121 WEBB ST - BUILDING INSPECTION (3) � l
51L/P1sIl" P
What is the current use of the Building? I
Material of Building?6,, /OC2 (" If dwelling.how many units?
win me Building Conf "to L w? Asbestos? '�f>
Architeds Name 6
Address and Phone l )
Meehanies Name
Address and Phone
constn,ctia+ Supervisors License#-� �st- v HIC Registration# S
Estimated Cost of Project S a�O O PennR Fso C"istion
Permit Fee i C�fso J Estimated Cost X$7/$1000 Residential
Estimated CostX$i 1/$1000 commercial--
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An Additional $5.00 is added as an
Administrative charge. d-
Make sure that all fields are properly and legibly written to avoid delays in processing. r 0
The undersigned does hereby apply for a Building Permit to bVabovespecifications. Signed under penalty of perjury XDate
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CTTY OF SALEM
PUBLIC PROPRERTY - -
DEPARr-"-NT
%LM IL ldC v.�e eat::onus Uff•iueti NAgLM2'►*&Ib::0.
T>tt:YOt•7�•i•91b�f.�tt:9i7N�6+te1�
Construcdos Debris Dbp"of Affidavit
(required for all demotitioa ad tum"ation work)
Is at:eadance with the sixth edition of the State Handing Coder 730 0,11 section It 1.5
Debris,and the ptoviskum of M. GL a 406 S 54.
S%dl& H i amb 0 _ is issued with the condition dust dbe debris resaldng fan
this work shall be disposed of in a properly licensed waste disposal fbeility as defined by WIL e
I t I.S 156A.
rho debris will be u-mspocwd by:
rho debris will be disposed ofin :
nt„tte„r rka�ry)
4
`. CITY OF SALEM
- PUBLIC PROPRERTY
DEPARTMENT
bulOratry u1ltM4 LL
xi%ytas 12d sAtllt,►tassnan.rt7-rotg7s
Tbsa 97$.745.9595 o Fax:9M740.98e6
Workers' Compeasadoo Insurance Affidavit: Builders/Contractors/Electrktans/Plumbe»
.Applicant InformationeasePrfut L
eeffly
Name lkluvnvtslOrsatlirariorHtmllvldtnll:
Addrtss:
CityiSMWzip: [ p: g
Are you as employer?Cheek the appropriate belt
rype ofptrojeet(required):
1. 1 am a employer with 4. ❑ 1 am a general eonfraetof and I 6
employees(full sndtur part-time).• have hired the sub-cumrectors ❑dew c°nYtruetio°
2.Q 1 am a sole proprietor or partner- listed on the attached sheet. t 7.�Remodeling
ship and have no employees Theca cob eotstraatoes he
g. ❑Demolition
working forme in any capacity. workers*comp. insurance.
(Ko sockets'comp. insurance S. Q We are a corporation and its 9. Q Bud�rtg rtWititra
squired) officers have exercised their 10.Q Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I l.Q Plumbing repairs or additions
myself.[ro workers'comp. c. 132.4l(4),and we have no 12.Q Roof repairs
insurance required.)r :mploycc& [No workers' 13.❑Other
corals. insurance squirod.J
any VPkcnm the chucks bas e1 man also rill out dr section twice ahowiaa flair wakes•cwnpeartiw porky iofi asajwa
I Iw WIII re who WNW indimi g ewy an duina in wxk and then but amide eoonoctaa nowt•Ubmil a new aflubvit indicating a h.
•C.xant4m that cheep Ow brat now aaadsol as admtiaei abort.bowing tke near of die n&Mntragon sad tbeir wurkers'coup.policy innxmatlna
/um an ernployer that Is pros". workers,cam ens„den barurvace for r„y employees. Be%w is the par/fay„nd job sife•�
- «.
Insurance Company Vame:_ _ (,
Policy Al or Self-ins. Lie. p: zoo �,�. Expiration Date:
dub Site address:� - CilyrSlaluZip:
Attach a copy of the workers'compensation policy dodaration palls(showing the policy number and expiration date).
Failure to as:cure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of
tins up at 51.500.00 and/or one-year imprisomncnt,as well as civil pcnaltin:a in the form ora STOP WORK ORDER antra tine
of up to 5250.00 a day against the violator. lie advised that a copy orthis siatcmcnl may be forwarded to the Office of
Ira c+ngnumu of the DIA for insuraccc covera.,u verification.
