18 WASHINGTON SQUARE WEST - BUILDING INSPECTION (2) i
Ward
No— _., City of Salem
APPLICATION
MR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCT
IAWORTAKT--App/cwW to oampMh aI No to socdonM 4 A M6 N, and DL
L - AT 0.00ATWM /, paiNlCi
LOCATION Pam .
or BEIMWEM KAOM man AND pto�
OULDW40 LOT
9UBDMBIp/ LOT_BLOCK 9a
L TYPE AND COST OF 81Jt.DINO -At/9POICants Compble Parts A-D
A. TYPs OP MW"OVENOff IL PROPOSED USE•FOR-DEMOUTKW USE MOST RECEM USE
1 ❑ Trap Maeft Rawdaaw KraawdwdhK
2 O AddMMtl matWWA wear nwnhw of 12 O One WNti 18 O AMAWMML i.cnallWr
hPuskV wrs a0da4 IF am%A PM A 13; t8 O Chnack, taadba
30
�,s..7 wla�y /3 TWof O or WNh-Fnr ln.nhn 20O11 "
4 I ^`Pa�"'� 14 Q TwMwV PwAA mohL w dm Wkwy- 21 o pw"t-g
n„n EMWnwn0.d unU—_--- 22 Q Swim x0ft% GOO t>r8W
S 0 Wr.dtkV M MUM*, ,naldardnl Md► dw 23 O -I- V iwdlug,nw
or unit in bulrt0 in Art a 13; 1513 tM, an 24 ❑ 00ka bo k Wafrugbrt
a ❑ MMb UabcwWll 1e El 25 Ashu _.
7 Q re w ft mllt/ ( �tD 4�f 2@ Q sdtaal tdr>, oBr aauewlvW
,7 or,w-SM* 270 9WaAnrT�rr
ML OwN93g9 tP 280
e ❑ PdtRu m sit) cwPP Soon nonP�aet
In 29 LYJ ar,r•Sp=W �X —
w Sal
B ® A:BP(Feft swi%w wcul owwlanwtl
C.COST (Off W Q W w`ar4a ud-Or1b it doW PAOoaad um d bddga aa.Imd Pm l""Para.
wd 0 wasp Wnby bA*q w hoapil w -wory sdimA wmrww7 uPnoal G-ftVw.
1Q cow of:wrorn.r — -- _. • Q OQ O Pa1Odtr ar3lPdl P... trran to d.Pwatry.rPt4 lmw dIb b @dlna OAb euddr
- at iiOtraY1 PW4■it at Old"bddtq fY hwrq UrtpO.wrr P,aPord�
fi ha iyrarad ba nd Acbdas
it do aOwe cow -
tL Pranbaq ._..........._.__._.....
._.___—__.___-
t 1. TOTAL Cost OF IMPROVEWP(r D QO6 '
ILL SELECTED CHARACTERISTICS OF BUILDING -For new buildings and addition; complete Parts E -L.' demolition.
com is on Parts✓3 M all odws skip to/V
E, PMNCWAL TYPE OF FRAMs F. PRNCYAL TTPE OLHEAT"VO AL a TYT AGE OLSPOSAL L TYPE OF MICMAlaCAL
30 Q L�ivey l.at btam0) 33 Q Gr 40 P i aY CM00W '"dra bu--w M
Jt Mood�4ama 36 ❑ 04 41 cow4b+��Q7{{GQ32 Q shctvwasp 37 ❑ Elactriuy M O wa 4333 ❑ AO-ftwdmu 38 Q CPw IL TYFf OFJ�ATFl19UPPI.Y ,.w&we W M wwnrPr
34 ❑ Otr,w-saw 38 ❑ od w-sa ,2 2U r AA ft w Polar mnmw ,eQyM 47.- 43 a Atrab Malt cMwM
- -,
i osiammoma AL DEMOLITION OF STRUCTURES
As rwnea CO
,s low,a,r.!oral d+uw and Hall Approval from Historical Commission been received
r+m,►ew.s •••� for any structure over fifty(50)years? Yes____ No—
SO 'ml wrW R .. ..
