1 FREEDOM HOLW - BUILDING INSPECTION >� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wl\1ai'RIF.Y DRrA:ULL
%v(AyoR 12C WAst-u.NGroHSTRELT a SAtE.M,MAS5Actnat.TP'0197"
'rete 976-743-9595 9 FAX:976-740.9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.Applicant Information Please Print Leeibiv
Name isusincu/OrilaniratioNlndivlduul): ///n&C/c, ry �L
A dd ress: /1 j &17 Ice,G 0 C/. (,(f—
City/Starer'Zip: ��1��/f7 /y//fSS Phone M: 514
Are you mployer? Check the appropriate box: 'Type of project(required):
I. amt a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employc"(rull and/or part-tints).• have hired the sub-cuntractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling
ship and have no employees Theta sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
INo workers'comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions
myself. (No workers'comp. c. 152, §1(4),and we have no 12.❑ Ruof repairs
insurance required.j t employees. (No workers'
comp. insurance required.] 13.❑ Other
•An)applicant that checks boa el mutt also till out the mcti.ul hciow dtowiag thtir worincs'componsatiotl puliey infurneuiors
'itomwlwnen who submil this affidavit indicating they ars doing all work and then him,outside contractors must auhrnit a new arraavit indiaaing rte►.
:Conim urs that chock this box must aeached ata additional sheat showing the non,*of the wb-contractors and their work*='comp.policy informaritm.
I oar rat employer that is providing workers'compen.sadon Insurance for sty employees. Below is the polky and job.site
information.
Insurance Company Name: ✓Yf 1 r'� rc� t A��,'c r� o.
Policy li or Self-ins. Lic.t1: (�/G ' W$�J � Expiration Date: c�
Job Site Address: city/Slate/zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure w wcure coverage as required under Section 25A of.%viGL c. 152 can lead to the imposition of criminal penalties of a
ti nc up to S 1.500.00 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 aguinst the violator. lie advised that a copy urthis statement may be forwarded to the 011ice of
Inve,ngaiiutu ul'thc DIA for insurance coverage verification.
I do herebyterrify ur er die pains• 'd aIt'• of erjury that the information provided above is true nd correct
tii :ruure' Date,
7
O/firial use only. Do not write In this area,to be completed by city or town ojJleiaz
City or Town: Permit/License
Iss flak Aulburity (circle otic):
1. i1ourd of Ilealth 2. Building Department 3. Cityirosan Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ _ _ ___ Phone p:
,
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
���\ + t?c vr.w av::a��aeet•aaeu.>t.\:iu:at .,���s::ar
Tit:97%.74545" • F.\x:97s•ACM4L
Construction Debris Disposa[ Affidavit
(required Cor all demolition taxi renovation work)
in accordance with the sixth edition of the Shue Building]Code, 7S0 Cb1R section 111.5
Debris, and the provisions of M. GL a 40. S 54;
Building{ Permit M _ . ._ is issued with the coodidon that the debris resulting from
work shall be disposed of in a property licensed waste disposal facility as defined by .iGL e
I l 1, 4 I50A.
The debris will be transported by:
tnaaw of haat
The debris will be disposed of in
s�le�?
..1tC
i
i �
PUBLIC PROPERTY
DEPARTMENT
Y.1.WFJL6Y DRISUxl
MAvaa 120 WA9WJGWw b��r
. Wrx Y.WttAan:stilts 01970
141:97e.745-9M•FAm M740.9W
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: /t z .c -cz/- Building:
-- Property Address - - - -- - --- --- .---- - - -
11,C'116
-- -
Property is located in a;Conservation Area Y1N /U Historic Dlstrict Y
2.0 OWNERSHIP INFORMATION
4.1 OwnerofLand
Name: 7 �� G,
Address. / f A//`u -:r X
Telephone: D c-,o
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
w
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
grief Description of Proposed Work:
//P C
----- Mail Permit to: cOC. D. r err u,66
� � df
What is the current use of the Building? '
Material of Building?
if dwelling.how many units?
Will the Building Conform to Law? Asbestos?
Amhited's Name
Address and Phone ( )
Mechanic's Name
ff� OG
Address and Phone l c.? vo •-9"`-'c- � :*—Z�22—
Canstruclion supervisors License e
O 7 / p HIC Registration6�s�
Estimated Cost of Project$ O G•, Pem* as Calc Won
Permit Fee$ CJ Estimated Cost X$7/51000 Residential
Estimated Cost $11/$1000 Commercial----_
An Additional $5.00 is added as an
i 1 Administrative Charge.
16� Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby appy for a BuildingPermit to build to the abov to
n
specificatio . Signed under penalty of perjury
Date -
NI
s JIWA
IR)
t- •� e � _ s