49 AURORA LN - BUILDING INSPECTION (2) PUBLIC
F------;VK1CA'r1ON FOR PLAN EXAMINATION AND BU I LDtN(; PERI -Tr
ALL STRUCTURES EXCEPT] AND 2 FAMILY DWELLINGS
IMPORTANT:Applicants must complete all Items on this page
SITE INFORMATION
Location Name /jzo Building
property Address 4/
Nflip 9
Locatcd in: Conservation Area WN Historic district Y/N
Use Groups
(check one)
Residential (3 or more Units) R2
1�vpe of improvement Residential (hotel/motel Rl —
(check one) Assembly(churches) AI
New Building Assembly (nightclubs etc) A2
Addition Assembly(restaurants, recreation) A3_
Alteration Business 6
Repair/Replacement Educational E
Demolition Factory(moderate hazard) FI
Move/Relocate Factory (low hazard) F2
Foundation Only,_. High Hazard If
Accessory Building Institutional (residential care) I I
Other(describe) Institutional(incapacitated) 12
Institutional(restrained) 13
Mercantile IVI
Storage(moderate hazard) SI
Storage(low hazard) S2—
OWNERSIIIP INPORMA1]ON(Please type or Print Clearly) 7
OWNE`,R Name Vkl-46W W41H7
Address.,—OV 141, g2e��4kg�
Telephone —09 0)
60) '73(p �
RIP OF WORK10BA Pk" FORM Di
v V
L/
FSTI-NIA-1 ED CONS1 RUCTION COST 7949
1
CONTRACTOR INFORMATION
Name 30llw filllliTs9�s1f�//1L7� s�Sl'�OOTif�CsrS /l,
Address
Telephone y 3
Construction Supervisor's Lic #
Home Improvement Contractor#
ARCAITECT/FNGINEER INFORMATION
Name
Address
Telephone
Mass. Re,-istration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $1 1/$1,000 + $5.00= 90, 00
COMMENTS
The undersigned does hereby attest that all in/oruzation stated above is trite to the best
of my knowledge tinder the penalties of perjury
Signed
Date
CITY OF SALEM
PUBLIC PROPRERTY
�- DEPARTN1ENT
VLv:t tH I_'� At.vsl iiN,,[,INS lIt I l • S.vI i NI, AI.v�i Ai 111 q I
I'I.t: ')-8_,43 );,)5 ♦ F,X: 9, 8.?a=')S4u
\\'orkers' Compensation Insurance Af idwit: Builders/Contractors/Electricians/Plumbers
Ii l nlicant Information // �/� ♦y/y/� (,/'��y/ 'Nyllee�aasseee Print Leeibly
\;l Ill I Iluawc„ t h'gani/atit m.Ind IN iduall:
ALWICSS:
city,stateiZip: �'! X , D 7AA0 Pilone
tire vuu anent plover? Check the appropriate box: Type of project (required):
I L
,�y'1 um a employer with_ P_— 4. 6. 0❑ 1 am a general contractor and 1 New construction
cmpluyees (full andor part-time).* have hired the sub-contractors Remodeling
?.❑ n I :u a sole proprietor or partner-
listed on the attached sheet. 7.
ship and have nu employees These sub-contractors have 8. ❑ Demolition
working for the in any capacity, workers' comp. insurance. y. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its ME] repairs or additions
officers have exercised their
required.] 1 1. Plumbing repairs or additions -
3.❑ I am a homeowner doing all work right of exemption per MGL ❑ g P
myself, [No workers' comp. C. 152, §1(4), and we have no 12.�oof repairs
insurance required.] ' employees. [No workers' 13.0 Other
comp. insurance required.]
•:any.ippllcLut that cheeks boa 01 must also till out the section below showing their workers'compensation policy information.
I Iontcowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
:(',muaciors that check this boa must attached an additional sheet showing the name of the sub-contractors and their workers'comp. policy information.
!am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information. )
Insurance Company Nana: /
Policy #or Self-ins. Lic. #: r6�0a�}E7/T 008 ad,D Expiration Date: �'• 6���� /J p
Job Site Address: . /�L/ C�e City/State/Zip: ✓�!/e'�"�/Ai r
:attach a copy of the workers' rnmpensation policy declaration page (showing the policy nu mher and expiration date).
failure to secure coverage as required under Section 25A of,%1GL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 :tad/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a tine
of up to S250,00 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 cocertge verihcanon.
!do hereby k.cirri.' under the pain, and penrdtics of perjur}'drat die infurmulion pruridedi} rue anJ correct
i_n,tntre:
Phone ;
U/jiciul rice only. Do not write in this area, to be rontpleted by city or town official
City or To„it: _ _—_--—.— — ------- Permit/License #__--- _--
Issuing .Xulhority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
0. Other
Contact 1'crsun:__--_ — ——— Phone #:
Information and Instructions
Nla»acht IS •us Coe Ile rah La%sS chapter I 5' Icquues all emp Io%ci's [op I m ide %corkers' compensation for their cnlpfi»ees.
I'ursu.uu to this ,time, .111 emplowe is defined as *'.. c%ere person in the sci%ice of:norther under anv contract ot'hire.
cyvc.s or implied. oral or %when...
.1n einpLt l'er is dctined as "an indi%:dual, partnership. association, corporation or other le,al entity. or any two or more
"t the tolcgoing engaged in ajoint enterprise• and It1Cltidillg (Ile leg aI rrprc•.;rntati�es of a deceased etnpluver. or the
recei%cr or trustee of an individual. partner>hip. association or other legal entity, cmplo)ing employees. ilo%vever the
uh%ner ofa d%%elling house ha%ing not more (haul three apartments and who resides therein, or the occupant of the
dh%cllini house of another %%'ho employs persons to do maintenance. construction or repair work on loch dwelling house
or Om the grounds or building appurten:uu thereto shall no( because of such enlplo)ment be deemed to he an employer"
\I(1L chapter 152, §_'5CI6) also states that "every state or local licensing agency shalt 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."
Additionally, \IGL chapter 152, J2SC(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perRnniance of public work until acceptable c%idence of compliance with the insurance
requirenhents of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) nanie(s), address(es) Lind phone number(s) along with their certificate(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 carryworkers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department 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 Town Officials
Please be sure (hat the affidavit is complete and printed legibly. The Deparauent has provided a space at the bottom
of(he affidavit for you to till out in the event the ORice of lm'estigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license 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 file for future permits or licenses. A new affidavit must be tilled out each
year. Where a hone owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The ()(five of Investigations %could like to thank you in ;advance for your cooperation and should you have any questions, -
please do nor hesitate to give us a call.
the I)epartnlent's address. Telephone and fix number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
ILc%isul5-'_6-05
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
i
DEPARTMENT
\t'. N I!� `X'Ail II\��:JN�acET • �.\l. N, \f.\,i.\� :i: .i. ..'1'�
(F I
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p _ is issued with the condition that the debris resulting from
[his work shall be disposed of in a property licensed waste disposal facility as defined by V1GL c
111. S 150A.
The debris will be transported by:
(name of hauler)
I'I,e .!,:br.s will be disposed of in
1 aJr..e�t tua.lty)
i