9 FLYING CLOUD LN - BUILDING INSPECTION What is the current use of the Buildi ?
Material of Building?_Li Qo dwelling.how man units?
Wilt the Building Conform to Law?
Asbestos?
Architect's Name
Address and Phone 1
Mechanic's Name ° l
lli s Sf e ' dc9 `l,
Address and Phone
Construction Supervisors Uc,e�nn^se 5
S HIC Registration M
'N - Permit Fee Calculation
Estimated Cost of Project
Permit Fee i 1 Estimated Cost X S7/51000 Residential
_-- _ -- .-_--- Estimated CostX$il/51000Gommerciat---------
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Pe rtfrtTo' uild to the above stated
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specifications. Signed under penalty of perjury
Date
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EITy--OF
PUBLIC PROPERTY
DEPARTMENT 32&
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MAVM 120WA"N=Wb'i1 "•IMA. 4MAMACIMSgIS01970
TEL-97e474S.MS•FA1e M740.9M
APPLICATION FOR TIIE REPAIR RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCOMAN FOR ANY FMSTINCI
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Nana: Building:
--- ----- -
Properly Is located In a.Conservadon Y/N Hatarlc Dlshid Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: _
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Neer
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Bdef Description of Proposed Work:
C �
-lam d� + e-
-- -Mail Permit to:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wtstnrRIXY uatSt:04-1
MAY(* 12C Vfastaw'fontS EE r a SALEM.MASNACI11.1T.'1'1\0197r
Tta:97111-743-9595 a FAX:9M740.9946
Workers' Compensation insurance AtQdavit: Builders/Contractors/Electricians/Plumbers
Anniicant Information Please Print Leeibiv
Name tau%iiwu/Orgsni:ationtindividmi):
Address' )�� ✓� S 1
City/smccizip: +�lc� e�CS�E� phones: Oc)�{ O
Are you an employer?Check the appropriate box: 'type of project(required):
1.P 1 am a employer with ;1-- 4. ❑ 1 am a general coutractor and 1 6. ❑ New construction
employees(full uul/or put-tine).• have hired the sub-comractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet ?• Remodeling
ship and have no employees Them wbcortuactors have S. ❑Demolition
working for the in any capacity. workers'comp. insurance. 9. ❑ Building addition
[no workers'comp. insurance S. ❑ We are a corporation and its
required.)
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. (No workers'comp. C. 152,§1(4),and we have no 12.0 Ruof repairs
insurance required.) t employees. [No workers' r 13.❑Other
comp. insurance required.]
'Amy:tpplicam the dwcks has 01 map also till ma the section below showing their wurkes'aanpenawiue pAiKy infunwA m,
'I luntaowners who submit this affidavit indicating Ilrry ate doing All work and then hie outside cantrnotors must submit a new amdavit indicding s h.
-Ca nwtun that chock this box must attached an additional shm showing the name tithe wb-contrxton and their workers'comp.policy information.
i am an employer that Is providing workers'contpensadon insurance for my employees. Below is thr po/fay and Job silo
information. �—
Inurance Company Name:
Policy q or Sclf-ins. Lie. #: _ Expiration Date:
t
Job Site Address: 2 �w G'A capstawZip: "'e'
Attach a copy of the workers'6mpc!itsatlon policy declaruNou page(showing the policy number and expiration date). ..
Failure to secure coverage as required under Scction 25A of.\,IGL c. 152 can lead to the imposition of criminal penalties of a
fine 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 5250.00 a day against the violator. lie advised that a copy of this statement may be forwarded io the Office of
Int.angauutu of the DIA for insurance coverage vcriticatiun.
do hereby ce 'y as er-tithe pains andd�penoldes of perjury that rise information Provided above is true and correct.
tii•:,:tlure. �N-C_. `�-'^- Date. l 7
v
Clans a -z8ST 6046
OJJleAd use only. Do eat tvrire is Mls area,lobe completed by city or town offichd
City or'rovrn: __, PermiNl.icease 11
Issuing Aulburity(circle one):I. Ilr,ard of health t. Building Dcpartment 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
C.outaet Person: . _ _ _ Phone p:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employers.
Pursuant to this statute.an employee is defined as"...every person in the service of another under any contract of him
etpress or implied,oral or written."
An empfoysi is defined ss"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 uusum of an individual,partnership,astahciatioa at 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."
AtGL chapter 152.¢2SC(6)also states that"ovary 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 commenweakb for any
applicant wbe has ant produced acceptable evidence of compliance wit►the insurance coverage required."
Additionally.MGL chapter 152,§25C(7)sates"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 nil out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary.supply aubcontraceor(s)name(s),addresses)and phone number(s)along with their cortificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partrnerships(LLP)with no employees other than the
members or partner,are not required to carry workers'compensation insurance. if au LLC or LLP does have
employees,a policy is required Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insuranco 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 boa sure that the affidavit is complete and printed legibly. The Department has provided a speed 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 as a reference number. In addition,an applicant
that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Addresi'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 pennit not related to any business or commercial venture
i i.e. a dog license or permit to burn leaves etc.)said person is VOT required to complete this affidavit.
I'hc Otii,x of ilivestigalions would Cue to thank you in advance for your cooperation and should you have any questions,
nlcaee do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
O®es of lavestiptloos
600 Washington Street
Boston,MA 02111
Tel. k 617-7274900 ext 406 or 1-877-MASSAFF
Fax M 617-727-7749
Rcvi>cd S-ZG-oS www.maw.gov/dia
r CITY OF SALEM
PUBLIC PROPRERTY
DEPARTv1ENT
%L\„•M 1 Vr.\911W::ot�s
To: AW4J-,)M •F- 976-74Cr9M
Construction Debris Disposat Affidavit
(required ror all demolition aid renovation work)
In accordance with the ninth edition of the State Building Code, 7S0 CAiR section 111.5
Debris.and the provisions of MGL c 40.S 54;
Building{Permit N _ . ._ 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
11 t. 4130A.
The debris will be transported by::
— — (name of hauler)
the debris will be disposed of in
(nameO(latl:lty) 7
i..d.:rc.� of YaiiLl;q
.Jt