166 BOSTON ST - BUILDING JACKET CITE" Ot S.Al.l \I
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APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMI.1'
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: Applicants mull complete all items on this page
SITE IN'FORM,1"1'1y/N• r..� - --
Location Name �!"� .a1I tI/- Building
Properly Address
Located in: Conservation Area Y/N Historic district
AI'I'LICATIONDATE //J' 0,e�0/
Use Groups
(check one) -
Group Humes R3 Ra_ _
Residential Q or more Units) R2•
Type of improvement Residential (hotel/motel) Rl _
(check one) Assembly (Theaters) Al _
New Building_ Assembly (restaurants & clubs) A2r_A2nc_
Addition Assembly (churches) Al _
Akeratiunglw: Business B_
Repair/ Replacement —V,� Educational E_
Demolition_ Factory (moderate hazard) F1 _
Move/Relocale Factory(low hazard) F2_
Foundation Only High Hazard 11 _
Accessory Building Institutional (residential cave) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile NI _
Storage S1 _Mnderuc 1-I:Iz:ud
Storage S2_Low I Lvard
ON'.NE RSI IIP INFORMATION(Please tN a Print Clear) � ---�
0WNER Name o ,
Address
Telephone
Signature
1)I•:SCItIPT1ON OF %%O K TO B :1' :It!'OIL'11F.D
//D 9 l� d
ES I I:MA I ED CON'ST RUCTION COST ,/foci•
SAA-0 7-0
!(ob ffl,:�r.04 irT•
C'l IN'I RAC'I'Olt INFORMATION
Name
Address
Telephone `oZ
Construction Supervisor's Lic #
Home Improvement Con tractor #
.\RCili l'I•:CUENGINEER INFO"IATION
Name
Address_
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
_ W
Estimated Cost x $11/$1,000 + $5.00= �J
COiNI NI ENI•S
The tindersigrred applicant does hereby attest that all information stated above is trite to the best of my knolvledge
under the penalties of perjury
Signed (owner) (agent)
APPROVED BY :
DATE APPROVED:
CITY OF SALEM
PUBLIC PROPRERTY
DEP AR"I'MENT
ry
': \\ .\,ni��.,,e<lrn:rr • 1\I ul, \L\,; I . :Irl '_
III: '/'8-Vj.9j4J5 I'\Y: '),8 '4 ,.i4
Construction Debris Disposal Affidavit
(re(juired I'ur all demolition and renovation work)
In accordance n ith the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resultin.- from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
9
(name of hauler)
I lie debris will be disposed of in
(name ut laclhty)
(addre,s ol'facililvl
y0�
,Igualure of psmit applicant
,late
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:I It RI FY'DA MA OLL
MEscm 12C WASHI.N6toNS'rxehf • SALEM.MASSACIn XIA IS 01970
'ftu.:978-743-9595 # h:%x: 978-740•7846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A ) )licant Information Please Print Le ibly
,
.latmd tBusiness/Org m7atioNlndividual):
Address:ar �A�
Cityistateizip: Phone rt:�?�
:\re you an employer? Check the appropriate box: 'Type of project(required):
I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
e yloyccx(full and/or part-time). have hired the sub-contractors
2. 1 ton a sole proprietor or partner- listed on the attached sheet. ; 7. [�Itemodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in an capacity. workers' comp. insurance. 9, Building addition
b Y ' P� Y• ❑ g'
INo workers' comp. insurance 5. ❑ We are a corporation and its 10.WE'lectrical repairs or additions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.�lumbing repair or additions
myself. tKo workers' comp, C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) r :employees. Li o workers'
comp. insurance required.) 13.❑ Other
-.Airy up pltcant that checks box of ma>t AI>n IIII nUl ttlC\l'ltlJll IN:IUW ilWWlnjl tbClr N'O(kl<Y compcnulion policy intiumation.
'Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors moat submit a new al'fdavid inditasing weh.
-Cont rxtun That chock this box must attachdd an additional-heel showing the name of the subvontractors and their workers'comp.policy informarion.
/any an eutpfayer that is providing workers'compensation insurance fur my employees. Below is the policy and job site
information.
Insurance Company Name: ....._
Policy 4 or Self-ins. Lic..tt,: �y (� ._...____ Expiration Date:
Job Site Address: ��i7 /T/Af�4 V� City,,State/Zip: j ev ?,o
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 of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violator. De advised that a copy of this statement may be furwarded to the Office of
Invrstigalions of the DIA for insurance coverage verification.
l do hereby c•r ' rider the pains/spud pent es of perjury that the information provider/above is true and correct.
Sienauura:
�` -//�� /�J Data / OC��2
Officiu!use only. Do not write in this area,to be completed by city or Town official.
City or Town: Permit/License
Issuing Authority (circle one):
1. hoard of health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ ____ Phone#:
Information and Instructions
D9nvachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplgree is defined as"...evey person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the IJreLomg engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,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."
MGL 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."
.additionally, b1GL chapter 152, 325C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements 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)name(s), address(es) and phone nwmber(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 carry workers' 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 that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicetse 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 "rill 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 roust be tilled out 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 dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
the Oificc of Investigations would like to thank you in advance for your cooperation and should VOL] have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia