40 LAWRENCE ST - BUILDING INSPECTION WWW- � % ;,tDoG• OQ.(T-
The
-The Commonwealth of Massachusetts
�y Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7ih edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Fa nily Dwelling ANN&
QCT This Section For Official Use Only
Building Permit Num )r Date Applied: ` �/,�p' r •0
ak
Signature: '�i lil ave
� Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
A0
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal eOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
1YM40..
Name Address for Service:
°1l8-T44—4011
'gnS1 ature' Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': ccng-b,..,cN ♦jt z 9r`6' I;uatL AAAt}yw WI Neu+ '�' Zang
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees:
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees:$
Check No. Check Amount: Cash Amount:_
6. Total Project Cost: $ ❑ paid in Full ❑Outstanding Balance Due:
0a
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
66"n � 4i13�
License Number Expiration Date
Name of CSI.,-Helder List CSL Type(see below)
►_ rY, 5�ceet , moi C,� , c�i2Koq
Ad ress T Description
- U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 FamilyDwelling
Signature M Masonry Only
01111'q=!y RC Residential Roofing Covering
Telephone • <` WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home�Immpro�vm�ent Contractor(HIC) 1�831ay
8940 nl !ti
HIC Company Name or HIC Registrant Name Registration Number
tzo 9WQQ a t k as Qatsc.. %\KU. ozlte� 3130 j�mO9
TiAd ess
r [e1�-was{-Q NZ 0 Expiration Date
Signature _ telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........gr No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, i' Ray, _(S r p ' e< as Owner of the subject property hereby
authorize c, nn to act on my behalf,in all matters
relative to work autbpriz by this 'Iding permit application.
-� C
Signature ofnerDate
"SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name ^
�_ �� 3- 4-J
ma�r ---
Signature of Owner o oozed Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
1
D g
❑ co
Z
O
. . . . . . . . . . . . . . . . . ... — — . — . — . — . — . — . — . — .
® 1E]
H ❑ ■
- - - - - - - - - - - - - - - - - - - - - - - - - - - _ _ - - - - - - - - - - - - - Z �'
FRONT ELEVATION RIGHT SIDE ELEVATION LEFT SIDE ELEVATION
SCALE, 3/16" 1'-0" EXISTING SCALE: 3/16" 1'-0" EXISTING
CONTINUOUS RIDGE VENT SCALES 3/16° I'-0" EXISTING N
1
a EXTEND EXISTING CHIMNEY NN �
O Q
ASPHALT SHINGLES TO MATCH EXISTING N CONTINUOUS RIDGE VENT NEW VINYL WINDOWS WITH INTEGRAL
ON 30 # BUILDING FELT ON 5/8" PLY- 12 CASING TO BE 'HARVEY INDUSTRIES"
OR EQUAL. DOUBLE HUNG TO HAVE TILT-
WOOD SHEATHING ON 2 X 10 RAFTERS Q
AT 16' O.C. FASTEN TO WALL PLATES 7 ASPHALT SHINGLES TO MATCH EXI5TING IN WASH FEATURE. p