_ Dip Sale Number
K.liJ1MER 01 00"TMIr VMelerO s"11Cq Past Conlrot
SI 6¢Iraae _ _ __ ___. ...
HAVE THE FOLLOWING UTILITIES BEEN DISCONNE M.
vw
SZ p�daprr_.._—_._._.-------___.._....__.. •-
EkLlIG
ss Fa do.ae .... ---------- Gm
ra_—_--.___.._ Sewn
54
'�"d'd DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
BEFORE A PERMIT CAN BE ISSUED.
N. COMIPI FTE THE FOLLOtAIph G:
Historic District? Y No— (ti Yes.please ando"dopanenWm from H19L Com.)
Conservation Area? Yes— No Iti enckm Order d Conditions)
Has Fire Prevention approved and stamped Plans or aPW Yea___ No—
Is Property lorrted in dro S.RJI district? Yes— No_
Comply with Zoning? Yes_ No— (if no,enclose Board of Appeal decfafon)
Is lot grandlatiered? Yae_ No— (d Yes,submit documenta*mM no,submit Board of Appeal decision)
If new construction,has Ne Proper Routing Slip been enclosed? Yes.._ No—
Is Architectural Access Board approval required? Yes— No_ (ti Yea,submit documentation)
Massachusetts State Contractor Licenses ?2 Yig 7 Salem License e
Home Improvement Contractors Homeowners Exempt form(if applicable) Yes_ No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX(a)MONTHS OF ISSUANCE OF BUILDING PERMIT
ti an extension is necessary.Please submit
CONSTRUCTION IS TO BE COMPLETED BY: in writing to the Inspector of Buddings.
V. IDENTIFICATION- ro be completed by all applicants
uaaaq addax VwrOI, snag:M.ant Ylw ZIP Cafe 'a1 Nor
1
C.rvr a
:es1♦
t dId✓s
CaNSV LuY rh
1
aIV!p Y
E.grr
I r'ereby cw*that the proposed work.s authorized by the owner of record and'hat I have been autonzed by the Cwrer to-make this application
as his authorized 3gent and we ages@ to conform to all licable laws of Nu;unsdctbn Applicator date
Sigrature of applicant Address
i
� a
` DO NOT WRITE BELOW THIS LINE
VL VALIDATION FOR DEPARTMEW USE Oran
Building
Permit mbar u»croup
Building I g Fn Grdiq
Permit iSsued
knq laadne
Permit Fee f load
Certificate of Occupancy : Approved by
Dram Tile /
a
Plan Review Fee = rt1LE
NOTES AND Dote• (For department use)
$e C, f2,0 v
C �
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by. Completed by.
f
E
A ZONM PLAN ERAAONERS NOTES
OISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
WM OR PLOT PLAN•For AoPkAw Use
ON
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REPUCE E%LSlNG WOOC POSiS
REMME MING SPED N ITS
-- DUREEY, FPEEZEA
RELOCPTE C[MPpCECR TPASN
PONEAUNIL Mp S4Ui OFF fl6flREL
EONEWLCGER: \
ROOF TGRFN: OBLLIPSATDECKME'WM STAPWAY
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H = HOTEL TRASHAREA
1a I_n STAR
REVISION SEAL ARCHITECTS PROJECT LOCATION OWNER DRAWING DATA DRAWING NO.TITLE
Gray Arehitects,Inc. Hawthorne Hotel H & C Service PROJECT No.10014 TRASH AREA
ArchdeCtUre and
LandSeape ArchilecWre Trash Area CorpDRAWN BY:C.L.A. DEMO PLAN
sA Demy sereMo CHECKED BY:D.J.G.
