13C GRISWOLD DR - BUILDING INSPECTION q CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposaf Affidavit
(required fix all demolition aid renovation wont)
In accordance with the sixth edition of the State Building Cods,7SO CNIR section I11.S
Debris,ud the provisions of MGL a 40.S S*
Building Permit 0 _ . ._ is issued with the condition that the debris resulting Barn
this work shall be disposed of in a properly licensed waste disposal facility as defined by WL c
I 11.S 1 SOA.
The debris will be transported by:
RJO✓ �L,s, `� C���-rhs
— — l namr of haulm—�
rho debris will be disposed of in :
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
X I\114`Rif Y URMIX.J.
MAYOR l2C VA%MNGT0NS7rR Fr is SAtEM.MAm vcln.�rnOl9T`
'rt1:97/•7439595 a FAX:9M740.9946
Workers' Compensation insurance Affidavit: Builders/Contractors/Electric(ans/Plumbers
Annlicant information Please Print Leelbly
Marne Ikonswss/OMmizationilndivufuul):.. RD/C-s J. L `h e ttr c4
Addrewc I — a W a. 6 .
CityiStarciZip: t2sde Phone 0: 22 S'fie- ell �
Arc you an employer?Cheek the appropriate box: "Type of project(required):
I.0 1 am a employer with 4. 0 I am a general contractor and 1 6. ❑ New construction
` l employees(full and/or part-tine).• have hired the sub-contractors
2 1 am a sole proprietor or partner- listed on the attached sheet. : 7. ❑ Remodeling
ship and have no employees These subcontractors have S. 0 Demolition
working for me in any capacity. workers' comp. insurance. 9. 0 Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its !0. Electrical
required.) officers have exercised then ❑ repairs or additions
3. 1 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 12.0 Roof repairs
insurance required.] t .:mployccs.(No workers' 13.0 Other,
comp. insurance squired.)
•Any 4ppbcant tlut checks has e1 muss also till our the section below thowias their woken'cumpansssim policy io6amoiun
'Ilunwawrun who submit this affidavit indimina any as Juina all work and then hire omdda eoatraCera m141 ouErsa a new amdavil indicaina rule.
;C,sntraaurs ihss theta this box rattiest, " I as additional.hat showing the name Draw iah� nnactas and their workers'corep.policy informaeua.
/am an employer that/s providing workers'compeatadon hisaranee for my employees. Below is the polity and fob.rile
information.
Insurance Company Name: w/�
Policy t4 or Self-ins. Lie. 0: NlA _._ _. Expiration Date:
Job Site Adtkcss: City/slawzip:
Attach a copy of the workers'compensation policy declaratioa page(showing the policy number and expiration date).
Failure to sccurc coverage as required under Section 25A uf.IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 and/or one-year imprismmricnt•is well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day eguinst llte violator. lie advised that a copy of this statement may be forwarded to the Office of
Imsugutimis ofthe DIA for insurance coverage vaifical;on.
/✓o hereby certify under the sins andpeas/tfrs ujperfary that dte iujormaflon provided above is true and settee[
O fWal use arr/y. Do aoi write he this area,to be romplged by dry or town off/riaz
City or'rosvn: _ PcrmibLlcense N
Issuing Authority (circle one): -- -
1. Itnurd of Health 2. Building Department 3. Citylfown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: _ Phone q:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employerm
pursuant to this statute,an employee is defined as"...every person is the service of another under any contract of hick
e%press or implied,oral or written."
An esepJoyer is defined as"an intbvidttal,patmash*association'corporation or other legal entity,or any two or mote
of the foregoing engaged in a lour enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual.partnership.association of other legal entity.employing employees. However the
owner of a dwelling house having not more than thsee apartments and who resides therein Of 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."
stGL chapter 152.42SC(6)also states that"every state or Weal licensing agency shag withhold the issmaea or
renewal of a license or permit to operate a business or to construct buildings In the commenwesltr for any
aat wbo rag not produced acceptable evidence of compliance with the Insurance coverage required."
applk
Additionally,MGL chapter 152,425C(7)states"Neither the commonwealth a"any of its political subdivisions shall
enter into any contact for the performance of public work until acceptable evidence of compliance w ith 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),addresses)and phone nutnber(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 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 Departsunt 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 oa the a lire.
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 fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to till in the permit/license 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 submit 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 new affidavit must be filled out each
year. 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 burn leaves etc.)said person is NOT required to complete this affidavit.
I'hc Oi rice of Invc.46'.- ions would like to thank you in advance for your cooperation and should you have any questions,
please du nut hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oak*of Invatlptlens
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-977-MASSAFE
Fax N 617-727-7749
acvi.ed 5-26-05 www.mass.gov/dia
FEPAR
PP'G
TMENT
IO.GMA"ONSCU L
NA�POe 130 WAUG wm+ST%W•SNYtti HAMAC3VJr'ris 01970
APPLICATION FOR THZ REPAIR. RZNOVATION CONST RU ON,
DE,KOLITWM OR CHANGE OF USE OR OCCUPANCY FOR ANY XWMG
STRUCTURE OR BUI1.D1i11IC
TO SITE INFORMATION
Location Name: SulldkV
Property Is located in a.Conservation Ares Y/N_A/ His m owula YM
2.0 OWNERSHIP INFORMATION
11 Owner of Land _
Name:
Address: /3— G r is t.a o 1 r;
Sa-1� , /N4A
Telephone
3.0 COMPLETE THIS SECTION FOR WORK IN EUS71lIQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Chang* in Use New
Demolition Existing
Approximate year of Area per floor NO Renovated
Construction or renovation
of existing building New
adef Description of Proposed Work:
----- - ---Mail Permit to: 2, L' eu.-c �Y-
What is the current use of the Buildng?
Material of Bulling? If&mWng,how many units?----!
Will Buldi *Conform to LIMO?
Y c s Asbestos? a
Arahitsas Name_
Addra«and Phan@ N/ l t
M eelumids Norm Ro � �� J L"Li u r c tom;
Address and Phone
T� 0/ 9/* H: ag dR.
Construction Supery�LkwM 0 C-S D �0
Estimated Cost Of Proledvoc�_� Permit FeeCalarlatlat
Permit F«f � Estimated Cost X:71$1000 Residential
Estlmsted Cost X$1111000Corumwdat` ------
An Additional$5.00 is added as an
Administrative dwige.
Make sun than all flalds are WOPer1Y and legibly written to avoid delays in processing
The undersigned do«hereby apply for a Building Permit to^b to
build t 1110 above Stateds *m Signed under Penalty of Perjury ^ \��F-
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