WITH METAL HURRICANE CLIPS. ON 30 # BUILDING FELT ON 5/8' PLY-
WOOD SHEATHING ON 2 X 10 RAFTERS
AT 16' O.G. FASTEN TO WALL PLATES rl
WITH METAL HURRICANE CLIPS. o�ov a
q
- - - - ' - ATTIC
66KRlNfG GUTTER AND DOWN LEADERS TO MATCH - - . - . - . -ASIC 9 p
EXISTING BEARING Yflb r�9pZr
❑ ® ® ❑ ® I X 3 OVER 1 X 8 TRIM AT EAVES ❑ -
® ® ® ® AND UNDER LU MIN PRIME ALL wlc�_
CONTINUOUS SOFFIT VENT
SIOES AND ALUMINUM GLAD. 30X30
ao AWNING PRE FINISHED ALUMINUM FLASHING OVER PEEL AND STICK MEMBRANE 8o X 4e 30X43 w Z w
•� VINYL SIDING AND CORNER BD5. AT INTERSECTION OF ROOF AND L. HG. DBL. NG. IY s+ Z
12 WALL. TYPICALLu
N
- � - - - - - 2ND FLOOR 2ND FLOOR U N
- - EXISTING - - - - - - - - - - - - - - - - - - - - - - EXISTING LLI
® ® - PRE FINISHED ALUMINUM STEP
FLASHING OVER PEEL AND STICK VINYL SIDING AND CORNER BDS. ~
FTTI
MEMBRANE AT INTERSECTION ❑ U W
OF ROOF AND WALL. TYPICAL
m
30 X 30-30 X 30 Q Lu W
4 X 4 P.T. POST WITH PINE AWNING=AWNING
CLADDING AND CAPITOL PRIME N
ALL 51DE5 AND ALUMINUM }t
CLAD. tsT FLOOR
- - - - . - - - - . - . - . - -
- - - - - - - -
EXISTING - - - - - - - - - - EXISTING ( �
FRONT ELEVATION RIGHT SIDE ELEVATION LEFT SIDE ELEVATION
y SCALE 3/16' I'-0" ALTERED SCALE: 3/16' 1'-0" ALTERED RIDGE VENT CONTINUOUS- SCALE- 3/16" 1'-0' ALTERED
C z
2X8 COLLAR TIES 12 F= ITJ
ASPHALT SHINGLES TO MATCH EXISTING ' a 'jJ
ON 30 # BUILDING FELT ON 5/8' PLY- LL }fir+•+
WOOD SHEATHING ON 2 X 10 RAFTERS
AT 16' O.C. FASTEN TO WALL PLATES '0 PREFABRICATED EP5 AIR CHAMBER FOR
WITH METAL HURRICANE CLIPS. CONTINUOUS AIR FLAW Wco
PEEL AND STICK MEMBRANE 36" ONTO II- W
ROOF AT ALL EAVES.
- - - . - . - - - - . - - " - - - - - - - - - - CONTINUOUS ALUMINUM DRIP EDGE Q Q V
'^\ F- W W
■ ❑ ■ ❑ J
- - - RAFTER. I ATTIC co
-- - ---- , / \`\ -- BEARING z
2X8 CEILING JOS I6' O,E'� 1%2v PLASTER BOARD ON WOOD GUTTER AND DOWN LEADERS TO MATCH Q
1 X 3 OVER I X 8 TRIM AT EAVES
AND UNDER SOFFIT. PRIME ALL i FUiNR� G AT 24" O.C. FINISH WITH
- - _ _ - - - - _ - _ SIDES AND ALUMINUM CLAD. R 38 GLASS FIBER TT 'SN5ULATION I PLAS'YE7,2 VENEER COAT 12'
CONTINUOUS SOFFIT VENT Q
PRE FINISHED ALUMINUM FLASHING OVER I NEWWALL.
X 4 57U15�BEARIF1Ci
OVER PEEL AND STICK MEMBRANE
AT I
i o
NTERSECTION OF ROOF AND � � �
WALL. TYPICAL i � -
i
m
EXTERIOR WALL TO BE 2X6 WOOD STUDS
REAR ELEVATION / I AT 16" O.C. FINISH EXTERIOR WITH 1/2'
SCALE, 3116" - 1'-0' EXISTING ` PLYWOOD SHEATHING WITH TAPED JOINTS
314' T 4 G PLYWOOD SUB FLaOR 15# BUILDING FELT AND 51DING TO MA7ea
GLUED AND SCREWED TO EX15T11VG EXISTING. INSULATE STUD CAVITIES WITH
2 X 8 WOOD FLOOR J015T5 AT 10-tZ.C. R 19 GLA55 FIBER BATTS. FINISH INTERIOR
CONTINUOUS RIDGE VENT _ � ! DOUBLE UP EVERY OTHER JOIST AT \� WITH 1/2' PLASTER BOARD AND PLASTER
i LONG SPAN (+/- 11 b ) SEE FRAMING N VENEER COAT.
