11 CHURCH ST - BUILDING INSPECTION 206 Crry-oF-SA%1Ll2.XN1i - --
PUBLIC PROPERTY
DEPARTMENT
N{\MGM CV ORLSCWl
N.�volt 120 Wwutw'mu b'rW=0 S LbAk Ywsuau -1-M 01970
To-97 USAWS•FNC VW740-9W
APPLICATION FOR THE REPAIR. RENOVATION. CONSTRUCTION.
_DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION J
Location Name: Building:
-- -- Property
Property is located in a:Conservation Area Y/N Histortc District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land D\nw L UL _
Name:
Address:
Telephone: Q — 14 [ - 5-7 2
3.0 COMPLETE THIS SECTION FOR WORK IN EYISIINCI BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: �n
'Z
-----------Mail Permit to: ------ __.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\tll:[RI 11Y DRISCOLL
NIAMR 120 WASHING)ON STREET♦ S.LLEM,MASSACf ISp:1 IS 01970
Tiil.:978-745-9595 • FAX:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information tt, 1 Please Print Legibly
Name (Business/Oreanizatilor11Jlndilviiduul)):/ 1Ck it Lb d e
JlQ (Y�
City/Statei'Zip: kJGlnn ,c t ` n Phone >
Are you an employer'.'Check th ropriate box: 'type of project(required):
1.❑ 1 am a employer with ✓ 4. ❑ I am it general contractor and I 6 ❑new,construction
em tlo ees full and/or art-time).' have hired the sub-contractors
t Y ( P' 7, ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers' Cora insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL i I.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work g P P'
myself. [No workers' comp. c. 152, y 1(4),and we have no 12.❑ Roof repairs
insurance required.j t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any applicant that checks box#1 must also Jill out the section wlow showing their workers compensatiun policy infurnution.
'I tomeowmm who tubmil this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
iContmctun that chuck this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I ran un employer that k providing workers'compensation insurance fur my eniployeca. Below is the policy and job site
information.
Insurance Company Name: �.- _.-�- m --- ��/} Gt
Policy k or Self ins. Lie. f::�1` 13 I S 31 1 3 13_bj=✓7_1 l Expiration Dater+_'" "--0 VC
Job Site Address: 1` C�uPS�, S�_ City/State/Zip: &L h, (0 I )0
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:`4GL 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 font of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Bc advised that a copy of this statement may be forwarded to the Office of
lavrstigations of the DIA for insurance coverage verification.
l do her•by tij n<ler nun(s�rntd l�naltics perjury that the information provided above is true and correct.
Si �natu _ ' W/'��/`^' LEA Date'L9 -
phl �.ql`h -y bC121
Official use only. Do not unite in this area,to be completed by city or town official.
City or Town: -- ___-- Permit/License —
Issuing Authority (circle one):
1. Board of licalth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector
6.Other
Contact Person: - _ Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.cnmployaes.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
Art employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing 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, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfonmancc 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-contractors) name(s),address(es)and phone nuniber(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 fill 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 ass reference number. In addition,an applicant
that must submit multiple pennit/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 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of investigations would like to thank you in advance for your cooperation and should you 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
Oftfee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax #617-727-7749
www.mass.gov/dia
CITY OF SALEM
3 i PUBLIC PROPRERTY
DEPARTMENT
\t.�rCK 12C WAS)It\GiON*St'REET • SALV%11. MAUAC,it.S[l'ISC191C
TF.I:978-745.1595 . F.+x:979-7iG9ai6
Construction Debris Disposal Affidavit
(required for all demolition attd renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit At _ _ 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 I50A.
The debris will be transported by:
(name of hauler)
Hie debris will be disposed of in
(name of facility)
.. . _._ ._ iadilresa of facilely)
— "i_::atu,� ol,)crn;ita(;p.iuot ----
•:aIC
J �
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 100098
Type: DBA
Expiration: 6/92008
CHET'S CARPENTRY
Chester Dembowski
2 VALLEY ROAD
Danvers, MA 01923
Update Address and return card.Mark reason for change.
DPS-CAI O 50M-0 -PC8490 0 Address Renewal Employment Lost Card
Board of Building Regulations
One Ashburton Place, m 1301
Boston, Ma 02108-1618
License: CONSTRUCTION SUPERVISOR LICENSE Birthdate:. 07/10/1953
Number: CS 055465 Expires: 07/10/2008 Restricted To: 1G
CHESTERJ DEMBOWSKI
2 VALLEY RD
DANVERS, MA 01923
Tr.no: 26885
Keep top for receipt and change of address notification.
DPS-CAI 0 50MM/SPC8M
What is the current use of the Building? CC) �v
Material of Building? It dwelling.how many units? '
Will the Building Conform to Law? ?
Archited's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Constru tion Supervisors License# OS LW S HIC RegistMtbn# ULoo�101
G7 Estimated Cost of Project Permit Fee Cak,uta W
S —
Permit Fee i� Estimated Cost X$7r51000 Residential
Estimated Cost X$11/i1000 Commercial--------- -
An Additional $5.00 Is added as an
Administrable charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the a e stated
specifications. Signed under penalty of perjury
Date
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