8 WILLIAMS ST - BUILDING INSPECTION the wilding? �S �
current use of
What is ttro T'
many units?
Material of Buddit? '
how
—
Will the Building Conform Asbestos? nA
to Law? -
Architeds Name '
Address and Phone
Mechanies Name c� A
Address and Phone it 3 i r`r� i C ��/CD✓
Conatrtrcion Supervisors U snss tl HIC Registration B
Estimated Cost of Project i l6 G� PenT&Fee Calarlalbn
Permit Fee i a S"� Estimated Cost X$7/$1000 Residential
Estimmated Coat X S41/il000 Commercla4------- -..- . .
An Additional $5.00 Is added as an t,
Administrative charge. r_
Make sure that all fields are properly and legibly written to avoid delays In processing.
The undemIgned does hereby apply for a Building Permit to build to the above stated
X.
specillcatkxhs. Signed under penalty of perjury
Date
s � N
s
EITrOF LEA
PUBLIC PROPERTY 2 5/ CSI
DEPARTMENT
KMOARL e r u.ucou
uwvoa 130 WALU N=W 9ln=•
. AMACHLSKM01970
IVL-97e.743.9S"•FAZ 97L718.9g"
APPLICATION FOR THE REPAIR. RENOYATI N CONSTRUCTION
DEMOLITION,OR CHANGE OF USE OR OCCUP Tray. FOR ANY EXISTING
STRUCTURE OR BUII.HING
1.0 SITE INFORMATION
Location Name: ci n 4n Bulidlnw
-—--. .- - Property Address } ----
JQ1� � L /d __ .--
Property is located in e:Consewation Ares Y4 H "Ic ok ld YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
rS r�
Name: o rnoM
J Address: S kL,%J ,, 11 ;a m9,
Telephone: qA
3.0 COMPLETE THIS SECTION FOR WORK IN MaanM BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (siy Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: 1[� )`/L 0 A �T�� `J /� �o,X 3 p„
i
a
Mail Permit to: C/ eq 97 7 / d 0�
CITY OF SALEM
00 PUBLIC PROPRERTY
6V A DEPARTMENT
M%1111 Fully Ua1X:ULL JJ
MAYOR IX WAaru.Na ON STRtfT•SAIF34,MASSACI It Wl IS 0IM
ThL-97$.743.9595 •FAX:978.740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aonlicant Information Please Print Leeibly
VaMCtBuciiw,.sOrganizatiorulndividuall)): t'TCQ/Oe UeeAgA
Address:
city/State/zip: Phone it: / 7r�
Are you an employer? Check the appropriate box: 'type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees(full and/ur part-time).• have hired the sub-contractors 7. ❑ Remodeling
2.�I ant a sole proprietor or partner- listed on the attached sheet. t
ship and have no omployces These sub-cortuactors have S. ❑Demolition
working for me in any capacity. workers' comp, insurance. g, ❑ Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exerciser!their
3.❑ 1 ant a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
'
insurance required.] t employees. (No workers' 13._] Other `�K 1 t1 � _
comp. insurance required.]
A.ty applicant am checks box nl must also till ow the section below otowiag their ww1ans cumpansutiwl policy infurmaiaci,
'1 twmmwnera who submil ibis affdavil indicating they are doing an work and then hire outside conrnpon most.ub"lis a new affidavit indicting Mich.
;Contrxwn thu cbeeb this box must ataclwd an additional Abois showing the new of Ills suts conrracton and their workers*comp.policy infoemadon.
fain an employer that Ls providing workers'compentadon hisurance for ttty employees. Below is the policy and job site
injurrnutium n /{
Insurance Company
Policy a orSelf-ins..�Licss...tF,,: Fxpirrtion [)air({��,�f//�,
Jt)b Site Address: /� ytlA��/QlYGcP �]L � City/State/Zip: �.L�f/1�, ✓If a4 QIq -70
Artach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failurc to secure coverage as required under Section 25A of.%,IGL c. 112 can lead to the imposition oferiminal penalties of a
tine up to S1.500.00 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 it day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Im c+n.auoos ul'ttte DIA for insurance coverage verification.
l du herckv certif under ter pains prnu/t/er ujprrjury that the injormafion provided above is true and correct
� Si•:ruure' ..- �7 Dent :
Phuoc#i 9 //
Official use only, no not write in this area,to be completed by city or sown 0011441 /� —�
Cityor Town: Pcrmi l.' e s
t/ Ic n e p -
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.City/fow�n Clerk 4. Ele i . umbing Inspector
6.Other
Contact Person: — - _ Phone p:
Information and Instructions
Massachusetts General Laws chapter.132 requires ail employers to provide workers' compensation for their employees
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire.
express or implied,oral or written."
An employer 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,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant 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
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 evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
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."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)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
self-insurance license number on the appropriate line.
City or Town 0MC1212
Please he 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 purmitllicense number which will be used as a reference number. In addition,an applicant
that must subunit multiple pernitilicense 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.
Tho Oi tier of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
O®es of Investlgattons -
600 Washington Street
Boston, MA 02111
I
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax p 617-727-7749
Rcvi.ed 5-26-05 www.mass.gov/dia
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