140 WASHINGTON ST - BUILDING INSPECTION (2) What is the current use of t e Building?
Material of Building? H dwelling,how many units?
Win the Building Conform to Law? Asbestos?
Architeas Name ti n n
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# CS 0�t;-4IL4 HIC Registration#
Estimated Cost of Project i 'W() Permit Fee Calculation
Permit Fee s Z S- — Estimated Cost X$7151000 Residential
-- - - _ .- -- - _- — Estimated Cost X it1/$1000 Commercial-------- -
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to b Id to a above stated
ific
specations. Signed under penalty of perjury X
Date _o
VI
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CITY of
PUBLIC PROPERTY
DEPARTNMNT
a4l
MUrae 130 WASUNcmN hrXWF "LAMk%LASSA01lSlYIS 01970
TEL-r 474S-9S9S•FA=M7404M
APPLICATION FOR THE REPAIR. RENOVATION,CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: aumng:
-Property Address -1Z5rt - --
Property is bcated in a;Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: IL40 t w
Address: --f V
l c, � A i � - ""'"'"4�Dow ..G(q(�
Telephone: 00 po
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation t qqC)
of existing building New
priPf Description of Proposed Work: (
--- - ---Mail Permit to: , --
CITY OF SALEM
z ,.1r i PUBLIC PROPRERTY
1'' -;=-�r' DEPARTMENT
rilUI1:�.RLIiY URI1(:O1.1
MAYOR 120 WASHING fora STREL'T• SALe\e,MASSACf It serfs 0197.^,
'fta_978-745-9595 • FAX:978-74 9846
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/oreanizationllndividuul : 4
Address: O (no
City/State/7..ip: Phone �� - U�
Ar you an employer! Check the appropriate box: "1'ypc of project(required):
I. I am a employer with 4. ❑ I am a general contractor, and I 6. New construction
employees(full and/or part-tine).` have hired the sub-contractors 7 t$Remodeling
2.❑ I am a sole proprietor or paMer- listed on the attached sheet. t
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
'No workers'comp. insurance 5. ❑ We are a corporation and its
P•
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work g exemption
right of per MGL 11.❑ Plumbing repairs or additions
Pon
myself. [No workers comp. c. 152,y t(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
'Ally applicant drat checks box All must also lilt out the section tut ow showing their worker compensation Put y in0xmutiun.
t 1 tomcuwm;n who submit this affidavit indicating they are doing all work and then hire outside coin actom must aubmit a new;I fill davit indicating such.
�Commctors that check this box most.attachtxi;m additional shun showing the name of the sub-contractors and their workers'comp.policy information.
/ant an employer tlmt is providing workers'compensation insurance fur ray employees. Below is the policy and job site
inforntraion. L
Insurance Company Name:
Policy 4 or Self-iris. Lic.#: _—.__.._.......,_________.— Expiration Date:
Job Site Address: City/State/Zip:
Attach it copy of the workers' compensation policy declaration page(slowing 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 S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. fie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage varitication.
1 do hereby certify a der de�
rains and penalties of perjury that the information provided above is true and correct.
Sienawre: Datc'
t h e t a :�)te 2-Z- r)Q.ri )
FFOfJi,cialusely. Do rant write in this area, to be colmpleted by city or town ojjicial.—...__ Permit/License# --ity (circle one):alth 2. 1uilding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact 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 errrplgyee is defined as"...every person in the service of another under any contract of hire,
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 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."
b1GL 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 lieen 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(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 confimnation 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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/licease 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 tilled out each
year. Where a homeowner 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 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-2�-os www.mass.gov/dia
CITY OF SALEM
SO
PUBLIC PROPRERTY DEPARTMENT
\I.ut'K 120 W.\y IrVG:JNSCREET SAU:%1, u .LCIi
'rFI:976-745-1595 &f.%X:972•7iG9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit # _ ., ._ 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 MGL c
111, S 150A.
The debris will be transported by:
- --- (name of hauler)
flie debris will be disposed of in
(name of faaihty)
— IaSdrrs. of fadLt,/)
or ]i 1 lIc SI]1),IC1Jl
1Id