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25 WILLIAMS ST - BUILDING INSPECTION it Cn y-O�XL - PUBLIC PROPERTY DEPARTMENT Kl.%(BFM"DRISCOLL MAYOR 120 WASHINGCON S7REEr♦$A1Ev,MAcsncxt:st'ns 01970 TEL 978-755-9595 4 FA)c 978-740-9U6 APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: /yf jC ✓yJ ter/j Building: Property Address: S Ij S s�� m O q70 Property is located in a; Conservation Area Y/N Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN t=YlcrlNG BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use o2 �� New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: �l/Kehi� t,✓lrvt y�dw S . Mail Permit to: i" What is the current use of the Building? Material of Building? If dwelling. how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone Mechanic's Name MD✓�� /�� Address and Phone Construction Supervisors License# f 4� HIC Registration# Z 3 Estimated Cosof Project$ ).STo Permit Fee Calculation Estimated Cost X$7/$1000 Residential Permit Fee $ Estimated Cost X$11/$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 Permitgeed specifications. Signed under penalty of perjury X al �� N O r r� \`T c CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT K NEEN Y DRISCOLL .MAYOR 120 WAsFmvGToN STREET a SALM,MASSACHUSETTS 01970 TEL•978-745.9595 a FAX:978-740.98" Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �/, Please Print Let>ibly Name (Business/Organiationandividual): Address:_ �67 C.le-5 5k City/state/zip: /CP�t7ll2Py i1Ir9 CJ/�� Phone #: Are you an employer?Check the appropriate loot 1.❑ I am a employer with 4. I am a general contractor and I Type otproJtxt(required); employes(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. -Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp. insurance. (No workers' comp. S. 9• ❑ Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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' cOmp. innnanre required.] 13.❑Other *Any appuamt that checks box el must also allout the section below showin t Homeowners who submit this aRidavit indiutia 8 their workers'compeantion policy insommlies, tConuacton that check this box must attached an additions)sheet sho awm the name md then of the subeoo actors outside n moat submit a row camp. policy by mro oa ics, tractors and ttatr wohats•camp,poury inrotta.uco. fain an employer that Is providing workers'compensation Insurance for my employees information Below isthe policy and fob site n Insurance Company Name: 6Lfi '4 cif , Policy#or Self-ins. Lic.#:_ m L 7-66 b 93 �• Expiration Date: Job Site Address: o?J w , I I j g r. S 5;4 ��vr i j4 City/State/Zip:- 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. I5 fine u to$l 5 2 can lead to the imposition of criminal penalties P 00.00 and/or one-year ion penal ea of i y imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against violato . Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA uranc o ge verification I do hereby certify a r the p ' d penalties ojper/ary that the infrmation provided abo e is tryeand coned Si a Phone# OJ)?cial ase only. Do not write in this area, to be completed by city or town offliclaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/fown Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other Contact Person• Phone# Information and Instructions • Massachusetts General Laws chapter 152 requires all employers to prov de workers' compensation for their employees - Massachusetts 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 10 employer,or the receiver or trustee of an individual,partnership,association or other legal entity.employing employees However the not more than three apartments and who resides therein,or the occupant of the owner of a dwelling house having construction or repair wont on such dwelling house dwelling house of another who employs persons to do maintenance, » 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 al of a license or permit to operate a business or to construct buildings in the commonwealth for any renewal applicant 0 who hu not produced acceptable evidence of compliance with the insurance coverage required." "Neither the commonwealth nor any of its political subdivisions shall Additionally.MGL chapter 152,§25C(7)states enter into any contract for iha performance of public work until acceptable evidence of compliance with the insurance have been resented to the contracting authority- Applicants requirements of this chapter P Applicants if Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and. es and phone number(s)along with their certificate(s)of necessary,supply sub-contractor(s)name(s),address( ) employees other than the insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with rLP have members or partners,are not required to carry workers' compensation l»",,.a^ce• If an LLC or LLP does employees.a policy is required Be advised that this affidavit may be submitted to the Department Accidents for confirmation of insurance coverage. Also be sure r sign and date the affidavit. The affidavit wshould be returned to the city or town that the application for the permit or license f being requested not the Department Industrial Accidents. Should you have any qucstions regarding the law or if you are required to obtain a workers' artment at the number Bated below. Self-insured companies should enter their compensation policy,please call the Dep self-insurance license mrmber on the line. a City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Deparunent 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. icant Please be sure to fill in the permitftiense number which will be year,as a reference number. In addition,an need only submit one affidavit indicating current that must submit multiple permit/licetsse applications in any given policy information(if necessary)and under"Job Site Address"the applicant should write"all May b Provided to(the town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe p applicant as proof that a valid affidavit is on file for future permits or licenses A new afudmvir must be filled 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 bum leaves etc.)said person is NOT required to complete this affidavit. ur cooperation and should you have any questions.questions.The Office of Investigations would like to thank you in advance for yo 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 O®ee of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 of 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPERTY DEPARTMENT wIOFJLiY oanant wraa t30w mess♦SALEWNAtSACHLMMOITM Construction Debris Disposal AfAdavit (required for A demolidon and renovation work) in accordance with the sbcth edition of du State Building Code.780 CUR seetim 111.5 Debris and dw provisions of MGL a 41%S A Buildins Pernit 0 is issued with the condition dut the debris resulting Boa this work sbail be disposed of in a properly Second waste disposal dcility as defined by MGL e I L 1.S 130A. The debris wiu be transported by: (cams ofbwdar) The debris/w/ill be disposed of in: /noyy(/7<i Adm kE2 4,19D. (none of facility) (mtdraa of facility) siaaaaee of pam�it applicaas /o �� o� dam ted;.r7.G,e /