salere.Massecnus DISEp
TEL 918106 R4N Fusvew1.1,, SCALE:1I8"=V-0"
E. I GRAYe ETTTECTS®^,^ 18 Washington Sq.W. 10 Colonial Rd.#4 DATE: 2123/11
Salem,MA 01970 Salem, MA 01970 D— 1 .O
N0. DESCRIPTION DATE
REVERSED WIXt OWN'
FENCE TO RERUN,rvR NEW 4k6 AT PERM TER.FliWDE
NANGERSWATCIXWER1
PAR,NGLOT
NE_W PL Zi5 ROG11 llNTl� PARNWGLOT
p UtlPSiFR pppy�E HANGERS R-15_
Hu
RELOCATED
[UNPAIVON _—NEW L<P---051==
POW"UNR STAGE lU
O ANDSNUTOFF Q -ILtd
CWPACTCR TWO NEW ZWANT1IISRED_
AULFRAMNGMEMBERSFCRNEWSNEO TOBENALED
$'TIC PLYYIWD DECXNG OVER IT,'.'DoR JUNTO OF DO,
'METAL I II SONG PANEL,PRUNED AND PTD,TO UATOR UMT.WERLPT5TDD5,TYP,
STORAGE
CONT�,ER
ALL fNAMWGMEMBE1L5 FOR NEW LApGE SHED 10 TPAS 6WREL$ O
BEECP£N£0 NTOPUCE Ftli EVSY 015ASSFApLY
ANDR ENEEANTY
TI.II SgWGPANEL.FANEOAND iPAyI
PTO.iONAi[X E%6T DARAEE
1
.. ._. ._. ... - 1'E'i I,'j11Z+iS 51ACgE➢PgVERS
-
--
CLEAR NEW 1%AT 1ENM11R,
'FRO NERA4C8i5 GMAT .
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NEW 2S1 Pi STUDS,TrP
ROOFSAHOVET gEWN,FAWO
NEW;AU9IXMULSUWTNT IOSECURETO '-'--______' 1{ $URWAY
EVERURPAFNWAUL = NEWPi3=fi_FLCgY106i5_J-
B' Z'x C B ._ lPR➢vDEPo>rCfPSFaSfi
CLEM
RAUP STOSU QiN(WOCO__
un i p�-r6sss r6--D==i=---
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°i __caNTNUE°.sACRoss -____:
R FTd _16GPAYR'61170 C'F x+�
OAS,oUAII6 FLOCA JORTS ISOC FCR
R i"�-',=&$YiXS1\65ERPFF6RDA65b8'f=='
PMpoodg5 Ell iktl REFRIGERATOR
==sHE__ ==,PTO.====____
PT LY15TUD WAILSAT IEOO
Len wow 31. ,==I+EW4X6ATPENNETCRPROV E====
!I ,==xm+LtrsaenrcoRRE«s-___=,_-
REAR
ENTR1 t
11'-04'x
-Sx LINE OF ERNTNGROGPP80vF
/1HAWTHORNE HOTEL-TRASH AREA -.-- — ---
/SCALE.VB=1 L" STAR
REVISION SEAL ARCHITECTS PROJECT LOCATION OWNER
DRAWING DATA DRAWING NO.TITLE
Gray AFGnn InO.
e015,ArGnch iMTe Hawthorne Hotel H & C Service PROJECT No.10014 TRASH AREA
LRnEScaDe ArcEILeCWre Trash Area Corp DRAWN BY:C.I. . NEW PLAN
SMIem9MRNs¢rYJluseftO19)0 CHECKED BY:D.J.G.
TEL.919 715m04.FAN V.LSEATB SCALE:1/8"=1'41"
E.a zGRAYARGHGEiTS®mv:_mn 18 WBShInJ[OD$Q.W. DATE: 2/23111
N0. DESCRIPTION DATE
Salem, MA 01970 10 Colonial Rd.#4
Salem,MA 01970 A-1 O
RE MSEO DOOR SWRG
PARKi_smT
PARKWGLOi
IINPSiFA —
0 SLMWNTEORAGE O]M
LELWGMWNTFO NEiA
0
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LWPACitli
� 3%6GAi 1I0[.
METAL NLFR NGMFA6EASFCR
STORAGE NEW SXEDTOM.M
CWIAREA All FRAMMGMENBERSFQR
NEWSHEDTOBENAEFO
ALL FRAMWG MEMBERS FLa NEW
VALE SXED TORE SCREWED NTn
PUCE.Fqi FKYD6A55EAP1Y
ANDaEAssEABLr
—cEu+c aun?Enueru
=cACBa -.
