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3A GRISWOLD DR - BUILDING INSPECTION (.'T-f'Y OFSALFN?l PLT JBLIC PR_0PF,'RA'Y I,j:1)78 745 9.51,15 0 1 rN: 1_8 16 F-APP 'ION FOR PLAN EXAMINATION AND BUILDING LDING PERMIT ALL STRUCTURES EXCEPT I AND 2 FAMILY D WE INIPORFANF:Applicants must complete all items on this page SITE INFORMATION Location Name.-?,# CcjfiJ_W04_&_A2,,fjV W"I Building Property Address Map# Lmatcd in: Conservation Area YIN --Historic district Y/N Use Groups (check one) Residential(3 or more Units) R2 Type of improvement Residential(hotel/motel RI (check one) Assembly(churches) AI New Building Assembly(nightclubs etc) A2_ Addition Assembly(restaurants, recreation) A3_ Alteration Business B Repair/Replacement Educational E Demolition Factory(moderate hazard) FI — Move/Relocate Factory (10W hazard) F2_ Foundation Only High Hazard 11— Accessory Building Institutional (residential care) 11 — Other(describe) Institutional (incapacitated) 12—Institutional (restrained) 13 Mercantile M Storage(moderate hazard) Sl — Storage(low hazard) S2_ OWNERSHIP INFORNIXI ION(Please type or Print Clearly) OWNER Name , Address,3/9' & JdZ�du Telephone DESCRIPTION OF WORK,10 BE PERFORruvi IT-D P ra Y ESTIMATED CONSTR(jc:TnJN COST r r y' • I CONTRACTOR INFORMATION Name Address e,- C- /Ar- Telephone 7J6r-317— fed 6 0 Construction Supervisor's Lic # O Ye el 2 9 Home Improvement Contractor# i 5'-2 3 S/.� ARCHITECT/ENGINEER INFORMATION Name �j Address Telephone Mass. Registration # PERMIT FEE CALCULATION Residential est. cost x $7/$1,000 + $5.00 = Commercial est. cost x $11/$1,000 + $5.00= COMMENTS The under i tied does hereby attest that all information stated above is true to the best of illy k Ito wle a under the penalties of perjury Signed Date 6 ' f7 }� — \; CDN ` � z -� CITY OF SALEM s PUBLIC PROPRERTY DEPARTMENT \\ nrkers' Compensation Insurance .\Itidasit: Builders/ContracafrsiElectriciansi Plumbers Please Print Legibly \ 1 )hunt Information �/��+ �.11I1i ilf�:.inc.• tlr:_.uutati,�n hi.lis .lu.tlC��� \tl.lres; (lip 5tatc Zip: tire you an emploerl Check the appropriate box: Type of project(required): 4. ❑ 1 an a general contractor and 1 A. New construction I ❑ I am a cn)plo)er w ith ❑ anplJyees (full and'ur part-time(.' have hired the cab-CJIllraelJrs 2,K1 .tin a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling hip and have no employees I hose sub-contractors hale S. ❑ Demolition ,corking for me in aqv capgcny. workers' comp. in y. ❑ Building addition INo workers' Corn insurance 5. ❑ We are a corporation and its p. 10.❑ Electrical repairs or additions required.] officers have exercised their tight of per NtGL I IF] Plumbing repairs or additions 3.❑ I am a homeowner cluing all work exemption g p myself. [No corkers' comp. C. 152, $1(4),and we have no 12.❑ Roof repairs insurance required.) ' employees. [No workers' 13.0 Other (5-, repi*, ✓- comp. insurance required.] •:\ny ipplicant that checks box NI muet also till out the section below..showing their wurken'eumpensation policy information.- t I lonicuwners who submit this ar'ftdavit indicating they are cluing ill work and then hire outside contractors must submit a new affidavit indicating such. ('�nnoUun that.heck this box must attic hed an additional.sheet showing the name ot'the sub-euNtietnn and their workers'comp policy infnrtnation. /run an employer that is providing workers'eornpensrnion insurance for any employees. Below is the policy and job site information. Insurance ('ompany Namc: Policy q or Self-ins. Lie. q: Expiration Date: Q Job Site Address: 3 C, ,r t C(.J 6 )to 4b rlLe City.State/Zip: `s A( C r.., oM"A ©I Fe-lo .\ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to sccutre coverage as required under Section 25A of SIGL c. 152 can lead to the imposition of criminal penalties of a line tip to SI.Son.00 and.'or one-year inprisonnient. as well as civil penalties in the Harm of a STOP WORK ORDER and a tine of tip to 1'_5li00 a dat .11!altlst the s Nlatllr. Be ads Iscd that a Copy of Ihls statement Inlay be ti)r\yarded to the Office of \ \ Inc c,u_au.ms of the 1)1:\ t„r inwr.ince coccragc ccrihcanon. V l ofo hereby t crri/i- a d r pains and p i !lies of perjuq� that the inJirrmurion prurida•d ahurr is trite cord correct. Gnyn.uure. Data o _ � pe.,�:e Ullicial asr anlr. no not trite in this area, to he rmropleted by city or nnrn oJJicia2 ( it% or town: -. - - _ . 