38 WASHINGTON SQ SOUTH - BUILDING INSPECTION (2) What is the current use of the Building?
Material of Building? -�'O cat If dwelling,how many units?
"a tlw Building Conform to Law? Asbestos?
yC� Asbestos?
Architect's Name A
Address and Phone �Az- ( I
Mechanles Name /✓
Address and Phone
Con&uct,on Supervisors LWAnae l/ (c(Z or HIC Regishatlon 0 i
Estimated Cost of Projed i Perm*Fee Cakulatlon
Perm*Fee S 2 S Estimated Con X$71$1000 Residential
-- -- — Estimated Cost X i41/111000 Com"rcia'
An Additlonal $5.00 Is added as an
Administrable charge.
Make sure that all fields are PrOPOV and legibly written to avoid delays in processing.
The undemigned does hereby apply for a Building Perm*to bu o the above state
I r---
specftatkms. Signed under penalty of pedury
Date g 7'
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PUBLIC PROPERTY
DEPARTM&NT
VG.�roFM.6Y ORWA"
%IA"Oe 13O WMMNGcw b%.M=•SAUfiK Wsuon;se-ns 01970
APPLICATION FOR TEE REPAIR. RENOVAIM CONSTRUCTION,
D&MOLITION.OR CHANGE OF USE OR OCCUIRANCY FOR ANY EXISTING
STRUCTURZ OR BUII.DING
1.0 SITE INFORMATION
Locadan Nam 13uiwkw
-- Property Address:-- ----- - _
Pr0FGrty Is kxatsd in s;COneamillon Area YIN Historic OwIrldlyffil `fgS
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name: S-
C-6 O
Address: 3 T I
Telephone: 7/ 2-
3.0 COMPLETE THIS SECTION FOR WORK IN EXISXM 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 aoe 7 New
Brief Description of Proposed Work: / ✓�D v q%. Lo
l
-- Mail Permit to: _
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
NI nY 1 AW.A.0It.
\ll t. lk 12C W.va irm-:Of%5:'Urr •&%L.N,MA%W'it *1"1 a%V C
T¢t:9M7+5.9595 •Fult:97i74G9946
Construction Debris Disposal Affidavit
(required for all demolition auui renovation work)
In accordance w ith the sixth edition of the State Building Code, 730 CNIR section 111.5
Debris, and the provisions of M. GL c 40.S 54;
Building Permit # _ . ._ is issued with the condition that the debris resulting from
This w dis work shall be posed of in a properly licensed waste disposal facility as defined by MGL c
1 11.S 1.50A.
The debris will be transported by:
mama of hauler)
I'lic debris will be disposed of in
wanic of fa%;i1Ity)
..ddrex. of'ta:Aay) .
C� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
nnmr RCEY natsc:OLL
MAYOR t29 tlfesnu.NG)'ae STREET 4 SAIEM.MAssACI n"isms ol97,^.
'1't•.c.:973-743-"95 4 FAX:979-740.9x46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A ) licant information Please Print Le ibl
Vafne(ducine.WOrganizatioN ut lndivuul): /7^�� �-D<= �`�`�d�2'� //\✓t�t
Address: C ( ^r k S -T— q
City/Stare/zip: I NFL 01�� Phone M: / ��^ l y 6
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ I ant a employer with 4. ❑ 1 am a general contractor and 1 6. Q New construction
2.Vf
employees(full and/or part-time).• have hired the sub-contractors
1 am a sole proprietor or partner- listed on the attached sheet. :
7. ❑ Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity, workers'comp. insurance. 9. ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercis d their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,§I(4),and we have no 12.Q Roof repairs
insurance required.) t employees. [No workers'
l3.❑ Other
comp. insurance required.]
•Ally applicant tlut clucks boa ei moat also fill an the seclian IwWw stowing ibeir work=cumpemaion pdicy infi,nrwiwi
'Ilwnvitwnon who submit this affidavit indicting thay arc doing as work and then hire outside contractors mwl.uhtntl a new affidavit indicating nigh.
Cantrxturs that check this box mull anwhed an additional shal showing the name of Cho subtontracton and their workers'comp.policy information.
1 am an employer that is providing workers'compensaton lissurance for any employees. Below is the policy and fob site
issjurrnutiva C ^ ) d C
Insurance Company Name: / /•{ - 4 V
Policy 4 or SclGins. Lie.#: _. Expiration Date:
Job Site Address: Cilyistate/zip:
Attack 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
rtne up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa 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 to the Ot)ice of
lus.angaliuns ul'thc DIA for insurance coverage verification.
1 do hereby certify under t/tie p in as penalties of perj bat the lafarmaNan provided above is true and
correct.
Phtn:c 7:
Uncial use unty. Do not sprite itt this area,to be completed by city or town oJJlchnL
City or'fown: _.. PcrmitJl.lcense
Issuing Authority (circle one):
I. lloard of Health 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: __ - _ - __— Phone q:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire.
..press 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 employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments 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 house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
biGL 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 line not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally,tv1GL 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 w ith the insurance
requirements of this chapter have been presented to the contracting authority."
I
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation andJf
necessary, supply sub-contractors)name(s),address(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 numb et on the appropriate 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 till in the permitllicense number which will be used as a reference number. In addition,an applicant
that most 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 or
town)."A copy of the affidavit that has been officially stamped or marked by cite 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 tilled 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.
1'hc Otiix of Investigations would like to thank you in advance fur 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
O®te of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE
Fax #617-727-7749
Rcvibcd 5-26-05 www.mass.gov/dia
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