partneabip. va of a deceased employer,er the
of the foregoing engaged in&joint and including the legal repraenba lo eaL However the
association or other legal eatiry,employing amp y of the
receiver a uuatee o[an ibdividua4 partnership. who resides therein,or the occupant
owner of a dwelling house having not mace than three apattnente d wbt eti�or repair work on such dwelling htwse
dwelling boys"Of another who employs Pawn&to do not
f such employment be deemed to be an emploYa--"
at on the grounds
a building appurtenant Ito shalt not bemuse
that"every stab Or load Scanting agency shag withhold the Issuance Or
MGL chapter license
or p)also o op is SIw cemtewawea"far NW
RYwd of a Seebte or parade b Operate a business or b =pU&w �the insurance coverage required'"
acceptable aVidanN Ot a common of its UdW subdivisions!hall
applicant who has not predeued states"Neither the commonwealth ter any Po
Additionally,MGL chapter 152.$25Q7)performance of public work until acceptable evidence
of compliance with the insurance
enter
egm into
��have presented to the connactins authority."
req
Applicants situation sod.it
Please fill out the worker'Compensation Compensation affidavit completely.by cheel°ng the boxes that apply to you
necessary.wpply�O�Og(a)nsme(s),addreo(a)and phone number(s)along with a)o employees o h then the
insurance Limited Liability Companies(I L C)or Limited Liabiiry pactearalupa(LLP) or I l p doer have
members or paMera.am not required to carry workers'Compensation insurance.
Be If an LLC advised that this affidavit may be submitted to the Department of Industrial
" Abe be sum b tip and dab the affidavIL The affidavit should
�i�far aggrmation of insurance eovaage not the Department o[
be returned to the city or town that the application for the permit of license is being requested.
industrial Accidents. ftould you have any questions regarding the law or if you are required to obtain s workers'
compensation policy.plesll the Dgweeaant at th number listed below. Self-insured companies should enter thaw
se a
selfinsurance license member on the
city or Town Omdah
Please besure r
fete and printed legibly. The Department has provided a space at the bottom
t the affidavit is comp
of the affidavit for you to fill out its the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill er.in the permit4kcitse number which will be used as a reference numb In addition,an applicant
that must submit multiple permit/lrcense applications in any given year,need only submit one affidavit indicating curt
policy m submit It ple pgr necessary)and under"Job Site Address"the applicant should write"all locations in__(ory or
or marked by the city or tow may
ay be provided to the
town).,.
own). A COPY of the afftdsvit.thst has been offlCWlY stamped Of
licenses A new a -&vk must be filled out each
applicant as proof that a valid affidavit is on file for fhtma Permits ilic related to any business or commercial venter"
yeas.Where a home owner a eitiub is obtaining&license er Pamir
(i.e. a dos license er permit
to burn lava ego.)said pawn is NOT required to complete thin affidavit
ns would like to thank you in advance fa your COoperaiOn and should you have any guesaOns.
The Office of investigatlo
please do not hesitate to give us a call.
The Department's address.telephone and fa:number.
The COMMeiwalth of Maasachtlsetts
Depadmmt of Industrial Accidents
Ofne*of tievadgadons
600 wahingtm Stfeet
Bost^MA 02111
TeL #617-7274900 ext 406 of 1-977-MASSAFE
Fax S 617-727-7749
Revised 5-26-05 www.meaa.gov/dia
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