26 GALLOWS HILL RD - BUILDING INSPECTION e�b��LEI ---
PUBLIC PROPERTY
DEPARTMENT
KISMERIEY DRISCOLL
MAYOR 120 WASHING"STREET•S•.:,MASSACHI3hTR 01970
17EL•978-745-9S9S 0 FAX 979.7404M
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: Building:
Property Address:
Prop"is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: Q/� D,/ mere
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
--- -- Mail Permit to:
V
What is the current use of the Building?
Material of Building? i A — a If dwelling. how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone l )
Mechanic's Name
Address and Phone
Construction Supervisors License# e' La J-- HIC Registration# i/ —i 7 7
Estimated Cost of Pr G- o< Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative 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 d above stated
specifications. Signed under penalty of perjury /� !
Date If 7
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xnreEnu,r nRnctxt
MAYca
120 WA*0=r0N STREET•SAt.EY,MASfACt=res 0lW0
TM-VS-745-9593 o FAX M7404ti46
workers, Compensation Insurance APHdavit: Bunders/ContractorgMeebicians/plombm
Applicant Information i Print .e,ra.s..
Name(Busi0eWOrp0i2auodfndivi&W):
Address:,—''7
City/State/ZiX va !'ram.CK— pone
An yo employer?Check the appropriate boss
1. I am a employer with 4. ❑ I am a Senegal contractor and I Typo ot�1 (� ):
_ym�byw(Asia and/or past-time).• have hired the sub.-contractors 6 ❑New caaamsetian
2. I am a sole proprietor or earner listed on the attached sheet t 7• ❑Remodeling
ship and have no employees Then sub contractors have 8. Q Demolition
working for me in any capacity. workers'comp,inatuaaee,
9. Buil
[No worker' comp.insurance 3. ❑ We are s corporation and its �i addition
required.] officers have exercised their 10.❑Electrical repairs at additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs a additions
myself [No workers'comp a 132,41(4),and we have no 12.0 Roof repairs
insurance required]t employed (No workers' 13.Q Other.
�P•maucam•e required)
-Any WU=o that Awke tea NI mot a"all out the swift blow show4eg shah•wasikme'oomysoatlea 7eaey hkPosmatloa,Homeowomo who sub"fhb d tm*mmatlea arty m dotes sE wok red rhea hhw c oida mmkaaam am a*"a new atRdna htdhathq ateh,
tConaeaan that check tW ton mars a v&w are sd"*W short showing da came of the sub4caftwtm red d>eir wag cony.Refry iothaesaoa
ram am employer that Is providing workers'compenaadon lnsarancejor my employees Below Is the polity and fob sbhr informaBaa
insurance Company Name•Policy N or Self-ins.Lie.N Expiration Date:
Job Site Address:_ 7 G ��� C , s �L/G c s� City/State/zip-
Attach a copy of the workers'compensation pogcy declaration pap(showing the pollay number and exphntion dab)6
Failure to secure coveralls as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-yea imprisonment,as well as civil penalties in the form of a STOP WORK ORDER ands Ana
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby terrify and and Pena/des of perfary tkat the injormarim provided above Is due and correct
signature,
Phone#s
o v1
official use only. Do not write IN this area,to be completed by city or town o,Q7ciai
City or Town: Permitfuceose N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cilyffown Clerk 4. Electrical Inspector S.Plumbing Inspector
6 Other
Contact Person: Phone*
Information and Instructions
ers to provide workers' compensation for their employees.
Massachusetts General Laws chapter 152 requires all employ P anyconnect of bite.
putwa an eapooyee is defined as"...every person in the service of another under
Putstwnt to this smtute.
or implied,oral or written'
express two or more
�oche legal entity.or any
An employer is defined as"an individual.Partnership.assoeiodole Corporation ves of a deceased employer.or the
and incblding the legal representatives employing er the
association or_ However joint mteePntm0. ens.
of the foregoing engaged m a J then leg
erntheses or�l o of the
receiver or uuswe of an individual,partaas6tR
owner of a dwelling house havoc{not s persons
to do maintenance.consou or repair WOh on atseh dwelling bout»
dwelling house of another Who employs� shall not because of such employment be�m be an empbyer.
or on the grounds or building aPP�°�
MGL chapter 152.12SQ6)also stun that"every slats er 10e81 Ikessbsg agency shag withheld the lbforlesso a or
f•the eommosweaNb for any
renewal of a Wows or permit to operate a bushes or to eosatrnet buildings
baurateeo cam
regdreeL
Applicant who bas sot produced sceWable evi&ucO of eemptlueo alth nor any of its Political subdlvnnoue SWAdditiondly,MOL chapter 152.125CM states"Neither the commonwe with the insurance
of public work until acceptable evidence of compliance
enter into see this his C for the performance
regoiremona of t chapter have been preapresented to the contracting autharitY.
Appikants our situation sod.if
Please fill out the worker' compeosodon affidavit Completely,by Checking the boxes that apply to Y
suh.contractor{s)name(s),address(es)and Phone numbers)along with their certi8cate(s)of
necessary, Limited Liability Companies(LLB err Limited Liability Partnerahips(LLP)with no employees other thin
the
' nCO' to carry workers'compeundon insurance. If e i p or ent does have
m��or Pittner`.are
not hv& Be advised that this of ldsvit may be submitted to the Department of Industrial
employees,a Polley is of insurance coverage Abe be sneer to sign and date the afitdavlt. The affidavit should
Accidents for coe city f to application for the Permit or license is being mpwste4 not the Department
be returned to the city or town that the app the law or if you us required to obtain a workers'
regarding
)ndua�mal Aa policy,please call the Depart 1stt th number listed below. Salt-itrsursd companies should enter their
compel
Po
self jourenes license number on the
City or Tows Ofgelala e at the bottom
Leto and printed legibly. The Department has provided s spec
Please be sure that the affidavit is comp
of the affidavit for you to fill out in the even the Office of investigations has to contact you regarding the applicant
Please be aura to fill in the parmiVliccom number which will be used as a refers nce number. In addition,an applicant
that must submit multiple P armt .ce°se aPPlieanon in any given Year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the aPplieaoe should write"ail location in ity or
officially stamped or marked by the city or town may be provided to the
town). A copy of the affidavit that has teem is or licenses. A new aFudrvu must be filled out each
applicant as proof that a valid affidavit is on file for firma°permits ventureyear.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial
(i.e. a dog license of permitpos
to burn leaves ere.)said person is NOT required to complete this affidavit
would lira to thank you in advance for your cooperation and should you have any questions.
The Office of iavesrigation please do not hesitate to give us a tail.
The Departmenes addressm telephone and fax number.
The ConomonwUlth of Massachusetts
Dgwftnent of Ia&nft al Accidents
MUG of Isvesd=adong
600 Washingtm Street
Boston MA 02111
Tel. #617-7274900 ext 406 of 1-877-MASSAFE
Fax 0 617-727-7749
Revised5-26.05 WWW.maS VV/&1
Y.
' PUBLIC PB+OPE M
DEPARTURCr
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