15 HAWTHORNE BLVD - BUILDING INSPECTION (3) What is the current use of the Building? if dwelling.how many units?
Matetwd of Budding? Asbestos? '
WW the Building Cw*m►to law?
Architeds Name
Address and Phone r C �y G
Mechcnies Name A
Address and Photo �14' C
Construction Supervisors License /J/ �/Z HIC Registration 0 ��A
Estimated Cost of Project=
li, pPr, Permit Fee CaICuhdOn
Permit Fee: . ,v Estimated Cost X$7/$l000 Residential
_ Es*nated Cost X$i t/i1000 Con merctm�--__
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly writterr to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
//
specifications. Signed under penalty of Perjury
Date?///^�
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PUBLIC PROPERTY G�
DEPARTbiE►�TT
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130�i/'�SwN('Z[Y�SST��+'�.wsuatis�rl3 OL970
TM-97s-745-9S9S•FAz 978.74&g$"
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION.,
DEMOLITION, OR CHANGE OF USE OR OCCUPA�Cy, FOR ANY EXISTING
STRUCTURE OR BUILDIN
1.0 SITE INFORMATION
Location NJeyW S'�/7h,-,7 fJc}_l o / guk%v /✓JA
__....... Property AddresV. AIA l{�/ 'JvJ �IV i SO4,
Properly Is located in a;Conservation Ares YIN Historic DIsMd Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land ,•1, �i 6Gz it a/_C �/
Name: �o- ��/Gt r r G/l 46oi/'o^
Address: Z/ Z ry wrn //� �vr
6GJlG"� '
Telephone: 01/2 2fy-D/Gb
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTINGVONLY
Addition
Renovation Number of Stories
Change in Use Demolition Approximate year of Area per floor (st)construction or renovationof existing building
ELdef Description of Proposed Work: / /
�rru�� i Sired Atir� /^-ST'�� AirK �ar �il�: l, � o IZ41
G1 N�rvsv/ A- raef fyl7<7
Mail Permit to: /i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
X rMURtl'y UR11(:L)L1_
4 AY01t 12C WAStlIXG I oNSTREET • SALL•M,MASSACIIt;SFA-ISO197C
TEL:978-745-9595 • FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A I licant Information Please Print Le ibiv
Name(Buciiwssiorganizatioivindividuap: Py �ff�GtiA/ �GG I(' 4, /2
Address: �� OJ ,9oC 2 6 2 City/Statei7..lp: _G �r4/ p?n!� d/S)d Phoneik 5p-�'L
Arc you an employer? Check the appropriate box: 'i'ype of project(required):
1.[E�1 am a employer with 6 4. Q 1 am a general contractor and 1 6. M New construction
employees(full and/or part-Lime).` have hired the sub-contractors
1❑ 1 am a sole proprietor or partner- listed on the attached sheet. t ?• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp, insurance. 9. Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME] Electrical repairs or additions
3.❑ 1 ran a homeowner doing all work right of exemption per MGL i 1.❑ 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.]
-Ally applicant that checks box#1 must also fill our the section W-uw showing their workers'cumpensutiot policy mlirctmtion
' I lomcowa;n who submit this affidavit indicating they are doing all work and then hire uuniide contrnclon must submit a new al'Rdavit indicating such.
�Comncmrs that check this box muse actwhod an additional.,heel showing the name of the sub-contrac(ors and their%vorkers'emp.policy information.
lain an employer that is providing workers'compensation insurmrce fur my employees. Below is the policy and job site
information
Insurance Company Name: eat C ✓Y G '
policy k of Self-ilu. Lic. #: ��D O1/` Sw Expiration Date:
/J' l
Job Site Address: .11 6YA `t'/5Gr't,r �l�Vr ' Cay/State/Zip:
Attach a copy of life workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
Fine up to SI.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
hnresligaiions ul the DIA for insurance coverage verification.
1 tin hereby certi undeerr the sins,ann]^d penalties of ppe�rjury that the information provided above is true turd correct.
ud
Sicenurr /Ui!%TZ '(//G7 `G •// Datc:
OJrchd use only. Do not write in this area,to be completed by city or town official.
City or Town: _ Permit/License q --
Issuing Authority(circle one):
1. Board of health 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.01her
Contact Person: Phone N:
Information and Instructions
Massachusetts General Laws chapter 152 requires 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 contrast 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. §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, Iv1GL chapter 152, §25C(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."
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), address(es)and phone ntnnber(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 till in the permittlicense 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 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. it 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 fur 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
1
QCITY OF SALEM
PUBLIC PROPRERTY
- DEPARTMENT
11An1e (?Q WA9IIXG:JNSiREET *SAL Ot. SIA%%C,: I[ il:['15719/--
Tn:978-745.9595 • FAX:978.74Cr9846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,.730 Cb1R 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
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debriiss/willbe transported by:
(name of hauler)
fhc dcbriiis 'will
`b/e disposed of in
dy�/rl3 llR r 61a
/(name of facility)
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