PLAN SHEET 1, 1 OF I ��\
CD
ASPHALT SHINGLES TO MATCH EXISTING _ _ I \ _ SECOND FLOOR z Q
ON 30 # BUILDING FELT ON 5/8" PLY- EXISTMG O W Z
WOOD SHEATHING ON 2 X 10 RAFTERS i '� `11
AT 16' O.C. FASTEN TO WALL PLATES fcc
WITH METAL 14URRIGANE CLIPS. I J F. � O
_ ATTIC /
BEARING EXISTING CEILING REPAIR AND > U
❑ I FINISH AS REQUIRED. W 11 1
EXISTING FLOOR, WALL AND ROOF /L�/L�J
FRAMING. VERIFY R 30 INSULATION VJ
CONTINUOUS SOFFIT VENT AT FLOOR AND ROOF AND R 13 AT EX15TING 2 X A EXTERIOR STUD
EXTERIOR WALLS. EXISTING 2 X 4 STUD BEARING iv BEARING WALLS AT FIRST FLOOR
WALL. i VERIFY MINIMUM R 13 INSULATION. W Z /�
NEW VINYL WINDOWS WITH INTEGRAL I w
\,J
45 CASING TO BE "HARVEY INDUSTRIES' i O 'R z
-30BL.. HHG. �L HHG. DDBL 14G. I EQUAL.�DOUBBLLE HUNG 70 HAVE TILT- (Z, Q
_ - _ - _ - , - . - . - . - . - , - . - . - - - 2ND FLOOR I R30GLASS FIBERBATT ! MM
INSULATION. WIRE IN PLACE 1.� F �_
EXISTING
VINYL SIDING AND CORNER HOS. � W
ai EXISTING FLOOR SYSTEM
❑ ❑ ❑ ■
PRE FINISHED ALUMINUM FLASHING - FIRST FLOOR W
OVER PEEL AND STICK MEMBRANE - - - - ' pclsTlnlG
--.-AT INTERSECTION OF ROOF AND
WALL. TYPICALMAI; EXISTING SILL PLATE
_ 157 FLOOR EXISTING WOOD BEAM AT EXISTING CONCRETE BLOCK
- - EXISTING R 10 RIGID INSULATION ON 'T' BASEMENT. REINFORCE WITH FOUNDATION ON CONCRETE FOOTINGS.
CONTINUOUS OB X 11.5 STEEL
EXISTING CONCRETE BLACK METAL FURRING AT 24' O.G. CHANNELS BOTH SIDES. FASTEN
rLE-=E:jlFOUNDATION ON CONCRETE FOOTINGS. I WITH 1/2' 0 STEEL THRU BOLTS APPROXIMATE GRADEcq
AT 12' O.G. STAGGERED.
BEAR ON FOUNDATION
U.
REAR ELEVATION EXISTING PIPE COLUMN SECTION A - ,A Q
SCALE: 3/16° . 1'-0' ALTERED AT BASEMENT
SCALES 3/8" I'-0"
N
A
1
I STORY SHED ROOF BELOW A
1 STORY SHED ROOF BELOW 2X8 CEILING / ATTIC JOISTS --. ..
301-4" AT 16" O.C.
14'-0' 3'-8" L 12'-8' _
"
W-6" - -- Z
_________ ________________ M
0
r__________ _ //__ FASTENRTOFTERS AT 16'WALL PLATES.C.
w �'J o 00 WITH METAL HURRICANE CLIPS. co
v
ROOF BELOW30 X j CERAMIC TILE FL. :9
" LE UP IN
I B E R O O M I $ 3 6 2 FRAME GABLE ROOF OVERHANG
x T HI EY EN ON WITH 2 X 6s AT 16 O.C.
