0005D GRISWOLD DRIVE - BPA-08-1010 PUBLIC PROPERTY
DEPARTMENT
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Ta.W&74&"".FAX W&740."*
APPLICATION FOR THE REPAtX RENOVATION CQNrr>a>rrc-rrnnr_
DEMO ON.OR CHANGE Of USE OR OCCUP > CV, FOR ANY 929H n M
STRUCTURE OR BUttLWNG
1.0 WM INFORMATION
Loeatlorl NO Me Buildtr
---- Pity Add
S ——/--- ----- - - - - - -- --
Trap"Is located in c CoiwNatlon Awe YIN_N/ Mbtodo DkMd YM N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name U E 0 k.i-l;
Addrem-
Talepllons: 17 8- i# - 1 ,;-i4E
3ACOMPLET2 THIS SECTION FOR WORK IN E7pa m 9UILDINGS ONLY
Addition Exisdng
Rormadon Number of Stories Rerwated
r
Use New
e you of Area per now (st) Renovated
w renovation
uilding New
iption of Proposed Work:� I � iS� i L2C �
o 6eN
Mail Permit to: /- R !1 a M4 o d
What is go Burro t use of the BOOM?
-� Material of Buadin? i�a o o c� K dwelirq,how martf f unMs?
b vwl to euilMp Conform to t.aar►
ye6 Asbasfos? N/A
Arcnttsors Nan+e N/A ( 1
Addr ss and Ph"
p tiNO" 2d��A J L 97f-s»' z
Address and Ph On
! b N a r zZ too- l7/�
\ Consbucjcn jscn Lies t1 CS 0l8 3 8 4, HIC Registration B —
Eellnu ed cone of Pr ojsat! 3, San P Fee Cala+latlon
Parma Fes i 2�2 -::D5Eadmaesd Cost X=7/:1000 Realdenliel
EaIfteted coat X$411:1000 CommadOi-
.&A/Wditlanal 1t0.0®ir}added as an
A*rdnwkmdvo dtargs.
Make sure that as neide are propwv and wow wret.n to avoid delays In processing.
tated
The undwsgrad does by here apply for a Building
Pwn*to bulld to the/above s
spaor"done. signed under pansy of pedun
Date
4I _
it A
CL
g
CITY OF SALEM
PUBLIC PROPRERTY
o` DEPARTMENT
�tvinr atFr ultta:sxt.
M.sr<st 12.^vlavrv:•roK4'txtsr a Sa
rnu,ltLsstxc.'tm.:tl•:7'IX 0197s
ThL 9711.745-9595 a FAX:97L740.9846
Workers' Compensation Insurance Affidavit: Builden/Contractors/Electridansn%mben
annllcant Information Please Print Legibly
Name tHusieeasKkaartiratiavlrattvtthmll:_ R o b 2 r a L -yC use U�c
Address: a r ttlJo
Cit /Stamizi I jyQ} of v
Y P !'hone 0. `� £?-s - St/ G z�
Are you as employer?Cheek the appropriate bolt: F(CJRemodolinS
ect(required):
1.❑ 1 am a employer with 4. ❑ I am a gcm;ral contractor and iotnattuetieu
etnpluyd es(full and/orpart-tine).• have hired the sub-contractors
2. I am a sole proprictar or partner- listed on the attached shut i elingship and have no employees Thews sob-wnuactors have litionworking for me in airy capacity. workers' comp.insurance. tng uldition
fNo workers'comp. insurance 5. ❑ We are a corporation and its . ng
required) officers have cxcrcisW their repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.§t(4),and we have no 12.0 Ruofnpairs
insurance required.) t cmployeea.(No woricers' 13.❑Other
comp, inwrantx requireL]
i A.q;,pelican that eh aft him et mead also rill oul ore seta,"ttvluw dtowias their workaW wtnpmsel"pulley iotimmwiaLL
ttutrtw,wrtea who submit Wier aftldavh iadioa mlt a"ere&iyt an work erne tam him matlda corn maom a"auh sit a now alndeeit iniiarina
futant,ion eta chock the box must anacMd an atld ilea l Am Jlowins ere mom of ate mdewtlfapom sod rhmr Wutkore'cant'.poliry mlbmtelua
/oar on employer that Is providing workers'compensaton buuronce for my employees Below Is the puNty and Job site
isrformatmw.In urance Company Name: AJ IA
Policy,#or Sclf ins. Lio.q: N`4 Expiration Date:
100 Site Addkcss: Cltylslaw/zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
I-ai lure to secure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of s
fine uP on S 1.500.00 and/or one-year iinprisomncnt,as well as civil pcnallics in the form of a STOP WORK ORDER and a fine
of uP to S250.00 a day against the violator. lie advi�tcd that a wpy of this statement may be h'urwarded to the OOice of
IUl'.�h�alVlnY UI [tic DIA for insurance covcra.0 vcriBcation.
