123 WEBB ST - BUILDING INSPECTION EIT�OF�
PUBLIC PROPERTY
y�d� DEPART'1VIF,11T
Kl.%OWJ S.V Duu:uu
MAYM
.. 130 WASWN .T[W brx •&'=;MAAAatLUMM 01970
TEL-978-745-959S•FAX:978-740.9046
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; Consmatl(n Area Y/N—JSC---Historic Dt*Ict Y/N A—
i 2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: I Ht3 l �q►J�/�
Address:
_l23 wt68 <T" yn�,
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
s
Addition Existing
Renovation 1&,,0C 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
13def Description of Proposed Work:
`T4 W ID EA157/A/t6 a G/IyCE¢SdF�o�F slu g ,OrsPo a>`� 5�
k141 k 690 2cc*6441W5. AOPW AG04plf 4*e 14,1)(SZIIAi /G E c C, lV~
�ulEuJIG/���2� �S�Hgr,T st�i"�Xd6SI � �(oE �Vr
— Mail Permit to:
17�sIDk.�nl��- r o
What is the current use of the Building? If dwelling, how many units?�—
r
Material of Building? I vbi� �
Asbestos?
Will the Building Conform to Law?
Architect's Name ( )
Address and Phone
Mechanic's Name Cr
jc=0sa�[•JAt�t1 Jf 9fi'1il D' - s�, �.•
Address and Phone HIC Registration# l66__ _��Y —
Construction Supervlsors License#
Estimated Cost of pr led 31 Q
Permit Fee Cakx+Wuun
permit Fee i t�� Estimated Cost X Z7151000 Residential
Estimated Cost X S111$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit build to the above stated
specifications. Signed under penalty of perjury
Date
I
N
Ptr
rid o
O 3
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a L 96 4
Cny OF SALEM
PUBLIC PROPERTY
DEPARTMENT
W,OEY..Y osuona
NAvas 130 WA"WCMU SMW=•SALEK MASSAC}Y:UM ats7o
Consimcdom Debris Disposal Affidavit
(required for in demolition sod Knovation work)
In aceordsoee with the "odidon of the State Building Code.7i10 CMR section It l.S
Debris,and the provisions of MC$.a 40.9 A
Building Pawk N is inn"with the mmWoa dLd the debris resulting floss
this work shall be disposed of in s pmperly iieensed waste-"speed 0tciUty as dented by MCM a
I L 1.S 130A.
TMm debris will be transported by:
PYNW� Ccr( /WTWW
l�a[iruled
The debris will be disposed of in:
BE WAS'Tt,'&6W
(tee of rxaia)
�sr
(addtm of&cduyy
sisasaice of licaat
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dw
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KLMBERLEY DRLSCOLL
MAYOR
120 WASHe4GTONSTREET♦SALEM,MAMChIWITS01970
TEL 973-743.9595 4 FAX 979-740.9946
Workers' Compensation Insurance ABidavit: Builders/Contractors/Electricians/Plumbers
Anolicant Information Please Print Legibly
Name(Business/ �+
Organiration/Individual):_(_.�tJf(,j"Ci1'`r ' Olt
Address: ASS Ie, I A I arf a v tr .F �'1
City/State/Zip: A M A4 nl4_Q Phone#: 199- 5 /-
Are ou an employer?Check the appropriate box:
1. I am a employer with�_ 4. Q I am a general contractor and IFORemo&lin
(required):
employees(full and/or part-time).• have hired the sub-contractors struction
2.Q I am a sole proprietor or partner- listed on the attached sheet t ingship and have no employees These sub-contractors have nworking for me in any capacity. worker'comp.insurance.
addition
[No worker' comp. insurance 5. Q We are a corporation and its
required.] officer have exercised their 10.0 Electrical repairs or additions
3.Q I am a homeowner doing all work right of exemption per MGL 11-El Plumbing repairs or additions
myself. (No worker'comp, c. 152, §1(4),and we have no 12.2"R oof repair insurance required.)t employees.[No worker' IL 13.❑Other
COMP.insurance required]
•Any applicant thin cheeks lox#1 must aiao fill out the section below showing their wwkeot-comprantio t policy intem mints
t Homeowams who submit this afftdavh indicating they an doing di wort and thin him outside commomes must submit a new affidavit'
tContncton thin cheek this box must attached an additional sheet showing the name of the subeonttacton and their mNlimaing
ann torah
workers,wmP•policy infetsnadoo.
lam an employer that it providing workers'compensation insurance or m employees.
j
information. YBelow it tha polJry and Job site
Insurance Company Name: (, /N/5,
Policy#or Self-ins.Lic.#:_ 1 333Sa). pa M Expiration Date: GS Q
Job Site Address: (�s) b S( City/State/Zip: As'1d*4 l/(gQ 3
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 penalties 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 fine
of up to S250.00 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.
/do hereby ce fy ander the ins and penalties of perjury that the information provided above it due and correct
Si atu
_ Dt
P
OJJIcJal use only. Do not write to this area,to be completed by city or town oJjlclai
City or Town• Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. Citylrown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person• Phone#•
Information and Instructions
rson in the service of another under any contract of hire,
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. • ,
pursuant to this statute,an employes is defined as"...every pe
express or implied,oral or written."
tion or other legal entity.or any two or mom
"an individual Partnership,association,corporation or the
o f employer is defined as and including the legal representatives of a deceased employer,
of the foregoing engaged in a joint enterprise' employing employees. However the
receiver or trustee of an individual,Partnership,association or other legal entity, or the occupant of the
house having not more than three apartments and who resides therein,
owner of a dwelling who employs Persons to do maintenance,construction or repair work on such dwelling house
dwelling house of anotheremployer.-
agency
or on the grounds or building appurtenant thereto sban not because of such employment be deemed to be an
MGL chapter 152,§25C(6)also states that"every state or local Ueensing 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 t 'Neither the oce Of pmasoa ealth nKanto with or any f political subdiv insurance coverage isions shall
Additionally,MGL chapter § public work until acceptable evidence of compliance with the insurance
enter into say contract for the performance of p
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 sub-contractors)name(s),addresa(es)and Phone numbers)along with their certificates)other
Of
necessary, PP Y or Limited Liability Partnerships(LLP)with no employees other than the
insurance. Limited Liability Companies(LL workers' compensation;".nn.^ce• If an LLC or LLP does have
members or partners,are not required to carry affidavit
may
ent of Industrial
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retuned to the city or town that the application for the permit or license is being requested obtain aDepa t of
Industrial Accidents. Should you have any questions regarding the law or if you are required antes should enter their
compensation policy,Please call the Department at the number listed below. Self-insured comp
self-insuranca license number on the itiate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Depaztntent 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 sore to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permidliccost 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 locatiomrovided to in (the
ty or
town)."A copy of the affidavit that has been officially stamped or marked by the city or,town may be P
applica as proof that a valid'affidavit is on file for future Permits or licenses. A new affidavit moat be filled out each
r..
year.Wre he a home owner or citizen is obtaining a license or permit not related to any husincw or commercial venture
(i.e. a dog license or permit to bum 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 Invesdgadons
600 Washington street
Boston.MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia