161 FORT AVE - BUILDING INSPECTION Wlhat is the cement use of theeuiidtnp?
mats"of qu~ ad,— it wMi &I&how nail unft?—
W ill Me&AdbV C=ft m to Law? Asbedm?
Arohileds NameAddrew and
ma's Narne Oe¢N
Address and Phone HIC RepMtratWn f
E ,OOG Pena Fee Calo+lallon
E. Fee S d Es&rAwd Coat X S?If1000 Residential
pennaEs*naNd Coat X$41/$I000 Conrnmdsl --—An Additional S&OO in added as an
Admkdatrativa dlar0
Make an that ati flows an Propery and wgoY written to avoid d~In DroossdnlF
The undenlpned does herby aPON for a SumduV Penn*to buld to the above stated
apaoiflptlons. Signed under penatiy of perJury
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crrrors FM
Y PUBLIC PROPERTY
DEPARTMENT
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AlPLICATION FOR TM RUAIA. RZNOVATIIDtk rnNcarf:>rt�-rrnN_
DEKOLMON.OR CHANGZ OF USZ OR OCCUPANCY, FOR ANY ZXLV G
CTURZ OR
1.0 an INFORMATION
Location Nam 777
-- .. 7�714—
ftapanyAddraaac -- --- _ — --- - -
Properly Is bowled In a;Conearva0on Arne Y WANNto DwM Y
2.0 OWNEROW INFORMATION
11 OWW of Land 7�
Narwx
Address: A/
TNaphorw. YI- 3f"?�
30:00LETE THISI SECTION FOR WORK IN E u== M UILDINOS ONLY
Addition ExtstMp
Renovation Number of Stories Renovated
` Change h Use New
Demolition Existing
Approximate year of Area per Roar(at) Renovated
construction or renovation
of existing building New
adef Description of Proposed ork:
--- -- ---Mail Permit UK (� c<-
i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
bt\IncRUY USMOLL _
N.\Y<7a 12C 11/AWLV:'fONS'ntmr a SA UK 1tAIISACYn. 7as 019y0
'rra.:9711.743-9595 a F.ax:9M740-9s46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetriciansn%mbers
Aonllcant Information Please Print Leeibly
Namettwvne:sror�ani:atiwvtm4vuhlatr.
- cityistatc/zip: o�rr1 i'twne a:_ S)6 �1f=3o3.L
.ire ye"a employer'Cheek the appropriate pox
®� F6.
.o/project(required):
I. am n empbyar with 6 4. ❑ 1 am a gtaatxat contractor cold 1 ❑A'ew construction
employee*(full and/or part-time).• have hired the sub-contractors2.❑ I am a sole proprietor or partner- listed on the attached shed 1 ❑Remodeling
ship and have no employone Then sab4ontracroce haw ❑ Demolitionworking for me in any capacity. workers' comp. insurance. (Suildi
❑ ng addition
(No workcre'carp. insuratres 5• ❑ Ws ors a corporation and its Electrical nrquirtxl] officers have cxerciac d their ❑ repairs or additions
3.❑ 1 am a homeowner doing all wont right of exemption per MGL 11.
❑ Plumbing repairs or additions
myself.(No workers,comp. c. 152•§1(4),and we have no 12.❑ Roof repairs
insurance requited.] t employees.[No workers
comp, inwrant a required.] 13.❑Other.
'A.q*pkam art dxmks ban el moo also Cut the.celiac bvbw Ynrioa tacit wwkm,conquoug"twtK'y ierlMllYlllOn.
Ilunwmwmn who utbarir this of tdwn indiratina cry are Joityl sll wok and Cho NM out"eommoras mad sulenil a aaw anlaava inrialina utA.
:Cuntrwr n lkm Lh"k ass brat mum anaehsd m addllion d Am Mwiry er mow der subcontraom cad their wurkere'coop.policy mfarmeaoa
1111111C111111
/am an employer that Is providing workers'compensaten hrsurance for my emplayeea Below is the poi cy andlob sib
information,
insurance Company Vame: --
Policy s or Self-ins. Lie.0: _. . Expirruon Date:
lob Site Address: City,Statazip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to Wcure;coveraga as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties ora
fine up to 51,500.00 and/or one-year imprisonment,rs well is civil penalties in the form ofa STOP WORK ORDER and a ran
of up to 3250.00 a day aguinst ilia violator. Ile adviacd thus a copy of this slateawnt tray be forwarded to the Office of
Im*:angatmns ul'dte DIA for insuraree arveragu verification.
/do hereby certify t r t prrin3.w d naldes of, cry char the information provided abo
v
e is true mild correcL
Phr't'e,7
O/J)rirl use only. Ao wot write/a thir area,to be completed by dfy of fown oJJleiml
City or Town: PcrmiNlJeense N
Issuing Authurity (circle one): —_
I. Board of Ilralth 2. Building Department I.Cityffowa Clerk 4. Electrical Inspector 5. Plumbing Inspecto►
6.Other
Cunt et Person: _ Phone p:
Information and Instructions
Massachusetts Gcneral Laws chapter 152 quires all employers to provide workers' compensation for their employtxa
pursuant to this statute,an empfeyee is defined as"...every Person in the service of another under any contract of hire.
.%press or implied,oral Of wrinea"
orporation of other legal e
An e+a � a Ff" is defined "as in&vidua6 Pa MWWMV,association'cased employer.or the
or say two Or more
the foregoing engaged in a joint enterprise,and inchtdkng the legal representative of a deceased
association tic other h10 entity,employing employees. However the
receiver or mates of as indivieluai,parmerahtp. end who reside min.ar the occupant of the
owner of a dwelling haws having not more then three apartment
dwelling house of another who employs persons to do maintenance.cuastruction or repair work on such dwelling house
or on the grou
nds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter I52.#23C(6)also states that"ovary state or local licensing aracy shall withhold the issues"or
lo tbs commonwealth fir say
renewal of a Ileerlse or permit to operate evidence
business r to Of cD�buildings���coverage required."
applicent who W taint Prod accept _any of its pofitical
Additiosally.MGL chapter 152.123C(7)stares"'Neither the commonwealth
compliance with ensuraneel
enter into any contract for the performance of public work until acceptable
requirements of this chapter have been presented to the contracting authority."
Applicasu
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation arid,if
Ripply sub.contracter(s)narne(s),addresses)and phone number(s)along with their certificate(%)of
necessary. Limit ies L or Limited Liability partnerships(LLP)with no employees other than the
instance. Limited Liability Companies(L C) insurance. if an LLC or LLP does have
member or partners,are not required to carry workers'compensation Department of Industrial
employees.a policy is required. Be advised that dnu affidavit maybe submitted to the ilavi
Accidents for confirmation of insurance coverage. Abo bin sure to sign and date the u seed, not f. the This .part it should
be returned to the city or town that the application for the permits f he law f if you nse is t�am required to obtain Da Department of
Industrial Accidents. Should you have any questions regarding
colopenaattenl policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the apline.
City or Town O(Aelab
please be 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 applicam
fleas. be sure to till in the permiulicense 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)." f copy of the ufftdavit 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 now affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or penult not related to any business or commercial venture
l i.e.a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
1'ho Ot nice of Investigations would lie to thank you in advance for your cooperation and should you have any questions,
pleuse du not hesitate to give us a call.
The Department's address,telephone and fax number.
The Cotnnlonwealth of Massachusetts
Department of Industrial Accidents
ofilee of tavadpdoas
600 washingM Sunset
Boston,MA 02111
Tel. # 617-7274900 ext 406 or 1-977-MASSAFE
Fax N 617-727-7749
Revised 5-26-05 www.nim.gov/dia
CTTY OF SALEM
AN PUBLIC PROPRERTY
W.-I, DEPARr.AEM
>4�ata l�'L�N::JeiS 7ER�iK:f1.1t�Hgt3N a►�a::9
'ht:`tOr7�6+Ile��f•�97t;��69pt;
Construcdon Debris Disposal Affidavit
(requital for an dentoiidom and tenovadon work)
in mconhum with the sixth edition of ft Sure Building Cod%7SO MlA section 111.5
Davis,and the provisions of M- GL e 40.S SM.
gwlding Pon N _ is issued wilh the condition do dw debris resulting Item
this watt shall be disposed of in a property Licensed wash disposal Facility as dented by%1GL a
t 11.S INA.
The debris will be transported by:
InwasofhGaId.l
rhock-bds will be disposed of
P — -
..itt
4