/do hereby renify under th ins and peno/tbs of perjury that the infermaNew provided above is nee and correct
tii•aantrer _ . '•--•-'d" r . _ Date
Phtthea: 9 -2 9 - T7eiC-- 41/L L
011kitd mire only Do ea wrlie/w rib area,ro be ruatp/etd by c/ry or/oww o/Jii luL
City or Town: PermiNLlcense 0
Issuing Authurily(circle one): --
1. lArard of Health 2. Building Met rtinent J. City/fown Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Gmlact Person: Phone p:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers
to provide the service workers
another under n for
o cona'aee of ht�
lo
Pursuant to this statute,an employes is defined as"...every person
eapross or implied,oral at written."
Aft ettrp yar is defiled es"an ,p@90wnt p,aaanpaaon,corporation of other legal entity.air any two or
mote
of the foregoing engaged in a jo iint enterprise,and including the legal representatives of a deceased employer.or the
uaoeiadon or other legal entity.employing employees• However the
receiver or trustee of an individual,PatmetabtP. and who resides therein or the occupant of die
owner of a dwelling hoofs having nations than three apartments or re work on such dwelling house
dwelling house of another who employs Pew to tlO i�°fC°�e cosatructtat be dt catered to be an employer.•
or on the grounds at building appurtenant thereto shall not because of such employment
IvtGL chapter I52. 62SC(6)also states that"every also or beat licensing samity shah withhold the Issuance or
too rate a business or to construct buildings In the commonweaM\far any
renewal of a lice&"or Parma Pe
applicant wise ban oat produced acceptable avWenea of compliance with the Insurance coverage subdivisions
Additionally.MGL chapter 132,$25C(7).states"Neither the conutwatwcalth nor any of its political subdivifioas shall
enter into any of
contract
for the periproas"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 if
necessary.supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employe=other than the
members or Partners,are not required to carry wow'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 uffidavit. ills affidavit should
be resumed to the city or town that the application for the pcmdr
or the law or if ou is lng requested, not the aro re aired to obtain a Department
g of
Industrial Accidents. Should you have any quesDepartment
the number
u regarding the below. Self-insured companies should enter their
compensation polity.Please ill the Deparmnent
self-insurance license number on the. tine•
City or Tows Me"
Please be sure that the affidavit is complete and printed legibly. The Department has provided it space at the bottom.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applica
of the
e f sure to till m the permiUlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permiUlicense applicarions in any given year,need only subunit one affidavit indicating current
Site Address"the applicant should write"all locations in (city or
policy information(if necessary)and under"Job
town► A copy of the affidavit slut bas 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 filled out each
year. Whore a home owner or citi=n is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license" to burn leaves ate.)said person is NOT required to complete this affidavit.
1'he Oi lice of Investigations would"t to thank you in advance for your cooperation and should you have any questions,
pleuse du not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
DeptiMent of Industrial Accidents
Of lm of[ovestlpderaa
600 Washin6wn Strew
Boston,MA 0211 t
Tel. #617-7274900 ext 406 or 1-277-MASSAFE
Fax N 617-727-7749
2eviscd 5-26-05 WWW.Mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
A.Vstll af {O.a'I1.
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To.j ►74prls!•f.%*9W4&04
Construcdon Debris Disp"of Affidavit
(requital for an demolition MA rauovados roods)
In aotonhum with the si3A edidois of dw State Building Coded 7110 CNIA scetion 111.5
Debris,and dw provisions of M. CL a 40.S 34
Suiidiril;Permit A _ _ is isstaed widt dw condition diet dw debris resuldng Boas
(his work span be disposed of in s properly liconsed waste disposal &dlity as dented by WIL a
111. 5156A.
The debris will be wansportcd by:
NOcL-L,54e Car,61-+5
_. lltOtWt JP IIOY1ef1
rho:lcbris will be disposed ofin :
hl:untr ut'fa.d�ty)
Sole 1`74