28 GROVE ST - BPA B-2008-063 aks B-8-345 °.� CITY OF SALEM
3�I �.;j ��✓!' �� PUBLIC PROPRERTY . . .
DEPARTMENT
120 WAS11IXl:C0NSTREET ♦ SALE/. MASS.1Ct1LSL1-1530?^Z
TFl:978-745-9595 •F.%-`C:978a4c9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 790 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ __ is issued with the condition that the debris resulting from
di
this work shall be sposed of in a properly licensed waste disposal facility as defined by MGL c
t 11, S 1.50A.
The debris will be transported by:
- --_ (name of hauler) '
The debris will be disposed of in
(name of facility
iaddress of facility)
SI�Latal'C Jf �h:fllltt a )i1C 1i1[
,;are
l
�. the t,ommomvealth of Massachusetts
Departmenroflndustrial Accidents
Ojfice of Investigations
600 WashinVon Street
Boston, MA 02III-
wwlv.massgov/dia Tabin of ArlingUl T Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Le ibl
Name (Business/Organization/Individual):_ T NX
Address: /b,A
City/State/Zip: lA :)a, z Phone#:
Are you an employer? Check 1 e*appropriate box:
I. I am a employer with. 4. ❑ I am a general contractor and I Type of project (required):
employees (full and/or Part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the atiacbed sheet t 7. remodeling
ship and have no employees These sub-contractors have
working for me in any capacity. workers' comp. insurance 8. ❑ Demolition
.[No workers'comp. insurance 5: El We We are a corporation and its El Building addition
required.] officers have exercised their 10-0 Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself [No workers' comp. c.'152, §1(4),and we have no
insurance required.] t. employees. [No workers' ]2,❑ Roof repairs
comp. insurance required.] 13.❑ Other
Any applicant that checks box Al must also fill oul the section below showing their workers'compensation policy infomratim:
t Homcowneis who subnit this affidavit indicating they are doing all work and then
1Cont,acton that check this box muss attached an additional sheet showin the name hire outside wntraetors must subrrrit a new affidavit indicating suck
g of the subcontractors and their workers'comp policy infom tion.
1 am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name: UA V\t? Q .
Policy#or Self-ins. Lic. #: :ZL
. Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation policy decla City/Statelzip:
ration page (showing the policy number and expiration date).
Pailwe to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDE
of up to$250.00 a day against the violator. Be advised that a copy of this stat R and a fine
ement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the informarion provided above is true and correct
Suture: _
Date
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#•
GiTTU)frSAUL
PUBLIC PROPERTY
DEPARINI MNT
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APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANy EXISTING
STRUCTURE OR BiJII.DIN
1.O SITE INFORMATION
Location Nww auilding:
Properly Address:-
r 0v?- S E-
Property Is bested In s;CwswvWon Ares Y/N HlsImlo Disirld YM
2 0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Addrsas:
Telephone: -7S--
3ACOMPLETE THIS Minim FOR WORK IN EKUffJJNQ BUILDINGS ONLY
Addition ®Renovated
Renovation Number of Stories
Change in Use
Demolition
Approximate year of Area per floor(sf)
construction or renovation
of existing building New
Brie[Description of Proposed Work:
la C.L
— - --Mail Permit to: _ 345 �'rr-_i2n��y� S+� Gt r✓ -= (or-, /furs 0/(007
what is tM Current use of the Building? 'Res I a 1 —
�L nC
Material of Building?--hi.
!m ,___ If dwMtkrg.how many units?
Will tM Building Conform 10 law? B S Asbsstw?
pvchitseCs Name ( ,
Address and Phone
Mechanie's Name i
Address and Phone in lal[o skr q�7� �1�1 �S 7C� —
Consiruclion supelviaom License 0 HIC R"Wiratlon B
Estimated Cost E rc pw*Fes Calculation
Permit Fee: Estimated Cost X:7/$1000 Residential
-- Estlmabd Cost X$11/:1000 Cornmsrrla -_..._ .
An Additional$5.00 is added as an
Administrative Charge.
Make sun than an Maids are Properyr and may written to avoid delays In processing.
The undersigned does hereby apply for a Building pwrrA to build to the above stated
speacations. Signed under penally of Perry
Dots
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