21 WINTER ST - BUILDING INSPECTION (2) Ei`I'�OF�CE
PUBLIC PROPERTY
DEPARTMENT
IQ%WFJILFV DRISCOLL
MAYOR 120 WASHING"h-REEr•SAYE.%AiSAQHl: I-M 079711
TtL-978-7454SSIS•FAx 978-740-9846
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: Building:
Property Address: / G✓'/?
Property is located in a; Conservation Area YIN Historic District YIN 7&S
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: ��t� a / c _ c'
Address: —�7
Telephone: g-35 - C/,z Y� // v S5 /.IGZ �0 2
3.0 COMPLETE THIS SECTION FOR WORK IN PY14TING BUILDINGS ONLY
Addition Existing
Renovation ,j Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of lw'��4-07 Area per floor (sf Renovated f 3Gv
construction or renovation l`�o z�7 New
of existing building
Brief Description of Proposed Work:
6s �
--- Mail Permit to:
What is the current use of the Building?
Material of Building? 4/0 u�— If dwelling, how many units?�
Will the Building Conform to Law? l/t S Asbestos? /1 G
Architect's Name /V
Address and Phone l )
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ ZSOd d Permit Fee Calculation
Permit Fee$_ L [l Estimated Cost X$7/$1000 Residential
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 Permit to build to the above stated
specifications. Signed under penalty of perjury
Date 3 I�
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Kn.aERtBY DR6COt1
MAYOR
120 WA90= M STRW a SAIM4 MASSACJi[)i4M 01970
TEL 978-74S95" a FAx:M740.9gu
Workers' Compensation Insurance Affidavit: Builders/Contractorimectriciamyplumbm
Applicant Information ple1e„ rain.Legibly
Name(BusioeWOrganiado vinmvi hw): -L _
Address: ,L 3�;2,
City/State/Zip:� l— /?/- Phone
Are you an employer?Cheek the appropriate boar
1.0 I am a employer with 4. 0 I am a general contractor and I ilia o!Proi�(regatred):
�PloYas( and/or pap.-time).• L
ed the wbconnactass b ❑New conahtretion
2.0 I am a sole proprietor or partner- the attached sheet. t 7. [9116ne modeling
ship and have no employees ub-contrecpoo have S. ❑Demolition
working for me m any capacity. 'comp,insurance.
[No worker'comp.insurance 5. 0 We are a corporstion and its 9. 0 Building addition
required] ofRcea have aurciised their 10•0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MOL 1 I.0 Plumbing repairs or additioy
myself.[No workero'comp• c. 152,$1(41 and we have no 12.0 Roof repairs
insurance required]t employees.[No workers' 13.0 Other
comp.insurance required.]
;Any APPnew dod cheelu box al mot she jig art the seedon bales tbowing tbWw wa ,anmpantatlan pas,,y o>�matlaa
ltamaowama who submit ddm dgdwk mdiudog dwy us doing an wadi and ran lobs on noun maamton mot n h a nw stgdmrk btdiadeg tsri
tComact m do cheek uW boot now anaehW an addido W shmt dhowisg dw anew of rho .
and rhdr nartms'coma policy id ununi .
I am ON enrpbryer that is providing wor#arsI compenandon Lmara.,r for cry
Information eaapioyeea Befow b the poNry an/fob rba
Insurance Company Name:
Policy#Or Self-ins.Lie.#
Expiration Date:
Job Site Address: City/Statemp:
Attach■copy of the worker'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
of u up to S 1.0.00a d and/or one-year imprisonment,es well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a Ray against the violamr. Be advised that a copy of this statement may forwarded to
the Office of
Investigations of the DU for' coverage verification.
/do hereby csrdA under tAre pains and penoldea of psr/aq that the infofaradon provided above is ante and coffed
Signature•
Da�
Phone#:
Of)fdd use onIA Do not write bs this area,m be eoarpleted by city of town ofJfew
City or Town: Permlt/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City
6.Other frown Clerk 4. Electrical Inspector S.Plumbing Inspector
Contact Person: Phone#:
Information and Ilistructions
nsaMassachusetts General Laws chapter 152 requires all employers to provide workers' Compe a in the serviceanother under a forontrad�ofof bite.
