20 HIGH ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KINMER1EY DRISCOIl-
MAYOR 120 WASHINGTON$IILEEr• SALEM,MAS9ACHusEmS 01970
TEL:978-745-9595 4 FAx:978-740-9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY_ ,FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: do Building:
Property Address:
Property is locate in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land /P/ d
Name: _
Address:
Telephone: ✓ LJ �f O
3.0 COMPLETE THIS SECTION FOR WORK IN EXIS:rING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
6 e-, 46Q
Mail Permit to: ,n- /z-- 1 !n '�G `-6
��1-77j ���
What is the current use of the Building?
Material of Building? If dwelling, how many units? �—
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name z l
Address and Phone��/ r, '��a /ft " �-
Construction Supervisors License# L/6 L�HIC Registration#
Estimated Cost of Project$ `_"600. Permit Fee Calculation
Permit Fee$ �Oa(/D 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 to build to the above st d
specifications. Signed under penalty of perjury
Date
o
... � N
O
.b
d ` V V
c�
O
`+ R > aO+
U
U
y
a a
a Q a a» d
CITY OF SALEM
I '
PUBLIC PROPERTY
DEPARTMENT
KIbIBERLEY DRISCOI.I.
MAYOR 120 WASHINGTON STREET It SALF.M,MASSACHUSErIS 0I970
TEL 978-745-9595 o FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please/Print Le ibl
Va(RC(BucitxxslOrganization/IndividwJ): ,1 r ��� OQ, G
Address:
City/State/Zip: Phone9: �1�� 7l/S
Are von an employer'.'Check the appropriate box: 'Type of project(required):
1. am a employer with 4. ❑ 1 am a general contractor and I b ❑New construction
employees(full and/or r rt.time).• have hired the sub-contractors y ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.*-
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ 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 chcrks box ill rasa also till out the section Mauve showing their workni compensation policy in(urrtuttion.
'Flomuiwra:rs who submit this affidavit indicating they are doing all work and then hire outside contractual,most submit a new affidavit indicating such.
:Comrachxs ihat check this box must attached an additional shot showing the name of the sub-contractaa and their workers'comp.policy information,
l ani un employer that is providing workers'compensation i isurunce for my employees. Below is die policy and job site
inforarution.
Insurance Company Name:
Policy N or Self-ins.Lic.#: J U� � .. =n o Expiration Date:
Job Sire Address: r}O o _ City/Stateizip: � L Sf
Attach a copy of the workers'compensation policy declaration page(showing the policy nutuber and expiation date)
Failure Lo secure coverage as required under Section 25A of.%,IGL c. 152 can lead to the imposition of criminal penalties of a
tine up 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 slawment may be forwarded to the Office of
11INestlgationS Uf blle DIA for insurance coverage verification.
I du hereby certify Wide the pains an pe tics pe ury that the informadon provided above is true and correct
Sicnature. - Date:
Phone:i:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: __.._.___ Permitll.icense#
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their mployees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any corgract'afhirb;`
express Jr im
plied,lien,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, g25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate it 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 15'-, §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 till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors)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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/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.
The 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.
ncc 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-os www.inass.gov/dia