58 WILLSON ST - BUILDING INSPECTION PUBLIC PROPERTY
DEPAR'I'�IEA1T
KMAEA Er ORMCOLL
5'may MA.CUOHLSl1'[S 01970
TEL.973-74S-959S*FAx,97s.740-9846
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: Q Building:
-- Address:— — — — — -----
Property
Property is located in a;Conservation Area Y/N L, Hlatorlo District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land ;:d _
Name:
Address: 6 F V - 4.Z4 "'
Telephone.
3.0 COMPLETE THIS SECTION FOR WORK IN EXIS111M BUILDINGS ONLY
Addition Existing
Renovation 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
B6ef Description of Proposed Work:
Mail Permit to: 0 GC
i
What is the current use of the Building? "" 2
Material of Building? a a==4� if dwelling, how many units?
Will the Building Conform to Law? .H Asbestos? �e
Architect's Name
Address and Phone
Mechanic's Name ay
Address and Phone
Construction Supervisors License# 0 3 a J�G.t HIC Registration# i oo 16 '7
Estimated Cost f o ect$ F6u a, a o Permit Fes Calculation
Permit Fee$ Estimated Cost X$71$1000 Residential
- - - - _ - - - ---- ,-- -- Estimated-Cost X 511/i1000 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 to build to the above stated
specifications. Signed under penalty of P erl urY
Date / i��o 7
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Kjyoear w DR6COli
SL%Yoa 120 WA9mVGTON ST"zr a SAI-EK Mnssuatosans 01970
TEL-978-745.95" a FAX-978.740.9M
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busmas/Orgaoiutiodlnd vvi&w):_
Address: /6 `Z -.-& Qt:t
City/State/Zip: 4:r .*aa,019710 Phone#: 9 7 j� - -7 itS- 57s0 Z
Are you an employer?Cheri[the appropriate box.
1.[�!am a employer with 4. ❑ I am a general contractor and 1 Type project( ��:
employees(full and/or part-time).* have hired the sub.contracrors 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-conbactma have 8. ❑Demolition
working for me in any capacity. workers'comp. insurance, g, ❑Building addition[No worker'comp.insurance 5. ❑ We area corporation and its
required.) officers have exercised their 10.0 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(41 and we have no
insurance required]t employees.[No workers' 12.❑Roof repairs
comp,insurance required] 13.❑Other
*Any wpliam that checks box et mum alto w out the sw m baba showiaa thek work ea,eompmaayea Policy iabtmatloe Hanaowmn who e k rids this&TAmust ak a they am dohs all work and ttio him etmdAa eontraetom must submit a paw alRd wh todtados aa&
tCosusetam thn draek ehb boa mum attached ae.dditioeal sheet showbg the uame of the sub.emaacteta mad tbeir wartmm'comp.Policy b imastios.
f am an employer that b providing workers'compensadon insaroncefor information my employees Below 4 the policy and fob sill
C�
Insurance Company Name: G�
Policy#or Self-ins. Lie.#: i.v C 6 e-9r-3,r -3/ Expiration Date: 31-1 Jd 7
Job Site Address: 5-6— � — City/State/Zip �!j(� , o /yr`70
Attach a copy of the workers'compensation policy declaration page(showing the polity 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 31,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
O
of up to 3250.00 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 cerdfy under rho pains and penaldes of perluoy that the information provided above&nw and correct
signature, 710 -7
Phone#: q 7 —
QjWial use onlR Do not write in this area,to be completed by city or town oQ&iaL
City or Town: Permit/License#
[6.
ssuing Authority(circle one):
. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
Other
Contact Person: Phone#
I
Information and"'Instructions
Massachusetts General Laws chapter 152 requires all employes t ovide wor the service er another under any c' compensation for ontract of emplogee
Pursuant to this statute,an employee is defined as"...every person in
express or implied.Oral or written."
r is defined as an individual.partnership,association,corporation or other legal entity.or any two or more
An employe " idividua and includinassociationg the legal representatives of a deceased employer,or the
of the foregoing engaged in a joint enterprise. a other legal entity.employing employees However the
receiver or trustee of an individual.partnership,
than threethree apartments and who resides themm,or the occupant of the
owner of a dwelling house having construction or repair work on such dwelling house
dwelling house of another who employs Persons to do maintenance, to be an employer."
or on the grounds or building appurtenant thereto shall not because of such employment be deemed
MGL chapter 152,425C(6)also states that"every state or local Ikensisg agency shall withhold the issuance or
renewal of a Ikense or permit to operate a business or to construct buildings Is the eommonweakh for am
applie st who has not produced acceptable evidence of compllsaee with the insurance coverage reqsubdivisions
ion
Additionally,MGL chapter 152,$25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
r the performance of public work until acceptable evidence of compliance with the insurance
enter into any contract for
have bien presented to the contracting authority."
requirements of this chap
Applicants
n affidavit completely.by check
the boxes that apply to your situation and,of
Please fill out the workers'compensation atio es and phone number(s)along with their cettificatc(s)of
necessary.supply sub-contractor(s)name(s),addreae( ) LP with no employees other than the
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(L )
are not required to carry workers'compensation insurance• If an LLC or LLP does have
members or polio i Be advised that this affidavit may be submitted to the Department Of Industrial
employees a policy is required. coverage. Abe be sure to sago and date the affidavit. The affidavit should
Accidents for confirmation of insurance ge• notbe returned to the city or town that the application for the permit l a se workers'� Of
Industrial Accidents. Should you have any questions regarding`s law or
�you am required to obtain a
compensation Policy.please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the avoropriate
City or Town Officlah
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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permitllicense number which will be used as a reference number. In addition,an applicant
applications in any given year,need only submit one affidavit indicating current
that must submit multiple permiNlicense
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in__(city or
town)."A copy of the affidavit has been officially stamped or marked by the city or town may be provided to the
applicant idIaffidavit is on file for lone permits or licenses. A new af„davir must be filled Out each
as proof that a valid
or citizen is obtaining a license or permit not related to any business or commercial venture
year.Where a home owner
(i.e. a dog license or permit to burn 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 questions6
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of lnfitstrial Accidents
O®ee of Imvatlritlons
600 Washington Sheet
Boston,MA 02111
Tel. #617-727-4900 Cd 406 or "77-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www•> ass gov/dia