_ ------- ------- - _ _.l ___
W
= I �
I _ 4
cr
IACCEAM"-SS -� INEN 7 I
m - I I X Y DOUBLE UP FRAMING AT ATTIC
--- ----
--------- ------------- ---------------- MASONRY CHIMNEY LI EXISTING V AIR--_ BI" Ol-DS WALK-IN Y `u ACCESS. PROVIDE REMOVABLE
DOWN EXTEND 24' ABOVE -Q ' DOWN I -/ \., ACCESS PANEL
ROOF RIDGE. -- - — . — — -.-- — -
.. /'1
SHE VE5 Zy. $ — _ X I 4J r
_ --
-----------------
B E D R O O M B E D R O O M---------------- L _
O� BEDROOM BEDROO �F---1 Y N
�_ -- - - - - - - I O 2X8 COLLAR TIES AT RAFTERS
- - V I 1
N �
0 Q
I
j
m ROOF BELOW I J 30X80 I
Lo
(A)a
L______________________ _ __ ______ .....
ALIGN
BLOW ELOW
WINDOW ALIGNWINDOW x
U
H
SECOND FLOOR PLAN EXISTING SECOND FLOOR PLAN ALTERED 2 X 0 RAFTERS AT I6" O.C.- A ROOF FRAMING PLAN A
SCALE: 3/16" - 1'-0" SCALE: 3/16' s 1'-0' SCALE: 3/16° 1'-0' S Z
&or
ATTIC / CEILING FRAMING PLAN
- --- - _ A SCALE: 3/16" P-O"
EXISTING ONE STORY CEILING A LLa z
AND ROOF FRAMING TO CUT CY Cc, Z
A BACK AND REFRAME INTO
LL D i N I N G D I N I N G FLOORIOR ADDIITTIONS EE SECTION U p E
UP A - A SHEEP 2 OF 2UP ILL Lu tY $
Qz w
Lu W
----1 0 o L---- ---- o o L---- aO E o
_'- --�
B E D ROOM -I 1' t/ F'
j�1- ERAMIC TILE FL. �n U. EXISTING WOOD BEAM AT Q
�- m BASEMENT. REINFORCE WITH
I - -_ w v I �5
Ix 31- ' 2'-q" '-I
j
K I T C H E N O K I T G H E N n:9 CONTINUOUS CB X 11.5 STEEL
� � CHANNELS BOTH SIDES. FASTEN m r
WITH 1/2' 0 STEEL THRU BOLTS
a 9
AT 12' O.G. STAGGERED.
2-16 X 80 INEN -__ - � BEAR ON FOUNDATION
X(�j
O-O -- SAN 81-FOL WA�K-IN I W-5
O - - -- Z
RI IN UN ER WA
® �u
�j , m 3/4" T 4 G PLYWOOD SUB FLOOR
x 9
GLUED AND SCREWED TO EXISTING ru
L I V I N G BEDROOM L I V I N G B E R O O M NF. 2 ;X 8 WOOD FLOOR JOISTS AT 16'
uj
Q O.C. DOUBLE UP EVERY OTHER //��
III @ X 114N J0115T AT LONG SPAN (+/- 11'-b') a:
N_N_ W
U �
_
RPR-13-E009(MON) 16: 16 Imaginative Ins P. 001/001
,q a� CERTIFICATE OF LIABILITY INSURANCE DATE RAM pD YYYY)
04113/2009
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Imaginative Insurance Products, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
511 Washington Street HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Quincy, MA 02169
ALTER THE COVERAGE AFFORDED aY THE POLICIES BELOw.