LA6'S Ai LL--�� FREEZER
]S<SION V ISOC.
PROADENEWIA009 WLSUPRORTW
SECURE E%RING ROOF TOM"WµL - — STAR,NAY
SPACER.M.
MEYI SI iE
ADDNM2,1 rOUx GDN.
ACE_
O W W_EMATNEW Mep
'-E%MiN6A1BIIXUi
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REFRUGE.O2
BAl1ApYA _�y �—�—
REAR
ENTRY]
�
S'f"ORNE HOTEL-TRASH AREA __ ----"-
U SCALE'.1/8-=1YY BI>R
REVISION SEAL ARCHITECTS PROJECT LOCATION OWNER DRAWING DATA DRAWING NO.TITLE
Gray Architects,InC, Hawthorne Hotel H & C Service PROJECT No.10014 TRASH AREA
Architecture and
Landscape ArchiteCtU. Trash AreaAWN BY:D.L.A. REFLECTED
BM= CorpCor CHECKED BY:D.J.G. CEILING PLAN
Salem,Fnasucn°seus"`otwD p SCALE:1/8'=1'-0'
TELR7crin�n0°cwi R7 156"' 18 Washington S .W.
®"m'm"' 9 Q 10 Colonial Rd.#4 DATE: 2123/11
Salem, MA 01970. Salem, MA 01970 A-2.O
N0. DESCRIPTION DATE
A
------------------------------ _____ __
_ \ �— Pi M SUE PLATE AND 20 STUD WNIS,M.\
\ / III I SUING,PTO.TO RATER ENNEAD t
i SEWRE 17Oc.a NO OVER PT 2%A WOOD STUDS
iO3%fi�1ZOL.WITHSCflEWs
E%ISiNGOECNAWVE iORE1MN AX6 At PERME]EA,PRWUE
Ill HANGERS GV AT CORNEAS
PRO NEW 2,1010E%SING WLLIO. NEW OWBlE 2%IOTO SPM'NEW PTWp11 PoSi5 LIX.CREiE BLOCRPASEBEVQVp
PNOVNENMGwSACb IBA%IA1 I CNOEA&OCrc BASE
LOCATION OFNEWPOSi6 6'MW. w'W PflOVUEfUNGER5 NV310ATALLE%UING
� OECK.XINIS
I
121MRwARCWTNUWS
• ATPEWIETER I
NEW 4M POST BEYOND Y\ MREGAN@ AT O G,ONE EVERY OTHER
1{'$ECpE - BLOM,VERTEAT
EPOMRO DEMIN$CEN WE
-
EPDIASUING TO Rrn00p O[crcING Ww2d FRANNG HAWTHORNE HOTEL-TRASH AREA
wERLAAgmFEnre I ,�PERMINENT STRUCTURE BASE DETAIL
SCREWED
MEM9ERSNNEW S4 ED TORE SCALE.1-i-0
SCREWED WiO P.&M FOR LAW DUASSFNBLY EMU WNI FLASXNG ADHERED UP.0 Iw WATM UNDER CWNTEI READING
1Q iRW.PLO.�� AND REASSEUSLr
NIP/UENµGEgSNU210ATN1E%6TNGOECRKGTS
Pi DBL3d TOP PUTS IYP.
i1-11 SUNG,RED TO BATCH E%SING,G E PTM WOOD GNUS
1'9]'pLUNNUN ORp EDGE, 'i 2M STUD WALLS,M1P.
