276 WASHINGTON ST - BUILDING INSPECTION f
n.
CITY OF SALEM
�W,- 7' PUBLIC PROPRERTY
DEPARTMENT
KntaERLEY DRucoLL
MAY0a
120 WA2w4GTQNSTREET a SALEN.MAnAcKusErlsoiwo
TEL-9M745.9595 a FAX:978-740.9$46
Workers' Compensation Insurance Affidavit: Bustden/Contractorsmeetricians/plmnben
Applicant Information PI ase Print Logibly
Name lBusineaaro�o;auoo/Indiv;AtalY��-�� < <p .R�����"_,,. ,�
Address: `'»
City/State/Zip:1 %�_.(\ �cn Phone#:__
Are you AS empbyart Cheek the appropriate bast
1.®.I am a employee with—1p., 4. ❑ I am a genera7and
and I Type of Proles(required):
employees(full and/er past-time).• have hired thxom 6• ❑Nee'construction
2.Q I am a sole proprietor or parmao- listed on the at,t 7. Q Remodeling
ship and have no employees Theme S. Q Demolition
working for me in any capacity. workers,com .
(No workers,comp. insurance S. Q We are a corpts 9' Q . addition
required.) officers have exercised their 10.❑Electrical repairs or additions,
3.Q I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or addiduce
myself.[No works='comp. c. 152,§1(4),and we have no 12.Q Roof repairs
insurance required.]t employees[No workers• 13.Q Other
comp.insurance required.]
*AM'appaeam On Chair boa#t amet a" out the wdm babw sl owioa drlr aarkan'
liawuownws who mbm&tbb aeWavit�
aa a rust•�.doing as antic and ulna itka cupids aicbata must wbmtta aw,A►drvy
tCoaetM slat clack We boot mm amehod ore addftlamk slat showing er nun ottha mbeoouacton and uhak wakwa•oamP -.
'f am an employer that Is provfdlnj workers'compeRradon issareneajor my employees Below t:sire Policyand Job tip
lnjormadaa
Insurance Company Name: �O Va �
Policy N or SaWins.Lie.b �l �� , Expiration Date-
Job site address:_- . � istitWZi :h p
ci --
Attach a copy of the workers'compensation policy declaration page(shawls the
Failure to secure coven as [ Polley number and expiration date).
[e �N�d under Section 25A of MGL C 152 can lead to the imposition of criminal pennities of a
fine up to S 1,500.00 and/or one-year imprisonment•as well as civil penalties in the form of a STOP WORK ORDER and a}ins
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o f
Investigations of the DIA for insurance coverage verification
f do hereby cerrdJjp andeer die pains and pens/des ojper/aty that the injormadon provided above is true and coffee&
Signature: 4& n '/�
_ Date � ' �0'1
Phone I/• �1� ^ �"��� —��'�-1')
ogkW use only, Do not write bs thb area,to be completed by clip or town oQkid
City or Town: PermlNLicen"M
Issuing Authority' (circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone p
Information and Instructions
employees-
Massachusetts m General Laws chapter 1 S2 all MPloyers to provide workers'compensation for
thei
r r rmaployex.
