71 WEBB ST - BUILDING INSPECTION (3) What is the current use of the Building?
Material of Building? l� VT If dwelling.how many unitsT
Wig the Building Conform to Law? I Asbestos? Ald
Architeas Name
Address and Phone o ( I
Meohanids Name f�GUZI C t1 I/C'Fz L
Address and Phone 1-✓ HiC Registration a� /S� D
Constnrction Supervisors License S
Estimated Cost of Pro* iS �°� Permit Fee Calculation
Permit Fee S x4znl- Estimated Cost X$7/111000 Residential
-- — — Estimated Cost X$41/51000 Commercial---------
An Additional $s.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays In processing.
fThe undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date Z 7
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EITx-OF- ALEm - -
PUBLIC PROPERTY
DEPARTMENT
120 WA9wWMW MMr•1U0k MWACHMI-TS 01970
Tm-976-74S.9SM•F.=M740.9W
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION.OR CHANGE OF USE OR OCCUPANCya FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Prop" Addresw---
------
Property Is bested In a; Conservation Area Y Historic Dbtrkt Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 1368 V Al ot/ Gi s'
Address: -7 j � �� f
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN E7(ISIING 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 94a
of existing building New
Brief Description of Proposed Work: /
Mail Permit to: l/r-J 7 WV tr4 /�
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1?C W,%V 1tW::JP S.lElT 1atF V,MAN&u::u .hs'ls
Ttt.w w4s-im •F ut:-OMAC-9W
Construction Debris Disposat Affidavit
(required for all demolition ux1 renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CNIR section 111.3
Debris, and the provisions of M. GL c 40. S 54.
Building{ Permit N _ . _ 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 N1GL c
111, S 150A.
The debris will be transported by:
P W-,? f C,(-Tx�
— — (sums of lmuler)
TheJcbriis/will bee disposed ofin
fit/
a f( -51
(.runs ut'iacilsty)
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+ddre,> of tSciLtyl .
_ ��le -7
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wHIflFR[F.Y ORMOLL.
�I.vvcta 12CWA%m %r;raNSraEETaSAum.MAssAc:in.xernot9r
The_9711-743.9595 •FAX:9M7410.9t4e
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anallcant Information Please Priint�.Leeibly
dame tduainem/OrWizatioNlndivulual): (�)refT
Address:___ _ S�D S-14-
City/Statelzip: .St 61 e-t� lam/- Phone tl: 72f—
Are you an employer!Check the appropriate boa: Type of project(required):
1.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. [3 New construction
empluyces(full and/or part-time).• have hired the sub-cumnctors
2.0 1 am a sole proprietor or partner- listed on the attached sheet : 7. Remodeling
ship and have no employees Theca wacoatractors have S. ❑ Dernolitieut-
workin for me in an ca ao it . workers' comp. insurance
g Y P Y 9 0 Building addition
required.]
ired.]worit 'comp. insurance 5. We are a corporation and in 10.0 Electrical repairs or additions
rcquirttlJ officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. Ito workers'comp. c. 152,¢1(4),and we have no 12.0 Roof repairs
insurance required.] t employees.(No workers' 13 �p/�4idS
comp. insurance nq .❑ Other
uired.J - /9U/ t /
•Any;,,plicaut that checW box el must at**tilt nut the metiao bcluw towing that iviela s'eump awtiun pulmy inAanata wa,
'I temw,wnnm who submit this amdovit incilming they an;cluing all wmlt and than hoc oussi1M eoninniom mwa auhnit a row amdavil indicuting arch.
-C. ratwn that cheek this bast mum anaclad m adttitiawd Jntsl Jawing ale nano of rasa muUeontraeton attd that workom'comp.palmy inlartnadoe.
EM
i am an mnployer that/s providing workers'compensaton insurance for sty employees. Below is the pa/icy and job site
informmtiaa
Insurance Company Name:
Policy q or Self-ins. Lie.0: __. .. .___ Expiration Date:
Jul)Site Address: CilytstatuZip:
Artach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to wcum coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or onayear imprisonment, as well us civil penalties in the form of a STOP WORK ORDER and a fiat
of up to 5250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Imv.,itgauuns of the DIA for insurance covcragu vcriticatiun.
/do hereby certify wader the pains and penalies ufperjury that the information provided above is rime and correct.
Date' �/S�0 /
Pia na:g:
r)/khd use anfy. Do not write lit dds area,to be completed by ely or town a leimi
City or Town: __ Permit/l.1cense M
Issuing Authority(circle one):I. Board of health 2. Building Department ). Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Cuntacl Person: _ . --- Phone M:
I
Information and Instructions
Niassachusetts General Laws chapter 132 requites all employers to provide workers' compensation for their employceL
Pursuant to this statute.an employee is defined as"...every person in the service of another under any contract of hire,
etpress or implied,oral or written."
An noployer 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.parmer16411.association or other legal entity.employing employees. However the
owner of a dwelling house having not more than three apartnenb and who reaida therein,or the occupant of the
dwelling house of another who employs persons to do maintenance.cunstruction or repair work on such dwelling house
or on the grounds or building appurtenam thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152.¢25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renews,of a Bees"or permit to operate a business or to construct buildings in the commonwealth for any
applleant wbo ban not produced acceptable evidence of compgan*e wills the insurance*overage required."
Additionally.MGL chapter I52, §23C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract fat 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 rill out the workers'compensation affidavit completely,by checking the boxes that apply to Yoursituation and,if
necessary.supply subcontractors)name(s),addm*cs)and phone number(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
,elf insurance license number on the appropriate lire.
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 mint submit multiple permitilicense 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 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.
1'he Otlicc of Itnvestigations would like to thank you in advance for your cooperation and should you have any questions,
please do nut hesitate to give us a call.
The Dcpamnent's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
O®ee of Investla„dr."
600 WashingM Street
Boston, MA 02111
Tel. #617-72749M ext 406 or 1-977-MASSAFE
Fax N 617-727-7749
Rev iacd 5-26-05 www.mass.gov/dia