CGION I01MTCHNEWPID.SHED i1-115®WGPTOTO.TCHEXNTNG EPoNRWFNGWER�CXNrWLCODEM.GG hGFPNANG
AULFRABWGME.WEUFOR HAWTHORNE HOTEL-TRASH AREA ALL FRANK'G BEARERS W NEW SEED TO BE SwEWED INTO
NEW SHED TOBENAEFD ,FASCIA DETAIL PUCE FOR MY DRAS6EB&Y AND RE,DGEBI
PROVY]ENEw]w.2M rI1I A Ll SCALE:1'=V' I ADD NEW 2.IDTODUSTNG0&a10.PROWDE
SHEDWOR,PID. \ V HANGMSACEI INAXIAT IOMTMOFNEWPOSTs
______
-
ALK.S1M OF a00FMTXiW -------- — — F SHING
RAE CF FGCE EPDN RCOFNGMER - 'MIN,
EPoN RCOFNGiO -- -
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II-II SUNG,11, la-c- - A :
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E%I6iNG.OJFH PT REINsfAIL uEI N10DXM11 LGHTi S'Si
WOOD,STUDS 1M TgMAT PERINI RED,TIP,
EASTNGfREEZER NEW WlAIN sHEDpC(p$ 6TARWELL
BEYM:D TO REAM
BNIIBEYONNDTYP.
il-IIOWRs,PIp.
GRACING BEYOND _ i IMTFjM;PID,
9'3'
9-10'1 i( Ay'GNANIY UTCX I HEAWIUYTY T.NGE ALVM,3 PER DOORM,
� I,A iaW,Plp, 8'-11'1
il, A GgAVFIYIAtCN,M,ATAL11,MquDI
6S INGRATE➢ \
[UfNFO WC%i RILL N$'ZFC�II'UG WflVEO D]qi PULL/YP.
\ 5'XEAVYWbi 6EWgE p'idG RYb
HNGE]PERpO,i t02%{®IZO C AIMYGFNS
Rib✓QUREAO✓ODLEW NAAPs AT'
CONCRETE I( \ NEW STORAGE THREE stORAf£RDONFN1kANcEs
BLOM BASE P11 RII Pi 2atlSOL %AlE.1TP \ ii
EL 0'-B'
' � 3
MJO
_ r r GRADE I%6Ai PERNUTEA,PROVUEEANGERSWATCOPNwS
HZA HORNEH _-_•RASH E vI6 sTACREn iR'%InIr PAvwsAi EAcx CgiNFR STAG¢EDI&XV11ZPAVERSATEACHCORNw '
rl OTEL-TRASH AREA ELEVATIOWBUILDING SECTION
U SCALE.IRA-1-0
REVISION SEAL ARCHITECTS PROJECT LOCATION OWNER DRAWING DATA DRAWING NO.TITLE
GEay AECIIitBGl6.Inc. Hawthorne Hotel H & C Service PROJECT No.10014 TRASH AREA
AIEhjU pWre and
L:Ind6Gape Arcualectum Trash Area Corp DRAWN BY:D.L.A. ELEVATION/
SAN,Ma=g%w a,,OTe2D CHECKED BY:D.J.G.
SCALE:AS NOTED SECTION
EEJAaYi6G AN0UTEC S@i�66i�]9 18Salem,
$ ,W.
WashingtonQ 10 Colonial Rd.#4 DATE: 3/0/11
Salem, MA 01970 Salem,MA 01970 A-3 W O
NO. DESCRIPTION DATE
CITY OF SAL.EM9 jNLASSACHUSETTS
BLILDLYG DEPAIMONT
110 WASHLYGTON STREET, Y°Each
T-EL (978) 745-9595
Kl1®ERUY DRLSCOLL FAX(978) 740.9846
MAYOR M0.%LU ST.PMA"
DIREcroR OP PLeLic PROPERTY/BI;MOL-(G CONNISSIONER
Construction Debris Disposal Afl7davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cade, 780 CMR section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
l 11, S 150A.
