4 HAZEL ST - BUILDING INSPECTION (2) What is the current use of the Building?
Material of Building? /� i . If dwelling, how many units?
Will the Building Conform Law? S Asbestos?
Architect's Name
Address and Phone )
Mechanic's Name
Address and Phone �zll�xl;�74 r
Construction Supervisors License# HIC Registration#/3 9
Estimated Cost of Proj ct$ Permit Fee Calculation
Permit Fee$ A6VAe Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 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 uild to the above stated
specifications. Signed under penalty of perjury
Date d
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' PUBLIC PROPERTY
DEPARTMENT r�
91%n3F MYDRISCOLL
MAYOR I-V WASHINOrON STREET•SMEW MA.SSACHL:SM-M 01970
'CFI.:978-745-9595•FAx 978.740-9846
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFOR TION
Location Name: Building:
Property Address: ��
i
Property is located in a; Conservation Area Y N Historic District /N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: I�7 � � i I4�
Address: V 77 � � C1�l
Telephone: 41 -2
3.0 COMPLETE THIS SECTION FOR WORK IN E,l IILGYE t1E g:r' GG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use (/CJ L� New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
121 /nJ
- - --- ----- -- �s� - �, - -
Mail Permit to:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Mmolk I?C W.\9NXt::JK!7lEET •SAU M,
To:vm745-is" •F.\x:I)MAG9946
Construction Debris Disposal Affidavit
(required for all demolition atul renovation work)
in accordance with the sixth edition of the State Building Code, 730 CASR section t 11.5
Debris,and the provisions of v1GL c 40, S 54;
Building Permit M _ . ._ 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
1 11. S 150A.
The debris will be transported by:
(name of hauler)
7•hc debris will be disposed of in :
�0 r r/ c� G a it
(mane of fauittty)
li
00
�.L:fax. . (fx iLl_q
Y_ S /
.Jf: _
CITY OF SALEM
PUBLIC PROPRERTY
.y DEPARTMENT
w Naar RIEY DilrWoLL
MAYOR IX WA HLING(ONSTREET a SAtEM,MASSACIn%sl:'tYS0197'J
Th1:97S.745-9595 •Fax:9M740.9x46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anulicant Information Please Print Leeibly
Name(dusioeWOrganiratiordlndividuul): r,
Address:
City/Slare/Zip: Phone
Are y an employer?Check the appropriate box: 'Type of project(required):
4. ❑ 1 am u eneral contractor and I
I. 1 am a employer with� 1S 6. ❑New construction
employees(Cult and/or part-tine).• have hired the sub-contractors
�.❑ 1 am a sole proprietor or partner- listed on the attached sheet.
7. ❑ Remodeling
ship and have no omployt.'cs These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9, ❑ Building addition
IKo workers'comp. insurance 5. [1We are a corporation And its
requirud.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 PI bing repairs or additions
myself.(No workers comp. c. 152,§1(4),and we have no 12, Roof repairs
insurance required.] t employees. (Ko workers' 13.0 Other
comp. insurance required.]
-Aeey appliuuY unit chettks has nl local also till ow the secrian below Jtowiaa'W-r workua'cumpaloation pulicy infurmw utt
'I lonwwwnars who submit this affidavit indicating shay arc doing all work and then hilt outside contractor must suhtnit a caw afrdavil indicating etch.
:C.'ontr4mm that chuck this boa mug attached an additional About Jutwinz the nano of the sub-contractors and their workers'camp.pulicy information.
/an; an employer that is providing workers'compensadon insurance for my employees. Below is the pa/icy and Job sire
inforvnation.
insurance Company Name: /C> P_ /
Policy q or Seif•ins./Li�c.rl: C /� Expiration Date:
Job Site Address: "7/ i/ 2�� v/Z—L City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiry 1oa date).
Failure w secure coverage as required under Section 25A o0vIGL c. 152 can lead to the imposition of criminal penalties of a
tine 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. Ile advised that a copy of this statement may be forwarded to the Office of
Int esugations of thu DIA for insurance coverage verification.
l Jo hereby certif under t sins and peit"Ide jp ury tk a inforin I 1W above . bile mild correct
Sp,nahlrC: _ Dar .
Mime 7 i
Of file only, no nor Ivrite in skis area,to be completed by city or town aj]lcfaL
City or'rown: „ . _ Permit/License
Issuing Authority (circle one):
1. Ituard of licalth 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Cuutacl Person:_.__ _ __ Phone tt:
Information and Instructions
hlassachusets 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 contract o hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,associatitm 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 ousnce 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 shag 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 nor any of its political subdivisions shall
enter into any contract 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 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 cerrificate(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 confinntation 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
,elf-insurance license number on the appropriate line.
City or Town Officials
Please he 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 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 cr 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.
l'he Obis of lavesrigations 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
OfHee of Investipdoos -
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
Revised 5-26-05 www.mass.gov/dia