0001 GRAND TURK WAY - BPA D1-PARTNIENT
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11.1. 9-8---11-9i95 I'\X:9-%-'.tu-9sit,
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: : licanls must complete all items on this page
SITE INFORMATION/ (� �A
Location Name / I (lL..._- Building
Property Address
Located in: Conservation Area YO-Historic district 7
APPLICATION DATE
Use Groups
(check one)
Group Homes R3 Rel_
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) R1 —
(check
t _(check one) Assembly (Theaters) Al _
New Building_ Assembly (restaurants & dubs) A2r_A2nc_
Addition Assembly (churches) Al
Alteration Business B_
Repair/ Replacement_ Educational E_
Demolition Factory(moderate hazard) F1 _
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile M _
Storage Sl _Moderale Hazard
Storage S2_1-tmI l:zanrd
k
OWNE](Sun' INFORMATION(Please type or ' int CI earl -) �yG��
OWNER Name I � C.
Address ( +�„ W �—
Telephone
Signature
C.�!►�a lora,YIDyStlC.
DESCRIPTION OF WORK TO BE PERFORMED - / `'1'1"'wr^� •..
T
ESTIMATED CONSTRUCTION Cosi �S V441)
CON1'RACI'OR INFORMATION
Name Ac-
Addresst t fs J e✓ Ir
Telephonew34 —
Construction Supervisor's Lic # oZ ZS
Home Improvement Contractor# tl fC)O '77
ARCIIrr6,Cr/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERni1'1' FRF:CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
CONINIENTs
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the pen of perjury
Signed (owner)(a(-,ent)
APPROVED BY : ZIr1404.1r�
DATE APPROVED:
CITY OF SALEM
* , ,a PUBLIC PROPRERTY
:.a�.
DEPARTMENT
::I�t L'.`HI Ill'URIS(:url.
%Iwun WMI-iI..Nc IONS rKLLT • Ss L F.M.MASSAcm NI%I'iS 0197
'ria.:978-7.15-9595 • I-Ax.978-74.0.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant information Please Print Leaibiv
Vamc tl)ucincss/OrBanization�/lndyivi<lual): C�
��/S 7�f
Ci[yStatcr%5-p:/ 'e `� Phone /':
\rc von an employer? Check the appropriate box: 'Type of project(required):
r with to e
tl
I am a em 4. ❑ I am a gener6.al contractor and 1p y• ❑ New construction
employees(full and/or part-tine).' have hired the sub-contractors;un a sole proprietor or partner-
listed on rhe attached sheet 7• RemoJeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
lNo workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per NiGL It.[] Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof re airs
insurance required.) t employees. LNo workers' 13.❑ Other ✓�✓+�e--C� _
comp. insurance required.]
-Any applicant that checks box ill racist also IIII oot li1c Kction wow,ilWwlna their workers cumpenvttion policy inforraativa
I lomco.mrs who submit this affidavit indicating they are doing all work and then hire outside contractors must>u11m11 a new a1'6davit indicating such.
:Commcurn that check this box most attachal an additional sheet showing the name of the sub-contractam and their workers'comp.policy infbnnation.
I ant an eatplayer that is providing workers'compensation inauranee for my employees. Below is the pulicy and job.site
infuriation.
Insurance Company Name voluoG`-'�e�
Policy:tor Self-ins. Lic. #J� � Expiration Date:
Job Site Address) � ' City,,Stawizip:
Artach it copy of lite workers'compensation policy declaration page(showing the policy number and expiration date).
];allure to secure coverage as required under Suction 25A ul'.%IGL c. 152 can lead to the imposition of criminal penalties of a
Lina up to 51.500.00 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for Witu:11:ce coverage Nut ideation.
I do hereby certify udei't re rains and penalties V,o�ffp-erj�ury that the information provided love is true and correct.
Official use only. Do nor write in this area, to be completed by city or town official.
City or Town: - Permit/License
Issuing Aulhorily(circle one):
[. Board of health 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5• Plumbing Inspector
6. Oltier
Contact Person: ----- Phone #:
Information and Instructions
e-
Massachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplgree is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of iu 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."
`1GL 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, 325C(7)states"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 fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(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 contimhation of insurance coverage. Also be sure to sign and dale 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the penmidlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennitilicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and tinder"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 hone 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.
I he Ol I Ice of Investigations would like to thank you in advance fur your cooperation and should you have imy 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/iia
='' ._%>> CITY OF SALEM
� r
451 PUBLIC PROPRERTY
�- DEPARTMENT
V 12. U.�;Iu. ,.,
171 ')78-'45-9;95 • I \x: 778 74 9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition ofthe State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it 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
I11. S 150A.
The debris will be transported by:
- -
(name of hauler)
*1lie
�debris
p will be disposed of in/:
VB✓M SA �'�T- l...a��
(nalne of facility)
taddress of facility)
signature of1+permit applicant
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