The
71debris
swwill be transported by:
(name of hauler)
The debris will be disposed of in
jj
(name of rat:diiy
(JdEre o facility)
3's"fure orpermit applicant
zz Z- /
JJIC
CITY OF SALEM
PU13LIC PROPRERTY
DEPARTMENT
nn:, efl Y:n11K 1�11
i11 vt _
12C. ltrA1t$I.\(;It^SIVEL•T O )All'N,M.11f.11.I 11 V 11\v17J� '
Il.I. /7E711'li'IS r P,s v7N•/1C•na�ll
Workers' Compensation tnsurunce .witiaviC Builders/Contractors/Electrlcians/Ptumbers
'slMlicant to rrmation
PI
Volne I Iluunc sy Oraanualiont Indn,Juul1:
ildre.ss:
City,.Srare Zip
I'hune it: CPO y 06
.1rv) an.nlployer'!Check the allproprlate but;
I, I ;Im a dmpluyer with 4. I•)1»of project tirrqulred);
cnlpluyees(lull
aY r
ur pa— t-lillie).• ❑have hired the.uhJcl nir ollstatclr and e
a�ars
fi. 0 Kiiw ctawtructiun
'❑ 1 am a sole prnpriertir or partner- listed on rho anached sheet i y ❑Reirodolin`
.hip;old hrve no mnpluyecs Theao lob-contractors have
Linyself.
tier me in any capacity, workers' comp;insurance. g' 0 Demolition
ers'cuinp, insurance J. ❑ We are a corporation and its 9. ❑Building additiun
J ot►leen have enereiscd their 10.0 Electrical repairs or additions
mcuwner doing all work right of"4111ptioo per N(CL I LD Plumbing rcpuirs or additions
o gorkms'comp. c. 152,§101 and We have no
required•) r eropluydes. (No workers' 12.0 Rusafrepaire
' comp. insurance mquircd.l 12.0 011ler
•4nf.,�nrhrwe iher chdo boa el mum alms till uW the ucnun Wow aww.no The udiunwliw�
'I IM11rrwn rhY,Wlnul this rmdrVll indlulint I it wwlur'eun,r,lnuelan luaiey
h"Me a0in wurb ot Ilµwm'w w
hiHfldr rernrara'Wt iiYlenm a new Ased"it india,lint uwli.
(„Wlnwnr.Ihm Chills ihir bee m1 W�n>A°l,in a mt m
addniwn11,1►01'howine the nneN orthr lub•e01e1"mwa ,it thre MUIbe/a'rVn�,poley inawlnunll�
irI`/err an cnptoyer thatry Lr pvlr//nr worAeri'ru/nparrn/Ion hLrunmeafep my etnp/upeea Be/mv/a sAe pis/4y unr//rI siri
,1p/nr/vill
Insurance C•unlpany Vane^,&'�i ./ _
Volicy 4 or Sclr-ins. Lic.nl a ..� - --__
Expi anon Date;Jul)Site Addreis: �7� ,�,,v1n_`��/ . .. .
.lttaeA n cis City, IatuZip.
sty of the workers' eumpunsatlon pulley duclrratlon poste(sh wing the policy number and atpiratlun date).
I'alluru w sceure euseruge as required under Sccliun 2JA u1'NIGL c. 152 caa lead to the imposition of criminal penalliea of a
find uit nt SLJnO.tM y d/oristai uae-year nnprislnunent, as well as civil penalties in this turn ofa STOP WORK ORDER and a fine
of up rn i?SA.1M a Jay ituinst the riol.unc llc adviaed thus a copy of this slalsvinunt may be Iurw arde W the Ullice v►'
tin-:an�annnr uf;he I)1.\ .or mmru;ee;n�er.Iyu tcrilicanun.
/du h.•rrhy,;rli�y ranleY the p,ri mrd rnrri '
! r /her the in/urinrr/on prryidrtl abut-sr/a spite nerd a•orreet\i.t:libn: q
Irif/lriu/nse un/y, pa nor�yritr in this area, tube Completed by city of towN affi igL
I,suinµ .\ulhurily (eirela noe); Pcrnit/Lleense t _
I. IL,,IrJ of IlsvOh 1. Iluddill. Ucp.irtnn•nl :�k
u Cler J. LleefriralIs. IAharI Plumping Lnpccrar ,
i
I l'ni Llct 1%stunt
I'hune 7:
i
information and Instructions
tsars In the service of another utnler.ury covtnct of hire,
�g,ls;achu;eus General Laws chapet 152 rcywres all etnplo)ers to provide workers wInpensruon tot heir ct of hires.
I'ur.u.aft w sus,tatule.an emples•ee Is defined as"._every pe
,,pre,*Jr nnplicd, oral or written." o f ally two or more
to,•,npleper It defined]a"an Individual, Ilednership.association,carporafiun ur other legal entity, Y
rise, and including{he regal represe ty,e m to an$crop slo)ees.crilployet.Or the He*-ever the
,.I the IJreyJlllg engaged m ti ieml emery ant of the
ecetver or Itusee of.tit idiv,dual, panmershtp,asaoelauoo or other legal entity,employ '
none to three
maintenance,d wl auction of repair work on such dwelling house
owner of a dwelling house having{not more hee three aparemens and who resides therein.or the occupant
.Iwelhng house of anohar who employs fK
or on the grounds or building appurtenant thereto shall not because of such employment lx deemed to be an employer.'
.%tGL chapter 152. 4:SC(b) also states thrt''every state at local Ilcensbu dingsageac I shall om"A as " Issuance a or
ny
ce Uaaee wilh the Insurance coverage requlrad.'
renewal of a license of perntlt to operate,huilneas or to construct buildings la rho`ummo subdivisions shall
;tppllcant wile hoe not prod°lad acceptable
sla e$"Ncuher he otnmonw`%: d not any political
A,ditionully, sIGL chuper I S i-
aner into any euntrad for the Parfomwnce ul'public work until acceptable evidence ui cumPliwtce with the insurance
reyuirementa of his draper have been presented fo he contracting authority
AVV11coOta the boxes that apply to your situation and,if
etss scion atpdavit completely,by checking with than certifIcate(s)of
ple,nte gill out the workers' cutup es and hone nunsber(s)along with no employees other than the
necessary.supply.sub-contractors)name(s),address( )' D
workers' compensation insurance. if an LLC or LLP does have
insurance. Limited Liability Companies(LLC)or Limited Liability Pannenttipe lLL
ndustrial
member ar partners, are not required to carry
employees,ti policy ga required. as advised that thu�l�be sure be lfin aotd date the uflldavIL 111ent of lotlid°v t should
hcu fie for he permit or license is being requested, not the D-Putmant of
\ccidena for confirmation of insurance U coverage. the low or if you are required to obtain u workers'
he rearmed to the city or town that the upp ueatioas regarding
Industrial Accidents. Should you have tiny 4
compensation policy,please call he Daputtmcnt at she number listed below. Self-insured companies should enter thew
scif.insurance license number on the a ro tiara lino.
c'iry or'raw°Officials
rioted legibly. The Department has provided u sPua�he the
appbliaant.
Please tom
he surc that the affidavit is complete and p g ant.
Of dte afidavit fur you to lilt out in the event the Office of Investigations has to nce nui you regarding
licmu
in any given Year, need only submit one affidavit indicating current
I'IJase be sure to fill in the penniUlicense nwnbcr which will be used as a reference number In addition,an app
Iletl must submit mulliPler pennitilicatute applications be rovidcd to ho
policy information of necessary) and under"lab Site Address'the applicant should writ°"all ,nay e p o y
tuwnl.".\copy Of the ufflJuvit that has been of(1cWHY stamped or marked by the city or town may P
townapplicant as proof that a valid affidavit is tin file for ILtute Patmita of licenses. A now aflidavif nwst be Illled out each
grams is NOT reyuired to complete this affidavit.
year. ant as a home owner or affidavit
is ub n 11116l a license or Permit not related to any business or comnercia venture
(I,e. dug license or permit to burn leaves etc.)said P uu ha�c-LA uesuons,
I lu )I glee ul luvesfiyatitlna would like IJ dlank y'na In advance fur your cooperation and%ltUUld y Y 4
please du not hesitate to give us a call.
fhc U,Panment's ad lre+a, telephone and fax number:
The Comrnonwealth of Maswchuseta
Department of Industrial Accidents
0MCg of[avesdQadons
600 WasNngton Street
Boston, MA 02111
f ol. N 617-727-1900 ext 406 or 1.917-MASSAFE
Fax M 617-727-7749
www.man.gov/die