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9 WOODSIDE ST - BUILDING INSPECTION (2) j, • '._ CITY OF SALEM �• PUBLIC PROPERTY DEPARTMENT KIA61HmLEV DRL CO, MAVM - 120WASWNCrONSMEEr•�M.N(V'SACNLSEI'�01970 - - IFi 978-745-9595 0 FAx:978-740-9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code,780 CMR section 111.5 Debris,and the provisions of MQ.c 40,S 54. # is issued with the condition that the debris resulting from Building Permit a properly licensed waste disposal facility as defined by MGL c this work shall be disposed of is 111,S 150A. The debris will be transported by: The debris will be disposed of in: to DumL (Dame of facility) w (address of facility) f� s' of applicant date debri:af.duc =a CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASHNGTON STREET♦SALEM,MASSACHUSETTS 01970 - TEL 978-745-9595 4 FAx:978.740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/individual): 12&s ,­) Address:T� �7— City/State/Zip: C„ -k>yr t Phone #: -7 ?dr- 7(0�-/ Fr[NO u an employer?Check the appropriate boss am a employer with 4. ❑ I am a general contractor and I Type of project(required):mployees(full and/or part-time).' have hired the sub contractors 6 ❑New constmctionm a sole proprietor or partner- listed on the attached sheet, t 7. ❑Remodelingip and have no employees These sub-contractors haveorking for me in any capacity. g ❑Demolition workers'comp. insurance. workers'comp.insurance 5. 0 We are a corporation and its 9. ❑Building addition 3.0 required.] officers have exercised their 10.0 Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.0 Plumbin myself[No workers'comp. C. 152,§1(4),and we have no g or additions required]t employees. [No workers' 12' epatts comp.insurance required.] 13.0 Other *Any appliwnfthat checks box#1 must also fin out the section below showing their workers,compensation policy information. t Homeowners who submit this affidavit indicaling they are domelo work and then Lire outside tConnaaturs that check this box must attached so additional sheet showing the name of the sobo�nactors must submit a new affidavit indicating each. ontractors and then workers'comp.Policy information. i fo an employer that Ls providing workers'compensasion insurance for my employees. Below is the polity and job site information. Insurance Company Name:_ Policy#or Self-ins.Lic.#: Expiration Date- Job Site Address: Attach a copy of the workers'compensation policy declaration page(sit City/State/Zip: owing 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 oney+ear imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA r insurance coverage verification. do hereby certify er the pa d "enaides ofperjrtry that the information provided above is true and correct Si natur : Date: Z6 2 Phone#: - Ofcial use only. Do not write in this area,to be completed by city or town oJrciaL City or Town ' Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.Citv/Town Clark d Fte ._:__. 3. What is the current use of the Building? If dwelling, how many units? Material of Building? Wtti the Building Conform to Law? Asbestos? Architect's Name ' Address and Phone Mechanic's Name K^` ` ddress and Phone ' i F "A �stratton Z y Construction Supervisors License# �=HIC Reg , Estimated of Permit Fee Calculation ` Permit Fee$ Estimated Cost X$71$1000 Res�denbal s `Estimated Cost X$111$1000 Commercial T An Additional$5.00 is added as an ArJmmistrative charge-,' " 4Make sure that all fields are property and legibly written to avoid delays in processing. i, e The undersigned does hereby` g,Prrno bull to 'e above stated apply for a Buildin e ft t specifications: at Signed under penalty of perjury fr „ De D p L„ S Jie -t c } N O� a+ .+ - "S, _ �- � 9 Cl a } _ PUBLIC PROPER TY ' DEPARTMENT RI 0011-EY DRI"LL MAYOR 130 WASHINGrnN SnLEEr ' l•5�,SAIMAWl]i1:5t1'IS 01970 TO-97&T45-959S 0 FAM97&74W-9&16 APPLICATION FOR`THE REPAIR;'RENOVATION, CONSTRUCTION. DEMOLITION.OR CHANGE MUSE OR OCCUPANCY.FOR ANY EXISTING STRUCTURE OR'BUILDING :1.0 SITE INFORMATION Location Name: Building: Property Address: Property is'located in a;Conservation Area YIN Historic District YIN 2.0 OWNERSHIP INFORMATION ti ` 2.1 Owner of Land Name: Y Jn 4u r i Address: bo' oj> S> e 4S Telephone:. 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY, s . Addition, Existing Renovation ; Number of Stories Renovated Change in Use New Demolition �- Existing ACDP- pproximate'year of Area per floor (sf) , Renovated construction or renovation of existing'building New . Brief Description of Proposed Work: © z .a� Mail Permit to: s `D w '