5 WEBSTER ST - BUILDING INSPECTION r
$�VII�ST�E flll--E dD APPROVED BY T44E
Ii 5P XTDR ,PRWR TP A PERMIT BEWG GRANTED
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CITY OF SALEM
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No. itrv� '� ��� Data
Is Property Located in Location of _
the Historic District? Yes_No Building �Ji[ fir I f
Is Property Located in
the Conservation Area? Yes_No y
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever applyy'�'R---
oof7�- 'ejroof, Install Siding, Construct Deck, Shed, Pool,
RepaidReplace, Other:
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name 7)Qi1J 7-V(
Address & Phone 7f
Architect's Name
Address & Phone L )
Mechanics Name
Address & PhoneDc�ii
What Is the purpose of building?
Material of building? &,-e If a dwelling, for how many families?
Will building conform to law? Asbestos?
/�1 s
Estl City License k N A State License 0
Home Improvement
l l i Lic. i ?-) /� TS
r , Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: �l3STf'vC S S �1 '
/l J
No.
APPLICATION FOR
PERMIT TO
t
LOCATION
r,
PERMIT GRANTED
APP FD ^
INSPECTOR 6F BUILDINGS
Y `
K i
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The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office oflnvesdgadons
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers
Applicant Information / Please Print Leeibly
Name (Basintas!t)rtt¢niration/Indivi
Address: a(J eo
City/Stawmp: ` / �z Phone
Are yortam-employer?Chock the.appropriate box:
1.Ue9 ►am a empbyc with
4: ❑'I am a Type of project(required).
general contractor and I 6. ❑New construction
employees(fall and/or part-time).* have hired the sub contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. I 7. ❑ Remodeling
ship and have no employes These sub-contractors have 8. ❑ Demolition
working.for me in any capacity., workers' comp. insurance. 9. Q g addition
[No workers'comp,insurance . 5• ❑ We are a corporation and its' 10.❑ Electrical airs or additions
required.).; officers have ezec:sod then:
3.❑ I am a homeowner doing all work right of exerrgttion per MGL' 11.0 Plumbing repairs or additions
myself. [No workenV.comp c. 152,§l( we have.no , 12 ]'lioofrepays
in
ragnvod j t, empbytes [No'worke�s'
comp.insurance rogntred j 13.❑ Other
'Any epplicmt that cbecka boxy#1 Used also fill out.*section below sbowins dick waaksu'oompenesUon yoliry inlbmtattop;
t Homeowners wbo submit this affidavit indicating 0eX are dolag all wink and%en hike outside Eton riiirot aubMit a new affidavit indicating such
tContractms tbet check this boi road attached m additional sleet ebowing the now of the'ea&mutiec0ors e�there woticers'�.policy mfotmmion.
I am ati employer that is providing tvorkers'eompensadon haurtmee for my emi'iployeen Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Litz #: 0 5J 0 a 7 J Expiration Date:
Job Site Address: C G' '62:{ L — S City/StateMp•
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$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under the paku and penakies ofperjwy that the information provided above b due and correct
Sienatore /k� ✓� /` Daft-
Phone#:
Qaleial use onlyt. Do not wrke In thlr area,to be completed by ekyortown o,JTeiaL
City or Town: Permit/Ucense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Ckyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires an employer$to provide workpa' compensation for their employees.
Pursuant to this statute, an employee is defined as"...everyperson in the service Qf another under any contract of hire, .
express or implied,oral or written"
n employer is defined as an individual,partnership,association,corporation or other legal entity,or any two or more
A
A the foregoing engaged in a Joint enterprise,and including the legal representatives of a deceased employer,or the
rof eceive or trustee of an individual,partnership,association or other legal entity,employing employees. However the
three apartments and wbo resides therein,or the occupant of tl t
owner of a dwelling house having not more than ''
dwelling house of another who employs persons o do maintenance, construction or repair work on each dwelling house
or on the grounds or building appUf1Cnant thereon span not because of such emrQloYnKm be deemed to be an employer."
MGL chapter 152,$25C(6)also stairs that"every state or local licensing agency shall withhold the issuance or
renewal of a He or permit to operate a business or to co met buildings in the commonwealth for any
,.
applicant who has not produced acceptable evidence of compliance with the Insurance c v reel shun
Additionally,MGL chapter 152,$25C(7)states"Neither the commonwealth nor any of its po. _ _ . . divisions,
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
, r
Applicants
ation affidavit completely,by checking the boxes that apply to your situation and,if
Please fin.out the workers' compens
necessary,supply smb-coutracoor(s)name(s),addresses)and Phone number(s)along with no employees other than the
insurance Limited Liability Compames(LLQ or Limited Liability Partnerships(LLP)
with members or partners, are not °d to tarn'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 Indus
Accidents for conformation of insurance coverage Also be,sure to sign and date the affldavIL The affidavit should
not
be returned to the city or town that the application for.tbe permit Le is being if yo required obtain a wothe orke Department of
Industrial Accidents, Should you have any questans regarding
the compensation policy;please call the Depsrtrnent at the number.listed below. Self-i[Lwcd COtnpanie8 should eater their
self-insurance license number on the to 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 fin out in the event the Office of Investigations has to contact you regarding the applicant
er. in addition,an applicant
Please be sure to fin in the pemrit/ticense number which wilany
beused a�o�submit oneffidavit indicating current
that must submit multiple permittlicense applications in any given y
policy information(if necessary)and,under"Job Site Address"the applicant should write"ail locations in (�tY or
town)."A copy
of the affidavit that has been officially stamped or marked by the city or town may be provided to the
affidavit is on fie for fugue permits or licenses. A new affidavit mast be filled out each
applicant as proof that a valid
year.Where a lame owner or citizen is obtaining a license or permit not related to any business or commercial venture
(ie 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 tn give m a can.
The Department's address,telephone and fax ummber:
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 5-26a05 www.mass.gov/dia
CITY OF SALEMp MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASNINGTON STREET, 3RO FLOOR
SALEM, MASSACNUSETTS 01970
STANLEY J. USOvIC2, JR. TELEPHONE: 978-745-9395 EXT. 380
MAYOR FAX: 978-740-9848
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
m(Location of Facility)_
14
Y
Signature of Applicant
Date