0031 WASHINGTON SQUARE NORTH - BPA- -Q� PUBLIC PROPERTY
DEPARTMENT 13
MAYOR 120WAmNGwwh'ntEEr•
SAtI:K\ttiSSAQit;5tll5 01970
TEL-97s-745•959S 6 FAx 97s.740-9s46
.APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: / a S A -110:, SOL Building:
— Propert rAddress. ---------- - -
Property Is located in a:Conservation Area Y/N Historic DleMct Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: R&I
Address:
_ '3 wtnShIh
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
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
Brief Description of Proposed Work:
ixce, w 00 d Co t v YY) h
Mail Permit to:
What is the current use of the Building? /'r s+ v4 h 4 u
Material of Building? If dwelling. how many units? 3
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone Y
Mechanic's Name
Address and Phone ?� � J 7v'
Construction Supervisors License# 6l 9UU HIC Registration#
Estimated Cost of ad$ a 00,rT0 Permit Fee Calculation
Permit Fee $ Estimated Cost X$7/$1000 Residential
Estimated Cost X S41/51004
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 penalty of perjury
Date i I
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CITY OF SALEM
/ JX PUBLIC PROPRERTY
DEPARTMENT
tcndaEaLs,r uatscou
MAC`` uo VA9040 W S`rRM a SALEK MASSACJnJs&M o1WO
TM-VS-745"" a FAX M7e49W
Workers' Compensadon Insurance AtSdavit: BnildaWContnetor%Meetriciam/Mmbers
Applicant Intormadon Please Print Leatbiv
Name( dual): I e 7
Address:_
City/st&t9 ip: Ve,J a 1i— m A Phone N
Ara you as employer?Cloak the appropriate bast
1.0 I an a employer with 4. 0 I am a geaatal contractor and 1 1"of�1�( :
Jemployaes(iW1 and/or part-time).e have hired the sub-contractors 6 0 New e°°aoticgon
2.�'1 I am a auk poprietor or pattmao- lined on the attachod sheet t 7. ❑Remodeling
ship and have no employees These sub contractaa have 8. ❑Demolition
working for we in any capacity, workers'comp.insurance. 9.
q workers,comp.�ce s• 0 W�a�don and its ❑=addition
exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of c wnWdeon per MGL 11.0 Plumbing reWim Or additions
myself.(No workers'comp, c. 152,jl(4),and we have no
insurance required.)t employees.(No workers• 12.[3 Roofrepaim
comp,lonnatlae K4uire&) 13.0 Other l�4: ,2 ce&v n-n
;Any apyntant rut ahadu boa 01 area also as out the swdoa blow d oNaa dwir wmkma'
Hatttsowen who submn"aeldtva eldlesdag tiny as dabs ad wade d the NO atntdda eaaaaetaa Ana submit s saw aNdalt tCoeaaemn tom chak tbb bet net atnachad as additlael Am rbwiaa do ems artb aetp-ce etma d t6dr wa im-amp. Whansdon.
I am an lnl rmatiOA.�A l - if prOYldlnf WOlkera'C011r0enaOdOn lnrLIOIICf j0r my r npAopeet- Below is the Policy aNdleb alM
Insurance Company Name:
Policy N or Self-ins.Lic.N
Expiration Date:
Job site Address: City/strw2ip:
Attach a copy of this workers'cow
pensadoa policy decknWon pop(shOwiug 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 &
fine up to f 1,500.00 and/a one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER anti of Pee of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of&a of
Investigations of the DIA for insurance coverage verificatiolL
l do hereby cerdA under the pains and penalties osignature, 11e7 /Per/nrY that the lnjararadow provided abate it lone and coed
U
Phone N J-7 p 01 7
OQleW are only, Do not write its this area,to be cotap/ebf by cl y or town oQleiat
City or Town: Permitlldcense N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing inspector
6.Other
Contact Person: Phone*
Information and Instructions
Massachusett General Laws chapter 152 regitires all employ=tom ovide the service oft another uncompensation der any ofor�naact of hit%
Pursuant to this statute,an ewPtoyss is defined as ...every Person
express or implied.oral or written." MO
aasoeiauoa.eorpnacon or other legal entity.or any two at muter
oA.f the
n defined d ist an oirs vita,and including� g the�representatives of a deceased employe*.or the
of the foregoing engaged receiver of trusnas of an m&vAA partnership,association or other legal entity.employing erapioyeee H°weva the
owner of a dwelling bonne having nota three spotamns and who resides thereino or the occupant of the housedwelling house of another who emPlnYs Peraone toma do intenance:con on or�work on such dwelling
err on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an enploYW-m
MGL chapter 152.¢25C(6)also sates that every state or Ined Standoff agency sbat w'UhWd the issuance or
opera"a business or to construct buildings Is the commoawes"fee any
«aawd of a tleetite or perstt d cceptable evidems of eomptlaaee wl&the furerann eaverags regnlred."
applicant w M Prod S"23C(7)state-Neither the communweahh not any of its p H"with subdivisionsthe s shelf,
Additional►y, states
ct ft the paftmanm tpublic work until acceptable evidence of comp
liance enterdds chapter have presentedto the contracting audtority
req
Applicant
Please fill out the wodm a compensation affidavit completely,by checking due boxes that apply to you r aituatios and.if
necessar of
y.supply sub•connut°r(s)name(s).address(o)and Phone number(s)along withwithth no anployeess)other than the
insurance Limited Liability Companies(LLC)or Limited Liability n insurance.
(LLB
to carry workers'compensation mavra°CO an LLC or LLP does have
emembers or Pffilt0gre,am not required a Bo advised that this affidavit may be submitted to the Department of Industrial
Accident far
confirmation of insurance coverage Abe be sate CO saga and date the aflWIMrequested,
L The affidsvit should
not the Department of
be returned to the city or town that the application fin the permit or Ho me s is being 4n �
udustrin Aaaidenta. Should you have any qu ark regarding the law or if you are required m obtain a workers'
compensation Policy.Plea call the Department at the
number listed below. Self-insured companies should enter their
se
self-insmanee license member on the
City or Town Of16Cfak
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 dltcegarding the aPPHCMt
ens the ue CeDt�wee ohich�be used as a�e race numbervestigations has to contact you s In addition,an applicant
Please be sure to fill in the permi licadons is any given year,need only submit one affidavit indicating current
that must submit multiple permiV1tc"se app the applicant should write"all locations in----(City°r
policy information(it necessary)and unbar"Jab Site AdampedMe PP the city or town may be provided to the
town)."A copy of the affidavit that has been officially stamped it marked se tY
s on file for litttre Permit or licenaea Anew affidavit must be filledvsuttue
ut CAGb
applicant ss proof that a valid affidavit' e LCeese or permit not related to any business or commercial year.Where a horse permit
or citizen is obtaining is NOT required to complete this affidavit
' to bum leaves ere.)said parson
(i.e. a dog license�permit
ns would like to thank you in advance for your cooperation and should you have any questions.
The Office of invesdgatio please do not hesitate to give au a call.
The Deparmsent'I address.telephone and fax number
Thu Commonwealth of Mmuh»sett
Npat� um of Iadl>oW Accident
otAet at invesdVidena
600 WLAM90001 Street
Bastono MA 02111
Tel. #617-727-4900 Cd 406 or 1-877-MASSAFE
Fox Al 617-727-7749
Revised 5-26-05 1 wwaimgov/dia
CrtY OF SALFu
PUBLIC PItOPEM Y
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