�� napt to tins stature.an eehpfeyee 1a defined as"...every Person in the service of another under any contract of him.,
eXprcus or implied.oral Or writtaa." two ex mom
"an individual.pertoershhp,association.eon°Om or Other legal entity.or an or the
Of
hef0t yet is defined ns veer of a deceased employer,m a joist et+taprise.and including the h god representatives
However rho
re the es or tr m engaged GM the association at other legal entity. therein.accru Occupant e of the
receiver or t:tirtee of m individual.PereeiCta�
owner of a dwelling who having PuiO°s to do maintesnamce.constnheson or w to �lo "
dwellinil house such dwelling hOmw
of anther mereb shall not because of such employment
or on the grounds or building appurtenant
MGL chapter 152.42SQ6)also states that"every stab Of local lloeasing sileacy shaft withboid the
learre
pesnb a business or b coach ner buildings Is the eommoewes"for ray
re"Wal of s atom or permit to�e 2t*11 business
o[eompllates with the inaurases coverage regtdred-
a Yeast wbe bee art produced wealth nor any of its political subdivisions shall
Additionally.MGL chapter 152.J25M states"Neither rue coremno lo evidence
of compliance with the insurance
into an contract fen the performance of public work until accepbb
emter�ma of this chapter have bien presented to the conuscona audhorhty"
req
Applicio1a l to our situation and.it
Please fill out the wodrese eompenseteII affidavit completely,by chaoiting the boxes that apply Y
a addreas(es)and phone numbers)along with their castifiesce(e)of the
necessary.supply sub•coemacr°s(s) a<(Ly�er Limited Liability Patmerships(LLP)with no employes other than
insurance. Limited members partners.Liability Companies requiredto carry wad=l'cow insurance. an LLC or LLP does have
are notd. Beated that this affidavit may be submitted to the Department of Industrial
employ, s Pew is Hof insurance coverage. Ake be sure b sign and dab the af[ldaviL The afidavit should
Accident for confirmation of
be returned to the city or town that the application for die permit er license is being requested,not the Department
re die law or if you are required to obtain a workers'
Industrial Arc Policy,Please call theld you Department at va sm the number listed below. Sslf-insured comPMM should enter duff
compemsetiO6 Peym,
self-insurance license"umber on the MEZIM
City or Town Otficlalo has Provided a space at the bottom
Please be sure that the affidavit is complete and printed legibly. The Department
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant•
of thsa affidavit
wire to fill in then out in the evse ent
which will be used as a reference number. In addition,an applicant
applications in any given year,need only submit one affidavit indicating crnssent
that must submit multiple perms under
and"Job Site Address"the applicant should write"all locations in_(city or
policy. (if neeeraary) or marked by the city or town may be provided to the
town)."A copy of cue affidavit that has been officially stamped to or licenses Anew aCudrvir mart be filled out each
applicant as proof that a valid affidavit is ore file for tbtute perimi or commercial venture
year.'Where a home owner or citi business
zen is obtaining a license or pemtut not related to any
(i.e. a dog license or Permit to bum leaves cre said Person is NOT required to complete this affidsviL
ou in advance for your cooperation and should you have any grrradons.
The Office Of hhvertigations would like to drank Y
Please do not hesitate to give us a call
The Department's address.telephone TM fax
of Massachusetis
Department of b&'Md Accidents
p®a of invadEadons
600 Washington Street
Boston,MA 02111
Tel. N 617-727-4900 ext 406 of 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26.05 www.m83S.8ov/dia
CITY-op-3= --
PUBLIC PROPERTY
DEPARTM NT
•'X • XAssAtHLStTiSOt970
TEL 976745-9S95 1 FAx V&740.9W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION, -
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EMSTINGI,
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: : '.,N Building:
-.--- Property Address:-
Property Is located in a;Conservation Area YIN_ Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land \
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN �nATlurs 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 New
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building?
Material of Building? if dwelling.how many units?------ —
win the Building Conform to law? - o Asbestos?
Architect$Name
Address and Phone ( )
c �
)fit�c1 C''Jw�i
Mechanic's Name
Address and Phone
Construction supervisors license 0
HIC Registration* \h�—
Estimated Cost of Project$ ��� Permit Fee Calculatlom
Estimated Cost X$71S1000 Residential
Permit Fee S
Estimated Cost X SitlS1000 Commercia4-------- - -
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
0
y N
p L y
D ` A
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y S
- �_ —
i
CITY OF SALEM :f
PUBLIC PROPRERTY
� 4 I DEPARTMENT
n�ui�eni.er unisrcd.t.
xlaror. 120 WA,rnxcrON Srxear♦ SAI FM, MASSACHI:SI�nS 0197C
Trr:978-745-9595 ♦ FAX:978-740-9846
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 of MGL c 40, S 54;
Building Permit # __ is issued with the condition that the debris resulting froth
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:
i
--_ f hauler)
The debris will be disposed of in
(nam-e o a
(address of facility)
signature of permit applicant
/ / 1 07)
(late
dchms, fl.due