Ph: 617-773-0205 Fax: 617-773-0232 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURcRA; Atlantic Casualty
The Home Doctor Inc. NsURER a. PnIgraftaiw -
29 Cottage Ave Suite 9 wsuneR c Liberty Mutual Ina Co
Quincy, MA 02159 INSURER0
INSURER G
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIPICATE MAY BE ISSUED OR MAY
PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR IkUb)l TYPE OF NSURANCE POLICY NUMBER Dp MMI LIMBS
GENERAL LIABILITY
71/ OPMMERCIALGENERALUASILTTY EACH OCCURRENCE $ 300,00
�CLAIMSMAOE 0 OCCUR 3484 04/03/09104/0312010 B0°rs0,000
MED EXPM mw @Penarson $$ 51000
A PERSONALSADVINJURY S 300,000
OENERALAGGREGATE § 600,000
GENL AGGREGATE LIMIT APPLIES PEFL PRODUCTS-COMROPAGG f 300,000
V POLICY PROJECT LOC
AUTOMOBILE LIABILITY
ANY AUTO MBINED SINGLE LIMB §
a dtlenl)
ALLOWNEDAUTOS
B J SCHEDULEDAUTOS 05363546-0 04/03/09 04/03/10 iv°aOlI�wuRr § 20,000
HIRCD AUTO$
NON-CWNED AUTO$ BODILY ILUURY § 40,000
IPW=d ml
PROPCRTY AMAGE $ 100,000
IPor accidwrt�
GA RAGE LIABILITY AUTO ONLY-EA ACCIDENT E
ANY AUTO �T�N{Fp TiJN(k� EA ACC $
R- &%ITL N AGG E
FEXCESSIUMBRELLALARN.RY EACH OCCURRENCE E
OCCUR CUIMS MADE AGGREGATE §
DEDUCTIBLE $
RCTENTION f
S
VIORNER9 COMPENSATON AND TORY LIMBS GR
EMPLOYERS'LU1BIlITY
ANY PROPRIETORIPARTNERIERECUDVE WC1-31s-367513-018 06/21/08 06/21109 E.LEACHAOCOENT § 100,000
C OFFICCWMEMOER EXCLUDED!
Ms.dasObeunder ELDmfsaq-FAEMLD/EE 5 100,000
GAL PROVISIONS balm
ER CL DISEASE-POLICY LIM S 500,000
OTH
CERTIFICATE HOLDER CANCELLATION
Town of Salem SHOULD ANY OF THE ABOVE OESCRBgD POLICIES BE CANCELLED BEFORE THE EXPRATON
DATE THEREOF,THE SSUING NSURERWLLRNOEAVORTO MAL 10 DAYS wnrrMN
Fax: 978-740-9846 NOTICE TO THE CERTIFICATE HOLDER NAMED TD THE LUT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLGATTON OR LLIBS.ITY OF ANY MID WON THE NSURLR,ITS AGENTS OR
REPRE99WATNES.
AUTHORLO:D munmSENTATME
R Love
ACORD 25(2001!08) OACORD CORPORATION 1908
CITY OF SALEM
`i ,'�,' ; PUBLIC PROPRERTY
DEPARTMENT
�5.�
\I\III:M:11':Ix l•l•�I I
\I\•.•at IY W,\uuS\:I,x.N S 13[I,r a au hN,M.SssU 111 it I IS 3197'
71,1.718.7113-9545 0 P Sx 978.74;;'18+6
Workers' Compensation Insurance kfftda�it: Builders/Contractors/Electricians/Plumbers
y tilt Ont Infunnrlion �} _ Please Print Lejjbly
Ninn :IDu.ukvst)r�anlratinNlnJluduul l: sT1r- �txYy11 fir'-M'�
lddress: 55 ® AOCMS Skxte¢�
City,State,Zip 2t Thuneil: SOA-7kV- e20z
.\r¢ ya an employer." Check the appropriate box: 1)Pe of project(required):
i 4. ❑ 1 am a gcnural contractor and I 6i New construction
I. 1 :un a employer with ❑
cnglloyccs(full ind/ur part-untC).• hate hired the suh-curoractors 7. ❑ Remodeling
?.❑ I ship
a sola have
o em to partner-
listed on the attached sheet.
ship and have no employees These sub-tontractnn have S. ❑ Demolition
working for me in any capacity. \Workers' comp. Insurance. q. ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a unporation and its 10.❑ Electrical repairs or additions
officers have exercised their
I cd. a "o
rerun t m repairs Or additions
J ri ht of exemption a hICiL I L❑ I tun b b p
3.❑ I nm a homeowner doing all work g P P'
myself [Ko workers' comp. C. 152, ¢1(4),and we have no 12.❑ Ruof repairs
insurance reyuired.J t cmployccs. (Ko workers' 13 Ll Other
comp. insurance required.]
