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5A GRISWOLD DR - BUILDING INSPECTION (3) What is the Current use of the Building? Material of Building? A)Oo b / If dwelling.how many units? Will the Building Conform to Law? y ie_S Asbestos? D Architect's Name Address and Phone x ( ) Mechanic's Name Address and Phone ii:I HIC Registration# l�© Construction Supervisors License#_ Estimated Cost of Project S D 0 D Permit Fee CalxuWW Permit Fee f 1,074-090 Estimated Cost X$71$1000 Residential Estimated Cost X S11f411000 Commerclal---------- 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 ✓ 11� Date specifications. Signed under penalty of perjury X l� L (� t �0 I N v 3 > s` a �- EI1"-y-OF PUBLIC PROPERTY DEPARTMENT wumFysr o•�-•v I� . . TIEL-978.71S-9S93•FAX 97s-740.98N 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: ,U �p© . Building: Property Is located in a; Conservation Area YM IV Historic District YM IV 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land ZIO S r C L Name: -�7ro— Address Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN Ex1ATtNn BUILDING8 ONLY Addition . Existing . Renovation Number of Stories Renovated Change in Use o2 New Demolition Existing Approximate year of Area per floor (at) Renovated construction or renovation of existing building New Brief Description of Proposed Work: ---Mail Permit to: 6 } CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ril\Iflr RIF.Y URLK:ULL M.vvt7tt 12C WA%C%4T0N STREET a SALEM.WASsACI n.17'1'tX 0197: TE1:9711-7439595 a FAR:9M74069946 Workers' Compensation Insurance Affidavit: Builder/Contractors/Electriclans/Plumben Anillicaut Information Please Print Leeibly Name(Busincss/Organizatioraindiwdual): P I2Cs 1) IS n � t•fir.12c L 1 b IN III _ Addr G e!Li: Mao I .. CityiStateizip: Q5F&` �, PhoneN: 12 c — 4 Are you an employer?Check the appropriate box: 'Type of project(required): E 1.❑ 1 am a employer with 4. Q I am a general contractor and 1 6. Q new construction employees(full and/or part have hired the sub-cumractors ? Remodel 2. I am a sole proprietor or partner- listed on the attached sheet t mi ship and have no employcaa. These subcontractors have g. ❑Demolition- working for me in any capacity, workers'comp insurance. q• [No workers'comp. insurance S. [I We are a corporation and its Q Building addition required) officers have exercised their 10.❑Electrical repairs or additions 3.Q I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers comp. c. 152,§1(4),and we have no 12.Q Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp insurance n quired.] Anylicaur,W1 checks boa of muss also Till cut are need"below dh io their wwkas'eom P a panuufum pansy bmilnx,lwri 't i.an.a,wrten who submit"affidavit indkuing they twi ry any all work tine rhea bke outside caorrxmaltsto malts.uMna a raw amdsvit iadialiny etch. ('amrxwn that c►sst this box must anacb d m additional AM stowing tbo men of the mb-contractors and their woArm'comp.policy inrarmadus. i I am an employer that Is providing workers'compensadon insurance for my employees. Below is the polity and job site h injarmadots Insurance Company Name: Policy 4 or Self-ins.Lie.p: _.- .. .._-_ Expiration Date: Job Site Address: Cayislute/Zip: 4 Attach a copy,of the workers' compensation policy declaration page(showing the policy number and expirarluu date).. Failure to wcum coverage as required under Section 25A of.%,IGL c. 152 can lead to the imposition of criminal penalties of a ring up o7 S1,5001M and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a Jay against the violator. lie advised that a copy of this statement may be forwarded to the Office of Invcangauuru ufthc DIA for insurance c,)vcrage vcrificatiun. !ria!mn•by r.nijy�aa�J/e,r-d,ie-,-p\tyi/ns mrd emu/firs ajprrjury that the informutien provideed ab vvo is tie and correct. Si •:rnurc' _.N""" 'mot �J��//�� u4 t : / F� e 7 I 7 Ik PM,re� U/j7cial ase tidy. Do not write in this area,to be completed by city or town olliciai City or Town: _.. Permitil.1cense Issuing Authority (circle one): 1. IA,ard of health 2. Building Department J.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Cuutaet Person: __ Phone p: Information and Instructions Massachusetts General Laws chapter 152 requites all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, e%press or implied,oral or written." An employer is defined as"an individual,petutership,association,corporation or other legal entity.or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or truswc of as 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" NtGL 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 appUeaat who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally.MGL chapter 152,§23C(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." AppUoants Please fill out the wdrkeea'-compensation affidavit completely,by checking the boxes that.apply_to.your situation and,if necessary,supply subcontractor(s)nan*s),addresses)and phone number(s)along with their certificatc(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,arc 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 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 rill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in she pormit/liceutse number which will be used as a reference number. In addition,an applicant that must subunit multiple permitilicense applications in any given year,need only subunit one affidavit indicating current policy information(if necessary)and under"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 now affidavit must be tilled out each year. Where a home owner or citimn is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. 1'he o icc oY Invcstigations would Cue to thank you in advance for your cooperation and should you have any questions, plcube do not hesi(are to give us •a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of lovestlgations 600 Washington Street Boston, MA 02111 Tel. M 617-7274900 ext 406 or 1-977-MASSAFE Fax 0 617-727-7749 Revised 5-26-05 wya,,mas3,gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT l!C w.[91IW::JDiS 4EtT 0 S.\[i 4,fit.\VLU:'.I[ To:~454M F.UC 9716.74-9M Construction Debris Disposat Affidavit (required for all demolition atxl renovation work) In accordance with the sixth edition of the State Building Code, 730 Cb1R section 111.5 Debris,and the provisions of v1GL c 40, S 54; Building Permit 0 _ . ._ is issued with the condition that the debris resulting from dis this work shall be posed of in a properly licensed waste disposal facility as defined by M. GL e I11. S 150A. The debris will be transported by: flume of hauler) flic debris wilt be disposed of in M e I to Want of'r"111ty) (�elJ2 G`72�LjJ 01 v" la ..its