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2 HILLSIDE AVE - BUILDING INSPECTION I`t'Y"0F' r1L PUBLIC PROPERTY 4)� � DEPARTMENT AINWALEY DRI5l:OLL 1 MAYOR M WASHLIGrON S1REEr♦SALLK MAbSAQiLS1z1-IS 01970 1Et 978-745-959S•FAx:978-74W-9U6 APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION, DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1A SITE INFORMATION Location Name: Building: Property Address: r �- lVfl, �i nc 1,4 Property is located in a; Conservation Area Y/N /�49 Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: a o scq Address: Telephone: 3.0 COMPLETE THIS SECT(ON FOR WORK IN EXISTING 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: ��F�I�LI��� p.,v��.�iG� V titn�,( ,/�J'rl.61'.F'•i�� wi,✓Dc�r� �Vrki `1rw1A� /JuAc, 0ACA- Oal/ GrOI- 04K C'v- rfo A10 l)aw". S pffy, Mail Permit to: 2 <�"L( ��n� ��/✓� What is the current use of the Building? Material of Building? L-'6W If dwelling, how many units? ,OfAyf 1-- Will the Building Conform to Law? ,/ b' Asbestos? NO Architect's Name �02t © 1101 L Address and Phone 2 R�Ga j Mechanic's Name " 55 K/JI1 Address and Phone 2 -2- Construction Supervisors License# '166 cM HIC Registration# Estimated Cost of Project$—Z-ZO--/I" �� Permit Fee Calculation Permit Fee$ /30 Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit t ild to the above stated specifications. Signed under penalty of perjury ;late ate o N b 00 O d o S u Z 20, u y ° a `V 8 Gam`, 1' a-- �- --- -- - - -- CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT K�tBER1EY DRISCO[1 MAYOR 120 WASHNGTON STREET Is SALEM,MASSACHUSEM 01970 TEL 979-745.9595 •FAx:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /��q �p� Please Print Le iv Name(Business/Organization/[ndividual): �_05 ryp - (QJIjhc_v4� Address: 2 Z P,1?CZ-70 -7�) / City/State/Zip: '3 14ir-9 lw-4$S Phone #: Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and I _pylployees(full and/or part-time),• have hired the sub contractors 6. ❑New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity, workers' comp. insurance. 9, ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑PI bing repairs or additions myself. [No workers' comp, c. 152, §1(4),and we have no 12. Roof repairs insurance required.]t employees. [No workers' ❑ �r Glr� comp. insurance required.] 13. Other_ *Any applicant that checks box#1 must also fill out the section below,showing their workers'compensation policy information, Homeowners who submit this affidavit indicating tbry ara doing all wort and then hire outside contractors must submit a new affidavit indicating such. rContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer diat is providing workers'compensation insurance for my employees. Below is the policy and Job site information Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/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 MGL c. 152 can lead to the imposition of criminal penalties of a fine 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby terrify under the pains and penalties of perjury that the informadon provided above is true and coneet Signature• Date Phone#• ==Other only. Do not write in this area,to be completed by city or town offliciai n' Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector son• Phone#: Information and Instructions Massachusetts General Laws chapter 152 s defined requires`all e eryope�n provide service of another under any contract p lo� Pursuant to this statute.an employ 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 occupanto 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." d the ce MGL chapter ice a or permit t tales r to a busit"everyness or to cotate or localnstruct buildincensing g shall oimmolnwealth for any r renewal t a license or pe Pe applicant who has not Produced acceptable evidence of compliance with the insurance coverage required:' "Neither the nor any of its political Additionally,MGL chapter e p §o5rmance ostates ublic work until acceptable evidence of compliance with thetons shall insu ep P rance • enter into any contract for the pert p authority." requirements of this chapter have been presented to the contracting 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 number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the ve does ha members or partners,are not requiredBe adviseethatothisreaffidavtmt mmaaynbe submitted to the Departmeon insurance. if an LLC or nt of Industrial employees,a policy is required Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit shoal be returned to.the city or town that the application for the permit or license isbeing 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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill 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 re policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in ( •tY 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 afrdavitmust be filled eut 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. 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. 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/ilia CITY OF SALEM PUBLIC PROPERTY DEPARTMENT wvaa 130 WAMUNCION SMM•IMAKMAZAGiLSUM01WO MR.M745-9M•FAt 9M740.UU Construction Debris Disposal Affidavit (required for all demolition and renovation work) in accordance with the such edition of the State Build ins Code,780 CMIt section 111.5 Debrist and the provisions of MGL a 40.S.% Building Permit 0 is issued with the condition that the debris resulting 8lont this work shall be disposed of in a properly lice sed waste disposal Aidlity as defined by MCiL a 111.S 150A. nw debris will be transported W. /1/O,* C✓ar C41QW (asaas athawer) The debris will be disposed of in : (naan of facility) (addraa ar facility) atpumit applicant ou/�2�aG T date