69-71 HARBOR ST - BUILDING INSPECTION CITY O1' S It t,'.�'I
PUBLTC PRO Pt _Iz' Y
DEPART,\,1L;N T.
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APPLICATION FOR PLAN EXAMINATION AND BUILDING PLRNirr 1
ALL STRUCTURF,S EXCEPT /AND Z FAMILY DWELLINGS J
IMPOR7;AN1':A licanls must complete all items on this ;i c
SITE INFORMATION
Location Name IBuilding_
Property Address 6 j..V t i4af or J+
Map# —
Located in: Conservation Area Y/N Historic district Y!N
Use Groups
(check one)
Residential(3 or more Units) R2
Type of improvement Residential (hotel/motel R1 _
(check one) Assembly(churches) . Al _
New Building_ Assembly(nightclubs etc) A2_
.Addition Assembly(restaurants, recreation) A3_
Alteration / Business B_
Repair/Replacement ✓ Educational E_
Demolition_ Factory(moderate hazard) FI _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building_ Institutional (residential care) 11 _
Other(describe) - Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile M_
Storage(moderate hazard) S1 _
Storage(low hazard) S2_
OWNERSIIIP LNFI' RMA1 ION(Please type or Print Clearly)
OWNER Name 69-Y Ngrbor f,� 7"I•vs (Or/a» 50e�es,
Address 19 RezZQ Rd LR14AJy mil
Telephone
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RePICICC Some /04-0 C4jrd5 %k) hhhePI
ESTIMATED CONSTRUC'r1OF COST _ E0 0 0 0
CONTRACTOR INFORMATION __ q
Name Idl �aV, Ba
Address 9 /kZ-Z)4 1W W4 rl i I1`4
Telephone 9-74 952 y1Y
Construction Supervisor's Lie # 0 ` 5599
Home Improvement Contractor
ARCmTECT/ENGINEER INFORMATION
Name / V
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signed U '
a Date 6
s
i
CITY OF SALEM
3
PUBLIC PROPRERTY� 1 DEPARTMENT
Kim ft.RI-EN DKISCttl I.
NIA)OK 120 W'.t StlIN6IONS-nun.r:I * SAIA.vt, .\IASsACI it sern J1970
IIEI.: 978-74 9595 ♦ F:sx: 978-740-9846
Workers' Compensation [nsurance Affidavit: Builders/Contractors/Electricians/Plumbers
.kpplicant Information T� L/ ' � /^^ Please Print Legibly
Nat1721F3usincsvOrganization'Individual): 'ma.- DOt'l1•GO An (octsHlhe (ohshrvcho�,
Address: le) ):67_79 (Zd
City/State/Zip: 0Iq Phone #: ��� �Zl- /��1 Crl1 9�88SCY96�
Are.ou an employer? Check the appropriate box: FEO] New
ect(required):
I. [ am a employer with 4. ❑ 1 am a general contractor and 1 onstruction
em lu ees(full and/or art-time).` have hired the sub-contractorsP Y p deling2.❑ I am a sole proprietor or partner- listed on theattached sheet.ship and have no employees These sub-contractors have litionworking for me in any capacity. workers' comp. insurance. ng addition
No workers' com insurance 5. ❑ We are a-corporation and its[ P ical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL It.[] Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box kl must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l um an employer that is providing workers'c•onnpen.sation insurance for uty employees. Below is the policy and jab site
information.Insurance Company Name: Trej Ile1-c rsy
Policy #or Self-ins. Lic. #: 6146,
KU� a to X /99— Z Expiration Date: 3 IY O9
Job Site Address:
/
69'71 1`�6,b yc City/State/Zip: Ad 0170
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 MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 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. fie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si n ture G pg4�!2//6ackeo Date-
Official use only. Do not write in this area, to be completed by city or town official
Citv or Town: Permit/License #
Issuing Authority (circle one):
1. hoard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
Information and finstructions
�IaSSachusetts General Laws chapter 152 requires a I I employers to provide workers' compensation for their employees.
I'llI SUam to this statute, an emplu_ree is denied as "._every person in the service of another under any contract of hire,
express or implied, oral or written."
.Ali employer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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 un the Srounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.%IGL 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
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, NIGL chapter 152,'§25C(7)states "Neither the commonwealth nWany 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 rill out the workers' compensation affidavit 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 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permidlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license 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'tnay'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 burn leaves etc.) said person is NOT required to complete this affidavit.
'Fite 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 its a call
The Deparnnent'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
to dscd 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
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PLBLIC PROPRERTY
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DEPARTMENT
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Construction Debris Disposal :1t'tidavit
(required for all demolition aitd renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 C11R section 111.5
Debris, and the provisions of NtGL c 40, S 54;
Building Permit p _ _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
l __ Solid blas-
- �- nume of hauler)
I'hc debris will be disposed of in
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