0031 WASHINGTON SQUARE NORTH - BPA DEPAR'TVIENT
KIMBFIMEY DPJSCOu.
MAYOR I2V WASHiw.-TON SIREEI♦S AtYK%tA15ACJ4L'SFIIIS 01970
TFt 978-745-9595 • FAM 978-740-9946
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION77 77 T 7/'/
Location Name: Building:
Property Address:
Property Is located in a; Conservatio Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Landg ✓�
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition axist[ng
Approximate year of Area per floor (sq Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
6 vrf2
!2 ),0O Z liv< lCl2Gt_
- _
Mai[ Permit to: c
What is the current use of the Building? A'nA ' 3
Material of Building? - 691c& If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name Z2 a
Address and Phone v/1 6 ��W HIC Registration# 41
Construction Supervisors License#
Estimated Cost f Pro $ � Permit Fee Calculation
Permit Fee Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 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 penalty of perjury
Date
OI
a
F v >
u =
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERIEY DRISCOLL
MAYOR
120 WAsHNGToN STREET a SALEM,MASSACHusEr s 01970
TEL.979-745-9595 ♦FAX:979-740.9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lembly
Name (Business/OrganizatioriUdividual):
Address: ,/ 0✓ All LnA —
City/State/Zip: 6J,1 �A.e.---- Phone #: q 2 S-7& Q V -77
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4: ❑ I am a general contractor and I Type of project(require
2.0employees(full and/or part-time).+ have hired the sub-contractors 6. ❑New construction
I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.[I Plumbing repairs or additions
myself. [No workers' comp, c. 152, §1(4),and we have no 12.❑Roof re airs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.❑Other f�(
+Any applicant that checks box#1 must dent fill out the section below showing their workers'compensation policy infommtioa Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors must submit a row affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information
t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach 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
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
-o hereby certify under the painsand penaldes of perjury that the information provided above is truce and correct
Si natur • J Klam oi✓ Dat /aZ.:� d,6
Phone#: �i 7 rfi ' S 7 pj — p y 7 7
OJj7cid use only. Do not write in this area,to be completed by city or town oJjlciaL
City or Town: Permit/License#
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
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fort act ofloye s:
pursuant to this statute,an employee is defined as"...every person in the service of another under any
express 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 a employs o do maintenance, e tion or ntb
work on such dwelling house
or on the grounds or buildingPpurt � � shall not��of suchmploymeetbe deemed to be an employer."
MGL 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 in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL 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 with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and if
necessary,supply sub-contractor(s)name(s),address(es)and Phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLQ oor�L Limited Liability
Partnerships(If an or P)with no employees
does have
�the
members or partners,are not required to carrycompensation
s affidavit may be submitted to the Department of Industrial
employees,a policy is required. Be advised that thi
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 number 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 fill in the permitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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 the 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 filled 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for 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
Offlee of Invesdgations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
�- PUBLIC PROPERTY
DEPARTMENT
�tAYOa - IMWASmnt=(W SIM"#q"m Nfws�ncmu:sens0t970
T9L.976-74i9S"*PAX.978-74&9&4
Construction Debris Disposal Affidavit
(required for all demolition and mwvation work)
Ia accordance with the sixth edition of the State BuWns Code.780 CMR section 111:3
S.and the pmv
Debriidons of MGL c 40.s 34;
Building Permit Al
issued with the condition that the debris resulting ftm
this work shall be dispose d of is a pmpedy licensed waste disposal&c'Uty as defined by MGL c
111.S 130A.
The dews will b/e'transported bar.
(nsms of tooled
The debris will be disposed of in :
/hello � 67j
(name of iluy)
dLo
( of facility)
%pate of permit applicant
dj•
,telsi.am7:dne /