12 GRANITE ST - BUILDING INSPECTION 1
----CnY-OF-S-ALEM -
' PUBLIC PROPERTY
DEPARTMENT
KI.NRiFRLFIY DRISCOLL
MAYOR 120 WASHINGTON STREET S.VL.Y,XnSsAafLst'n5 01970
1Fi.:978-74S-9S9S •FAX 973-740-9M
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1A SITE INFORMATION
Location Name: Building:
Property Address: T
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.4 Owner of Land
Name: 21na C
Address: / 2— 6�n' /-
Telephone: L/•`G — T/
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 (sq Renovated
construction or renovation
of existing building I I
New
Brief Description of Proposed Work:
Sfrl� �er��F I Ll Sri
-- Mail Permit to: vrn2 / 640 7
M
What is the current use of the Building?
Material of Building? // If dwelling, how many units?
Will the Building Conform to Law? If/S Asbestos?
Architect's Name
Address and Phone
Mechanics Name Urn f `�✓0�
Address and Phone 72, t l mk Sf
Construction Supervisors License# HIC Registration# 12 699
3.
Estimated Cost of Project$ I/), 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 the above stated
specifications. Signed under penalty of perjury
Date
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CITY OF Si1LEM
r: PUBLIC PROPERTY
DEPARTMENT
MAYOR
1�A wwsFet cus 51 t 5 +4 u wsacatt:suM 01970
toy 978-74S-9S95#FAX:976740-99"
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,780 CMR section 111.5
Debris,and the provisions of MGL c 40.3 54;
Building Permit M 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:
(acme of
The debris will be disposed of in
(—am ne of facility)
fit ��K�44,
(address of rwility)
silpfanue of permit appli D
date
The Commonwealth ofMassachusetls
Department oflndustHalAccidents
Office oflnvesdgadons
600 Washington Sbwd
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Binders/Contractors/Electiicians&lumbers
Applicant Information Please Print Eeaibly
Name(susmessurpnization/lndividoal): /N
Address: / Pi/�Cos7i Yr3t / 5 t
City/State/Zip: /.476/,n?s•ler— Phone f7S--57P9-5��6
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with 4. ❑ lam a general contractor and 1 6• ❑New construction
employees (full and/or part time).• have hired the sub-contractors 7. Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet t ® elmg
ship and have no employees These sub-contractors have 8. ❑Demolition
working for mein any capacity. workers' comp.insurance. 9 ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ Ir aim aahhomeowner doing all work right of exemption per MGL I LEI Planlbing repairs or additions
myself [No workers' comp. c. 152,§1(4),and we have no 12.® Roofrepaus
insurance required.] t employees. [No workers' 13.❑ Odrer
comp.insurance required.] ;;.:
'Any applicant that checks box#1 must also fill out the section below showing their woalns'compenas6on policy.infom stion:
r Hom eownets who submit this affidavit indicating they are doing all work and diet hire outside contractors must submit anew afulevit indicates such .-
tContractm that ebeck this box must attached an additional sheet showing the name ofthe sub-coubactors and their w *tie comp•policy information. '
ram an employer that is providing workers'compensation it wmme for my employees Below Istria policy andjob ske
inormauiaL
assurance Company Name: In5
'oliey#or Self-ins.Lic.#: /� Expiration Date:
ob Site Address: ��_/�s,� . tty/SYate/Zip:
Wach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
railure to secure coverage as required under Section 25A of MGL c. 152 can lead to The imposition of criminal penalties of a
me up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
1f up to$250.00 a day against fire violator. Be advised that a copy of this statement maybe forwarded to the Office of
nvestigations of the DIA for insurance coverage verificatiom
do hereby eertrfy under thepalns and penalties ofpe#ury that the information provided above is true and comeet
ienaauae: Date:
hone#: —
ORZeld use only. Do not write in this area,to be completed by city.or town o0kJol.
City or Town: PerndMceuse#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
C Other
Contact Person. Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers.to provide workers'compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in hie service of another under any contract of hire,
;xpress or implied, oral or written"
kn employer is defined as "an individual,partnership, association,corporation or other legal emity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
-eceiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
nwner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
twelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
hr on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
k4GL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
•enewal of a license or permit to operate a business or to construct buildings in the commonweawfor any
Tplicaut who has not produced acceptable evidence of compliance with the insurance coverage required."
Ulditionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
ester into any contract for the performance ofpublic work until acceptable evidence of cornpliance with the insurance
equirements of this chapter have been presented to the contracting authority."
►pplicants
lease fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
ecessary,supply sub-contractor(S)name(s),address(es)and phone number(s)along with their certificate(s)of
mu-mice. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the
iembers or partners,are not required to carry workers' compensation insurance. If an LIE or LIF does have
mpxoyees,' fora policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
cidents for confirmation of insurance coverage- Also be sure to sign and date the affidavit The affidavit ofuld
Af
e returned to the city or town that the application for the permit or license is being requested,not the Department
adusttial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
ompensation policy,please call the Department at the number listed below. Self-insured companies should enter then
elf-insurance license number on the appropriate lim
%ity or Town Officials �•
'lease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
f the affidavit for you to fill out in the event the Office of Investigations has to coitact you regarding the applicant
'lease be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
tat must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
olicy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
)wn)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
liplicaut as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be fined out each
'ear.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
'he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
lease do not hesitate to give us a call.
he 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
ised 5-26-05 www.mass.gov/dia