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APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT/ AND 2 F.9MILY DWELLINGS J
INIPORTAN'l,:Applicants,must complete all items on this page
SITE INFORMATN II
Location Name SIO kr4' 4K&-+N SQ. Building Wry-&, lM 1'T
Property Address
Map p
Located in: Conservation Area YYN Historic distri Yi
Use Groups
(check one)
Residential(3 or more Units) R2
Type of improvement Residential(hotel/motel RI _
(check one) Assembly('churches) Al _
New Building_ Assembly(nightclubs etc) A2_
Addition - Assembly(restaurants, recreation) A3_
Alteration _ Business B_
Repair/Replacement_ F,ducational E_
Demolition_ Factory(moderate hazard) FI _
Mole/Relocate Factory (low hazard) F'2_
Foundation Only_ High Hazard If_
Accessory Building_ Institutional(residential care) I1 _
Other(describe) Institutional(incapacitated) 12_
Institutional(restrained) 13
Mercantile :rl_
Storage(moderate hazurd) S I _
Storage(low hazard) . - S2_
OW NF.RSIIIP INFORMATION(Please type or Print Clearly)
OWNER Name _
Address
Telephone g
DESC PITON OF WORK'1'O Bic PERFORM :)
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ES'1'LNA"f1iD C.ONSTRUC'r1ON COST .__�D� ✓w.._._-- _
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CONTRACTOR INFORMATION /
Name b _
Address 7 Y f ( � 4 c5 �l
Telephone
/'78 KLff GL(sZ
Construction Supervisor's Lic # 07,1 o 7 3
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION _
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signed
Date 0
CITY OF SALEM
PUBLIC PROPRERTY
a � DEPARTMENT
Jai,M:1 1 :1N19(.'I 1
MN ut 12L W,viftl\t.H).\SI:IEL'I' • SA tvt,M.\ll.\(.III it 1 Isu197,^,
Tcl: 778-713-9595 is F.tx. 978.71G7846
Workers' Compensation Insurance %ffidavit: Builders/Contractors/Electricians/Plumbers
\ ) tlicant information Please Print Leeihly
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Address:
City,State,Zip- ItPhonei': �70 d bzr
i
:tire too an employer? Check the appropriate box: 'Type of project(required):
1.❑ 1 ;,,it a cmpluycr with 4. ❑ 1 :un a general contractor and t 6. ❑ New construction
eny>loyces(full andifur part-tinic).• have hired the sub-contractors
listed on the attached sheet. , 7. ❑ Remodeling
2 1 out a sole proprietor or partner-
ship;Intl have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9- ❑ pudding addition
INo workers'comp. insurance 5. ❑ We are it corporation and its
I required]J.]
officers have exercised their 10.❑ Electrical repairs or additions
ri•ht of exemption per MC7L 11.0 Plumbing repairs or additions
3.❑ 1 :lilt a homcuwrke doing all work c Sl 52, s 1(4),a nd w have no
myself. (No workers* comp. ) I2.❑ RuuCnpairs .
insurance required.] t employees. [No workers' 13.❑ Other li
comp. insurance required]
•u% .yloicaul tlutt cheeks box III must also fill out the seclian Is,luw shuwina their wurkws cumpcnuaion policy inliumutium
I I somcuwttan who submit this a17idavir indicmina they am doing all work and then him outside cuturxtom must submit a new arrdavil i...liuims such.
-C.,mrnturs that check this box most auachcd.m additimal s11,vt shuwina the wunc of the tub.onlra fors and then workers'comp,policy mfurmantin.
l anf an employer that is pro vidint;workers'compensalion insurance fur my emplayees. Belnry is the pu/icy and job site
Insuraucc Company Vnme:� - - -._.._...._..----------
Irolicv 4 or Sclf-ins. Lic. ,r.: . ...___ Expiration Date:
Job Site Address: It City;state/ZiP /'t
Attach It copy of life workers'co npfimaliun p cy declaratiol page(showing the policy nuenbcr and expiration date).
Failure to ,,curc coverage as required under Section '_5A of klGL c. 152 can lead to the imposition of criminal penalties a a
tine up to S1.500.00 anl'ur one-year imprisoninent,as well as civil pcnalucs in the Lunn of a STOP WORK ORDER and a fine
,if up to S250.00:t day ,Igaiost file violamr. Be advised that a copy of this statement may be forwarded to the Office of
111% of the DIA for insto: rcc :ovcragc verification.
l I/o herrhy c erlifp u e -- IF urins fn nahiev of perjury that the infurfnalion providedafe is I ue rout c'arrect.
(o
U/Jiciui use filly. Do nnl write it,this area, to be completed by city up town officidt.
Cifv or Town: _-_ __ Pcrmitll.icensc At
6suin,,,, Aulhurity (circle one):
I. 1{oard of Ilcalth 2. Building Departrucut 3. Ci1,i A'tfu Clerk 4. Electrical Inspector 5• Plumbing Inspector
6. Other
Contact Pcnua: _. _._ Phone it:
Information and Instructions
..Vassachusetts Gcnerul Laws chapter 152 requires all employers to provide workers' wmpen,ation for their employees.
Pursuant to this statute, an employee is defined its "...every person in the service of another under:any contract of hire,
c%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
or the loreeoing engaged in a Joint enterprise, and including the legal representatives of a deceased cmpluyer, or the
receiver or trustee ul .al 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."
.%IGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewul 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"Neithcr 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 In escnted 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 nuntber(s) along with their certificatc(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 number on the appropriate line.
City or"town Ofticlats
Please be Sure that the affidavit is complete and printed legibly. The Department has provided❑ space at the bottom
of the affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennittlicense number which will be used :is a reference number. In addition,an applicant
that iml.%submit multiple perinit/license 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 rile 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
the i)IfKc of Investigations wuuld like to thank y'ou in advance fur your cooperation and should you have:my questions,
plea,e du not he-skate to give us a call
ncc D,:paruncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OtHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
x, ,%cd 5-sir-u5 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR'CA.IENT
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Construction Debris Disposal Affidavit
(rctItihed lirr all dunolition and rcnow;niun work)
In accordance a it, the sixth edition of the State Building Code, 78U CTIR section 111.5
Dcbris, and the provisions of MGL e 40, S 54;
Building Permit f! is issued with the condition that the debris resulting from
(his work shall he disposed of in a properly licensed waste disposal laciIity as defined by MGL c
I 11, S 1 5UA.
The debris will be transported by:
1 name of hauler)
the debris will be disposed of in :
Ls fdl��
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(nulnr ul laultly)
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�addrea.ut larlluyl
.Ignatwc of p.nnn .gtpllcant
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