/do hereby cerrijy under the pains all no ' s o /try Chet t/w h0watuden provided above/ sue tin correc[
,i,.:,at,lt• �wG- u .
U/Jfriel are tinljt no moot write is this aree,to be ramp/ded by e4 of town ofjlelaL
City or'raysn: PcrmidlJcense It
Issuing Authorily (circle one): —_
I. Iloard of llealth I. Building Department J. City/rows Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cntlacf Pcrson: _ Phone p:
Information and Instructions
%ta sachusetts General Laws chapter l52 requires all employe�rovvi theservice another under compensation
fo their CmPlOyceL
t of hire,
pursuant to this stand,an OmPfoyee is defined as ...every person
eapress or implied.Oral or written."
assoeiatiea.oorporatioa ar other kgpl entity,or any two or mote
te'PrO�is defined as"en M&vWusk P�W the le representatives owes of a deceased employer.or the
Of the foagoing engaged in a joint anterprise and including gal eP oYcM ilowevcr the
association or other WO eaoty,emploY' empl
receiver or trustee of an individual,pnrnaerihtP. and who resides tbetein.or the occupent of the
owner of a dwelling house having not chore tons three aparat►ants or re work on such dwelling house
dwelling house of another who empbys persons ro eta mamrecaus e. f Mir construction repair deemed to be an employer."_ y
or on the grounds or building aW_ UMnant th"M%tG s6s11 not because of sve6 eatploytrmmt
152.12SC(6)a m scares that"every state or local licensing a4eney shag witbb*M the issuance or
rest- chapter is the eommeetwes"far stay
renewal of a Ileesute or permit to accept•basblea or to construct buildings chc
appUmat wbe bag ant Prod acceptable evkMaee of a common with roc insany Of its coverage required."
AdditiOnOlty.MGL chapter 152.§25CM states'"Neidter the commonwealth nor tury of its political subdivision shall
�for the performance of public work until acceptable evidence of compliance with the insurance
enter into any authority.'
requiremenn of this cbaptw have been Presented to the contracting
Appliewts
please fill out the workers'compensation affidavit oomph taly,by checking the bones that apply to your situation and if
suloconvacror(s)name(,).addreas(a)and phone number(s)along with their certificate(,)of
necessary.supply LLP with tin employees other then the
insurance. Limited Liability Campania carry or Limited Liability n Insurance.
s l )
members or partners.am not tequirad to carry workers'compensation mawrance. [fan LLC or LLP don have
employees,a policy is required. Be advised that this affidavit re t be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage Also be sure t sign and date the affidavit Time affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Deparuncut of
Industrial Accidents. Should you have any questions regarding the low or if you are required to obtain a workers'
compensation policy.pieasp call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the line•
City or Town ORfc"
.�.
plcatie be sure that the affidavit is complete and printed legibly.` The Department has provided a space at the m.
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 pe:rmiVliccnse number which will be used as a reference number. In addition,an applicant
ons in any given year,need only submit one affidavit indicating curtest
that meat submit multiple permitllicense applicati
policy information necessary)and under"Job Site Address"the applicant should write"all locations in
f (if _(city or
town)." copy on(if affidavit that has been officially stamped or marked by the city of town may be provided to the
le for future permits or licenses. A new affidavit must be filled out each
applicant as proof that a valid affidavit is on fi
itimn is obtaining a license or permit not related to any business or commercial venture
year. Where a home owner or c
license or permit to bum leaves ere.)said pecsun,is NOT required to complete this affidavit.
I'hc Otii.c of Investigations would Hine to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us •a ca11.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
ofte of Involdpda"
600 Washington Stoat
Boston,MA 02111
Tel. 0 617-7274900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
2cviacd 5-26-05 www.num.gov/dia
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PUBLIC PROPERTY
DEPARTMENT
KL�WFJLEY Dnv.v
wroa 130 WAsuNamw bnLEEr•sAWK WssAaKst„s ot97o
TEL,9'.L7 S-M 9 FAjc 97{.740.gM
APPLICATION FOR TIIE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION,OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property is located in a; Conservation Area Historic Otetrid YAP
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: /
G✓/�-
3.0 COMPLETE THIS SECTION FOR WORK IN EXU TIAIG BUILDINGS ONLY
Addition Existing a
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
4
Approximate year of Area per floor (sf) Renovated
construction or renovation J�
of existing building < G0 New
Brief Description of Proposed Work:
0,1"/11 eg,(V�7
Mail Permit to:
r