1 WASHINGTON ST - BUILDING INSPECTION (2) CITYQF�ALE� -
PUBLIC PROPERTY
DEPARTMENL T
1q.WE.LEV DMSCOLL
."Vm �,�('1 -6
���" 1 120 W Ncrtw'MEtT9S��97b�,`ssncx�'rs 01970
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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: Building:
- Property-Address - — — -------- —_-- -
Property is located in a;Conservation Area YIN Ao� _Historic District Y/N AL
2.0 OWNERSHIP INFORMATION
2.t Owner of Land
Name: ope*r-
Address: 1 (,,.-,4s/.:n.} �-. 5;f. a/ /
Telephone: 7 _7 3 7
3.0 COMPLETE THIS SECTION FOR WORK IN rmw wra 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 INew
Brief Description of Proposed Work:/
--- Mail Permit to: e 4 s Y5" on�+ oei`i7/ 11114-
oq(3z
What is the current use of the Building?
Material of Building? K dwelling,how many units?--�will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanics Name Fe- `f?� 26S-7255
Address and Phone ��d �Y C:1( A X1832 —
Construction Supervisors License HIC Registration# �Z
Estimated Cost of Proj $ 7-S&D. 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 I,
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Perm o build to sta
specifications. Signed under penalty of perjury
Date i Y- f
f v N
v
x d u
f
o.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xnuaE M Daacolt
MAYOR 120 WA20WON STRM a SALEM,MASSACHUWM 01970
T¢:978.7459595 •FAX 978.74x9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers
Applicant Informadon /- rr Please Print Leefbhr
Name(Busineworganiutiamhuivihw):
Address: 4f5
City/State/Zip: 44vev-lk (k M74 0L832- Phone#: 'F78- 2,CS �n
Are you an employer?Check the appropriate box: Type of project(required):
1 I am a employer with 2j 4. ❑ I am a general contractor and I 6, []New constructionemployees(f A and/or part-time).• have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet = 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp. insurance, g, ❑Building addition
[No workers' comp.insurance S. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers' comp. c. 152,11(41 and we have no
insurance required.)t employees.[No workers' 12.❑Roof repairs
romp,insurance Kid) 13.❑Other
'Any appaew that clerks two[#1 must iso till am the rection below showing&*works n-
t Honwowuma wbo anhmit tib aAldave Mating they an doing a8 wvrk and Aon Wre amide canumon must ahmU a can amdsvit to a"
tContraetosa that c6ak tib box roup attached an a"doml Ae t shawbg tba came of tba sub.eonnaaoa and their wOd ma'comp•pocky ht{amation.
I am an employer that Is providing workers'compensodon insurance for my
lnformadaa aaployees Below Is the po!!cy and Job rite
Insurance Company Name:
Policy#or Self-ins.Lie.#: �f3N�57 fZ
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
tone up to$1,500.00 and/or one imprisonment,as well as civil penalties in the forst of a STOP WORK ORDER and oties f tone
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.
I do hereby c un rhe p ' and penaldes of perjury that the informadon provided above is true and correct
Phone 4: �lg- SGS- 72-55
[6.0ther
l use only. Do not write in this area,to he completed by city or town o,/Jlclal
Town: PermittLicense#
Authority(circle ane):
d of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
t Person• Phone*
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an esspleYee is defined as"...every person in the service of another under any contractof hire,
express or implied,oral or written."
e r is defined as"an individual,partnersbiN assoeiat M corporation or other legal entity.or any two or truore
An sarpl y< ahp,nd including the legal representatives of a deceased employer.or the
of the foregoing engaged in s joint enterprise, entity.employing employees. However the
association or other legal
receiver or trustee of an individual•of mot than
and who resides therein.or the occupant of the
owner of a dwelling boons baving not more than three maintenanapartmentce,
work on such dwelling house
who employs persons m do ••"re„*.,r• coastntcaon or repair "
dwelling hoose of another thereto shall not because of such employment be deemed to be an employer.
or on the grounds or building appurtenant
MGL chapter 152,§25C(6)also states that"every state or Wed licensing agency shell withhold the Issuance or
renewal of a LLeettsa or permit to operate a business or to construct buildings im the Commonwealth for amy,
applicant who has not produced acceptable evidence of comptlaaee with the Insurance coverage required."
Additionally,MGL chapter 152,§25C('7)states"Neither the commonwealth nor any of its political subdivisions shall
contract for the performance of public work until acceptable evidence of compliance with the insurance
enter into any
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
supply (s)
sub-contractor(s)name ,address(es)and phone number(s)along with their certificate(s)of
neer ceLimited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
insuranto carry workers'compensation insurance. if an LLC or LLP does have
members or partners.are not sed that this affidavit may be submitted to the Department of Industrial
employees,a policy is required Alio be sure to sign and date the aindevk. no affidavit should
Accidents for confirmation of msutswe coverage. of
the application for the permit or license is being requested,not the Department
be returned to the city or town that
Should yet have any questions regarding the law or if you are required to obtain a workers'
Industrial Accidenb at the number listed below. Self-insured companies should cute their
compensation policy.please can the Department
self-insurance license mmtber on thea line.
City or Tows Officials
ted le 'bl . The Department has provided a space at the bottom
Please be sure that the affidavit is complete and printed Bi Y applicant
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the app
Please be sure to fill in the pertrtitfticenso number which will be used as a reference number. In addition,an applicant
icense applications in any given year,need only submit one affidavit indicating current
that must submit multiple perrttivi
information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
policy or marked the city or town may be provided to the
town)."A copy of the affidavit that has been officially stamped
by
is on file for future permits licenses Anew afndavir moat be filled out each
applicant as proof that a valid affidavit
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-
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 ns a call.
The Depacnnent's address,telephone and fax number.
The Coilimonwealth of Massachusetts
Depaltment of 1nduSttial Accidents
o®ee of Invesdgedolla
600 Washwgton StMet
Boston,MA 02111
Tel. #617-727-4900 ext 406 to 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www,t iuLgov/dia
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