1'ermivl.icensr11 Issuing \uthorils (circle one): I. Board of IfcallIt 2. It inIding Department 3. ('ity, fawn Clerk 4. Electrical Inspector 5. Plumbing In b. Other , -- - ----— -- Phonrq:_.__ ._—.-- Information and Instructions \Ln.I.4u,c a, l•ir I ir.tl I .o\,CL.Ip ter I Icyuu c, .III ci np Io\cI, to pro\ide t\orkCrs Co n y\cn,auon for their entplo\ces. I•urtu.uu to till, 'Imute. .tn enrphnee i, JC(:inQ,l .I, ' c\Cry per,on Lit the ,tit tic It.uunhcr miller .in< Contract of hire. :\j,ic„ ,,r :mphl: . oral or t\nnen •� rmplorer t, .Ictincd .I, ".tq :ndr\:Jual. p.uu:cr,li,l), so0i.0 wn. .orporanon or other !Col cnnn. or .m) t\so or more I the tolc_outg Cngagcd in a until cntctpn,c. .uIJ inclu.lmg the Ic_al rrprrsCntam\c,ofa dcee.bed CHIPlo\cr, or the .,,cl\Cr or trtt,i" ,I in wdr\iJual, p.uutcr,hlp. a110CIALOn or other ICgal cnuty. cutplo'N ine cnq\lo\ces. I lo\sever the ,,•n ner of.I J\\cllung house hat ing not more than three ,tpartntcnts and t\by rc,lde, dtcrem. or the oC.wq,anl of the �h\ci:nlg hou,c „I inother t\ho emplu\, peron, Io do m.unrt•nanCe. Con,trurnon or rcp.ur stork on ,Lich d\selhng house „r „n the _tonnd, or budding .tppwtC:t.un tl:cteto ,hall not be:au,e oI t,01 cnq\lo\tncnt he devilled tx, he in cnnplo.%er." \I(,l. Chapter I51, ,'sUb) also ,late, that 'c\ery state ur local licensing agency ,hall withhold the issuance or n•ncss al of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant N hit has not produced aeceprable cs idence of compliance with the insurance cos erage required." \J.hnonally, .MOL Chapter 152, j2Sl'1-1 ,rates \either the Conunonw-calth nor any of us political ,uhdiv utons ,hall tinter into ally cUniraet for the perlo mince of public l%ork Unit] acceptable e\IJence of colitpllance with the Insurance rcyuucoWins of this chapter have been presented ro the Contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractors) name(s), address(es) and phone number(s) along with their CC111f1eatelS) 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 confirmation of insurance coverage. Also be sure to.sign and date 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 ,elf-insurance license number on the appropriate line. City or Town OfOcials Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to coniact•you regarding the applicant. Please be sure to till in the perrmiu license number which will be used as a reference number. In addition, an applicant that must submit multiple pemuulicense 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 'to%%ill." A copy of the affidavit that has been officially ,tamped or marked by the city or town may be provided to the .Ipplieant aS proof that a valid affidavit is on life for future permits or licenses. A new affidavit must be tilled out each }ear. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i c. .t Jog licen,c or permit to burn lea\es Ctc.),:Lid person is NOT required to complete this alfida%it. I lie I Mice of In\e,rtgations \could like to thank you in advance for your cooperation and should you hate nny questions, p!ru,e Jo not he,Itale to gt\c its a :all. - I he 1),p.unttcnt', addre,s, telephone.Ind Lit nurtther: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE ite.. ell Fax # 617-727-7749 www.mass.gov/dia CITY OF SALEM SL ' *\ PUBLIC PROPRERTY ;pa*Ki DEPARTNTENT I7i 4I-Nv 9,8 '4].v341, Construction Debris Disposal Affidavit (required 1br all demolition and renovation work) In accordance ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit 0 is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c 111. S 150A. The debris will be transported by: /j D L--y-k S I gpC" (: r;L f name ul hauler) The debris will be disposed of in (name ul IaahtY) �7 SQo`i� r (address ur facility) _ signature of pannit ap licant -- ._ date — --