•any.�,pbcua that checks boa nl must alto lilt out the wxllull Iwduw.bowing their wurkus'cunlpion p
enta ulicy unsir ion
I I lomeawmn who submit this antdavit indicuing They are Joing ell work and dtcn hire Wilkie I:aturxtan must tuhmil a new al'GJavit inJiwbng.uch.
-Comrxwn this thnk this box meet ntxhcd an aJditimal sh"".hawing the'tante of the sub:omrxtors and their wurkon'comp.pulicy mfwmatiun.
/can an employer that is providing worAers'eum vision insurance for my emplayees. Belnty is the policy and job.elle
information
Insurance Company Name: 1 -
I+olicv 4 or Self-ins. Lic. r+: _ . .. -__ Expiration Date:
lob lite Address: *ug Lo-missa.i" - StC_y-. C'ny;Stata Zlp: MSI
Attach is copy of the workers' compensation policy declaration page(showing the policy uutaber and expiration date).
I;ailuro to Secure coverage as required under Section 25A of>IOL c. 152 eau lead to the imposition of criminal penalties of a
tine up ht S1.5oo.00 andilur one-year imprisonment, as well as civil penahics in the funis of a STOP WORK ORDER and a fine
of up to)'_50.00 it day against Ilse violator. lie advised that a copy of thisStatement may be furca arded to the Office of
l u\:on�uunns cl the DIA :or Irtiurarcc co\cra 4l; \arilicalmn.
/ to hereby c crtifr under the painv and penalties of perjury that the lnfuronutlon provided above is true acrd correct.
OlJicial u.+e mdy. Do 1mr n•rite in this area, to he completed by city or town official.
('ill, or fawn- --_ -- PcrmioLiccnse g_ -
ISSuing.tsulhuriiv (circle ane):
t. i4ard of Millis 1. Building Depanuteut .l. Citl.'I'onn Clerk J. L'Icctrical luspecro� i, Plumbing Inspcetor
6. Other
Cunwet l'cnmlt .. -- Phone H:
f
Information and Instructions
\la�sachuscts Gcncral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Punu;mt to this .utuic,an empluree is defined;s"_.every person in the service of another under any contract of hire,
cypress or impficd, ural ar written."
An empluper is defined as"an Individual, partnership,association,corporation Ur Other legal entity, or any two or more
.11 the h,regolng engaged in a joint enterprise, and including the legal representatives of a deceased cmpluycr,or the
receiver or trWlCe ul au individual,piumer)hip,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."
\1GL 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."
ldditionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance utpuhlic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill 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 docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
\ccidents for confimtation of insurance coverage. Also be sure to sign and date the affidavit. The allidavit should
he returned to the city or town that the applicd6on for the permit or license is being requested, not the Lkpartment 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'rown Officials
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.
111;ase be sure to fill in the pennitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/liceuce 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 rile for future permits or licenses. A new affidavit must be filled nut each
Year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
i.e. it dug license or permit to bun leaves etc.)said person is NOT required to complete this affidavit.
I he t)I tice of lthvestigationl wuuld line W thank y'ou nth advance far your cooperation and should toll Iias'c any questions,
Please do nut hesitate to give us a call
The Dcparrhncm's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investlgatlons
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749 -
www.mass.gov/dia
i
CITY OF SALEM
r PUBLIC PROPRERTY
'ItsDEPART'�TENT
,:
I l l s V's •4;.);;J; ♦ 1 'i'8 '4:98L.
Construction Debris Disposal Affidavit
(required lbr all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 C'MR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
T�UmftAec DP-fet
tname of hauler)
I he debris will be disposed of in
9vmastQ.c_..S�fbi' __
(name of facility)
taddres, of Iacilitvl
Signature of permit.applicant
date