pursuant to this statuta.an c&spfoyso is defined a"..-every person under any
express or implied.Ord or written' two a more
aaaociatlm.corporation or other legal cnaty,or any
An esployer is defined as"an individual.partnership. ntives of a deceased emPICYar,a the
of the foregoing engaged in&joint enterprise,and mcbtdmi the b�r employes& However the
association or other legal entity.employing of the
receiver or truseto of an individual,partnersb<R and who resides therein.or the occupant
owner of•dwelling"arse having not nose than three SPIllogMMMMnts ¢ or repair weak m such dwa�haw
dwelling boos°of another who Mn*Ys P��no because f such employe mt be�to be m emploYer.'
or on the grounds or building appurtenant
that"every stab or Beal neeeateg agsery shag wlthhotd tM issuance or
MGL chapter 152.12SQ6)also & In the commoewe0h for aq
reeswat of a leeea or Par"to opera"a.badnns or b contract:w the hesurrauco coverage required.
who has a"pram acceptable evldetuee Of eomplWee of its fiord so"visions Shan
sAdPlicant diidonany.MGL chapter 152.$25CCn states"Neither the commonwealth nor any of compliance with the insurance
contract for the performance of Public work until acceptable evidence
requirements of this ehapoet
corer into anyhave bean presented to the Contracting&ushcc Wy w
Applicants situation and,if
please till out the wod9912'c jor(s) a me affidavit s(es)and
completely,by number the boxes witthah
apply to your
�s)namKs).gyp)sod Phone number(s)along with their cmti8e&tc(s)of
necessary.suppty e><Limited Liability PIMcrsWPs(LLP)with no employers other than the
insurance. Limited Liability ComPauies�workers'c ompanaston insurance• if an LLC or L.L.P does
ve
members or piers,are not required advised there this atAdsvis may be submitted to the Departrmnt Of
employItiMI
ee&,a pow is M*dr� coverage &MAbe be sure"a1g1 and dab the afSdavkL The affidavit should
Accidents for confirmation of insurance er lumw is being requt etEd.not the Department Of
be returned w the city or town that the application for the�law or if you are required to obtain a workers'
Industrials Should you have a�questions t number listed below. Sat inwred companies should cuter than
compensation policy.Pleas Can the Department lino
self-insurance noenae author On the
City or Tows Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
affidavit for you to fin out in the evens the Office of Investigations has to contact you regarding the aPPUC8OL
of the a
Please ff sari to fin in the permit/lice nse number which will a be used a reference number. In addition,an applicant
that must submit multiple permiNwmu applications A any given year,need hou submit-al affidavit indicating cutte>u
policy information(if necessary)and under"lob Site Address"the a !ed by the town may Provided w ns in threty or
r mar
town)."A copy of the affidavit that has been officially stamped er or licenses. Anew af5davir moat be filled out each
applicant a proof that a valid affidavit is on file for tltture permits
yeas.Where a house owner a citizen is obtaining&license or permit not related to any businessor commercial venture
to burn leaves etc.)said person is NOT required to complete this affidavit
(i.e. a dog license or P
you in advance for your cooperation and should You have any questions.
The Office of investigations would like to thank
please do not hesitate to give us a can.
The Depaameas's address,telephone and fax
of N(machUMM
Deparmnent of Inthsttial Accidents
offte of InvadVIII01011
600 washinBOOn sorest
Basta,MA 02111
Tel. #617-727-4900 W 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-03 WWWins sov/dla
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KI�MM.EY DRISCOLL
MAYOR
130 WASHINOTON MXESr•SAL EK MASSACHUSj`7M 01970
TEL 978-745-9S95 •FAX:978.740-9&16
HOMEOWNER LICENSE EXEMPTION
Please Print
Date 5 411 O
Job Location
Home Owner Address —
Home Owner Telephone
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit. <`
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and - uiremen .
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
r
Homeowner's Exemption
The Code states that: ,Any Homeowner performing work for which a Building Permit is
required shall be exempt from the provisions of this section(Section 109.1 —Licensing of
Construction Supervisors),provided that a Homeowner engages a person(s) for hire to do
such work, and the Homeowner shall act as Supervisor."
Many Homeowners who use this exemption are unaware that they are assuming the
responsibilities of a Supervisor(see Appendix Q,Rules and Regulations for Licensing of
Construction Supervisors, Section 2.15). This lack of awareness often results in serious
problems, particularly when the Homeowner hires unlicensed persons. In this case your
Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The Homeowner acting as Supervisor is ultimately responsible.
To ensure that the Homeowner is fully aware of his/her responsibilities,many
communities require,as part of the Permit Application,that the Homeowner certify that
he/she understands the Responsibilities of a Supervisor. On the last page of this issue is a
form currently used by several towns. You may care to amend and adopt such a
form/certification for use in your community.