15 AURORA LN - BUILDING INSPECTION (2) CITY OF SALEM
' PUBLIC PROPRERTY
-
) .
•:��. DEPARTMENT
MAYOR 120 WAS]11VGfONSTREET • SALr\i, \11ASSACc lt.SE VIS01970
TE1:978-745-9595 FAx:978-74G9846
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 l 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111,S 1.50A.
The debris will
be transported by:
Elie debris will be disposed of in
(name of taciLt
I altl(fCl1 J I 1 aC:�ll.J)
-
i ne t,ommonwealth of Massachusetts
Department-of Industrial Accidents
Office of-Investigations
600 Washington Street
Boston, MA 02111-
www.mass.gov/dia QLO�lII Ofr[IITg1l11T
Applicant Information
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plurlabers
Please Print LeQib)
Name (Business/Organization/lndividual):_ T
Address:_ �JLI5 ' T.X,ZfA(AjUDL S 1-
City/State/Zip:_ ( �CiYSQ r Phone #: sn
Arrryee�iyou an employer? Cbec appropriate box: -
1. `LrJ I am a employer with 4. ❑ I am a general contractor and 1 Type of proje:dd
ed):
employees (full and/or pari-rime).' have hired the sub-contractors 6. ,❑/New construction
2. I ama sole proprietor or partner- listed on the attached sheet t �• iYJ Remod
ship and have no employees - These sub-contractors have 8. Demoli
working for me in any capacity. workers' comp. insurance
[No workers'comp, insurance 5: ❑ We are a corporation and its 9' ❑ Buildiarequired.] officers have exercised their 10.❑ Electricor additions3. I am a homeowner doing all work right of exemption per MGL I1.❑ Plumbinor additions
myself. [No workers' comp. c. 152,§1(4), and we have noinsurance r vired. t. 12:0 Roof rep
required-] employees. (No workers'
comp. insurance required.] 13.❑ Other
Any applicant that checks box dl muss also fill out the section below showingtheir workers'co t Homeowners who submit this atTdavit indicatingthe are doing all w rrtpensanon t'°hey information;
Y g showing
and then hire outside contmgors mint submit a new affidavit indicating such
tContrectors that check this box muss attached an additional sheet showing the name ofthe sub-cunlraetora and their workers'comp.polity information. j
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: V\tt 0 '
Policy#or Self-ins. Lic. #: �_ ' ! /
Expiration Date: O'x
Job Site Address:
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 ofMGL c. 152 can lead to the imposition ofcrhninal penalties ofa
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOPWORK 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 for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature, ' '\ •� p
— Date:
Phone#:
ff
==Other
only. Do not write in this area,to be completed by city or town officiaL
Cityn:
Permit/License#
ority(circle one): -
ealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
on
Phone#:
� GrrY-Ut�SA.E� -
PUBLIC PROPERTY
DEPARTN ENT
�t4nEtlI.LY Nwr•
N Grp 130 WAUUX=W 2fUW•3�utK�IAirAQRSg1i 01970
I%L-M745-"".*FAM Yfe 7�49e1e
APPLICATION-FOR THE REPAIR. RF.NOVATrnrr_ CONSTRUCTION
DRr[OLITION. OR QW.GZ OF USE OR UOMP N Y__ FOR ANY RRISTING
STRUCTURE OR BUILDIN -
1.0 917E INFORMATION
Location Name: Building
Property Addrosc- -
U rorrA Ln .
Property ki kxxaied Ina;Co MM110n Ana Y/N Hlstorl0 DlsM YIN
2.0 OWNERSHIP INFORMATION
9.1 Owner of Land
Name: [ Qra
Address. Same-
relephorle:
3.000MPLETE THIS SECTION FOR WORK IN UILDINGS ONLY
Addition *N"
Renovation Number of Stories
Change in Use
Demolition Existing
Approximate year of Area per floor(sf) Renovated
construction or renovation
of existing building New
Md Description of Proposed Work:
- Mail Permit to: 11
Oru5+*,r1 G- cn &07
What is the Current use of the Building?
Material at Building? '"- If dweltkg.how many units?
we the Buhq Conf m to Law? e Asbestos?
Archmdo Name
Address and PhorA — l )
MedmmWs Name O
Address and Phone !it 70 (Co`S q7Z
Consbudfon Supervisors License tr
HIC RegMmtbn s
Esrinated Cost' �. () pw"Fee Calwlatlan
Permit as
! Estimated Cost X i7/s1000 Residential
Eadrnated Cost X 511/:1000 CO MMWC'd----
An Additional $5.00 in added as an
Ad minMni#ve charge.
Make sun that an fields are properly and legibly written to avoid delays In proeessirg.
The undeml ned do" hereby apply for a Building PamQt to build to the above stated
spe .ifbatims. Signed under penalty of perJury
Date
b
� N
N
s
2
i- a_