2A HALSEY WAY - BUILDING INSPECTION �y o�
' Board of Building Regulatio-6s andwSt` d
HOME IMPROVEMENT CONTRACTOR
Registration: 156273
Expiration=8l19,2009 Tr# 255824
ems-- --�
B.G. CARPENTRYDE,ING
WILLIAM GLIDD =`- _
24 PICKERING ST
ESSEX, MA 01929
Administrator
a..�- Board Of Building ° °a!yr dards
I Construction Supervisor License'
U ems.., CCB, 56974
_ - -
�iltg'yf6l1959
. jam_"12009.` TriF 14950
1 WILLIAMR GLID E 3r
24 PICKERING
ESSEX.MA 01929' commissioner
a,
CITY OF SALEM
I PUBLIC PROPRERTY
DEPARTMENT
\l.tvrx 120 WA5J fN*(::JvSiREET 1 SALrN. MAiiA4tt iL1-157:9/C
TF.1:972-745-9595 *F.":978J4G9M
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of M. GL c 40, S 54;
Building Permit k _ .. __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by vIGL c
111. S 1.50A.
The debris will be transported by:
C4 n4bA.<.4-4ti _
(name of hauler)
I'lie debris will be disposed of in
(name of facility)
._ iad.:rca. ofCaciLry�
V649�.-��
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CITY OF SALEM
- PUBLIC PROPRERTY
DEPARTMENT
R rMURIfy DRIWOLL
.%I,\Y a l2^C WASHING MN STREET • SALLM,MASYACInlgfi'risO197CC
Tlt. 979-743-9595 •FAX:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aonlicant Information n Please Print Legibly
Name (Busiiwss/OrganizatioNlndividual): a G.
Address: 2Y{ PWC- cI-r's$ jyl
CitylState/Zip: Zip CK MA 6I5-2,4 Phone It: 176 768 3Z V 6
Are you an employer? Check the appropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
mployces(full and/ur part-time).* have hired the sub-contractors
2.�V 1 an[a sole proprietor or partner- listed on the attached sheet. ?• (� Remodeling
ship and have no employees 'these sub-contractors have S. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance. 9
Y P' Y• ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical 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.❑ Roof repairs
insurance required.j t employees. [No workers' 13.0 Other
comp. insurance required.]
'.Any appi,canl that checks box NI most also rill o a the Section Wuw Showing their w'urkurs cumpensation policy inf rroauun.
'I lumeuwwrs who submit this affidavit indicating they are doing all work and rhm hire outside contractors most autmtif a new affidavit indicating such.
�Conoactr,n that check this box mustanxhed an additicaud sheet showing the name of the sub-contracrrn and their wurkars'comp.policy information.
I dnr tot employer tout ix providing workers'c•orrtpensation insurance fur my employees. Below is the policy and job site
information.
Insurance Company Name: _._._...._-. ...___
Policy#or Self-ins. Lie. #: . _ Expiration Date:
Job Site Address: City/Slate/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.'vIGL c. 152 can lead to the imposition of criminal penalties of a
tin.: op to S1.500.00 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 day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
In%csii.atiuns ul'Lhe DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sie t,nure' s✓ /� �tf� Date / r/D 7
Phmic:'i: 579 -76, A - 32-yt
official rise only. Do not write in this area,to be completer/by city or town offic•iatt
City or Town: Permit/License#__,__.__
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: -----.... .__ Phone 0:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,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 trustee of an 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."
MGL chapter 152, {t25C(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
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally.MGL chapter 152, §25C(7)states"Neither the commonwealth not 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."
Applicants
Please fill out the workers' compensation a-ffidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s) name(s),address(es)and phone number(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 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 licence 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 till 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 submit 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 tilled 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 bum leaves etc.)said person is NOT required to complete this affidavit.
fhc Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05 www.mass.gov/dia
C1TrOF-S3AA1Lhi!V1L _. _.
PUBLIC PROPERTY
DEPARTMENT — �
%"Von130vrwvurw-rc w Srtesr� „�" W Sh1 R Ot970
MI.97e.7 S-M•FAX M740-964
AppLICATION FOR TIIN REPAIR. RENOVATION, CONSTRUCTION.
D&MOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Narnw 2 A 141rz- qA-1 8uikWV 2
------ Property Address:---- - --- ------- ._ - - — - - - -
S47A
properly b located In a.Conservation Ares YIN Historic District YIN
2.0 OWNERSHIP INFORMATION
1.1 Owner of Land
Nams: g ._
Address: 2 4 /�/S'y w4-y
s A-/z,,.,
Telephow 9
3.0 COMPLETE THIS SECTION FOR WORK IN EXMn n BUILDINGS ONLY
Addition Existing
Renovation �; � Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building 1986 New
9det`Descriptionof Proposed Work: �emo`t E'xirt,.,f Ca6,.v�!`1
5 e/Jei.a/arN j' Ir te.,r_-.✓ .�.eJ.,r in/ it y.Y
—-- - - _--Mail Permit to: --- - -
What is the current use of the Building? co" 00
Material of Building? o Q If dwelling,tow many units?
"I the Building Conform to Law? Asbestos?
A/a
Architeds Name
Address and Plane 1
Mechanic's Name
Address and Phone /S 62 23
Construction Supervisors License to r.S S 7�/ HIC Registration N
Estimated Cost of Projsd i 8 3 0 o Per"Fee Calartatlon
Permit Fee S Estimated Cost X$7fs1000 Residential
Estimated Cost X S11lS1000 Commercial--------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 Jthe above stated
specifications. Signed under penalty of perjury � /
Date_ ii s/ n 7
�I
� N