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1 HORTON CT - BUILDING INSPECTION CITY PUBLIC PROPERTY DEPARTMENT KmOmu"ORISCOLL MAYO{ �� 120 WMMNG- W$I1J-r•SALLK M.►wAalLSerts 01970 1k7:973..745-9595•FAfi 97s.7.10.9&6 a APPLICATION FOR THE REPAM RENOVATION CONSTRUCTION DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EMSTING STRUCTL>RF OR BUILDING 1.0 SITE INFORMATION Location Name: Building: Property Address: I Property is located in a;Conservation Area YIN Historic District Y!N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land ` Name: Address: Telephone: �'c 3.0 COMPLETE THIS SECTION 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: ---- --- ----Mail Permit to: What is the current use f the Building? If dwelling,how many units?�� Material of Building? Asbestos? WiU the Building Conform to Law? Architect's Name Address and Phone Mechanic's Name �%T ` c��jc�� rj 7G [� — Address and Phone Construction Supervisors License# HiC Registration# Estimated Cost ofd ed 5 Permit Fes Calculation Estimated Cost X$7151000 Residential Permit Fee 5 Estimated Cost X$1115100()Commercial An Additional $5.0()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 stated specifications. Signed under penalty of pa luny ' ` Date I N r Y 4 i. ( a o a a o aC6 - - CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KUMMM MUC= .Anis 130WASMUCI MsUM•sMM4arAUAOK3Wfsats7s Construction Debris Disposal Affldavit (required for all damolidos mod ratavadaa work) In acwrdaoea with due snob edidm of dta Stats Building Cada.780 CMR sectim 111.! Debriss and dug luovisions o(MQ.a 40.9 Sop Building Pannit N is issued with dw m%Udm dtat dw ddmW mauldng Aom this wait shall be disposed of is A peoperly&meed wamta d RMW&dUW defined by MGL a I 11.S ISOA. The debris will be transported by: U 'A,) (cams The doWs will be disposed of in: coram.of fmaity) ("m "or hcwly) iyaaaur atpumk applicaar 16 � S�L — due `- CITY OF SALEM r PUBLIC PROPRERTY DEPARTMENT xwsearEY narscou MAYOR 120 WAsH3NGTON STREET a SAt.etf,MAssAcHUsErrs 01970 TEL 978.7459595 •FAX 978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQjbly Name(BusinessJOrganizauon/Individual): Address: :Z2G/12 ZS—f p2b( )io City/State/Zip:_4 )Ql-/.esft Phone#: Z1 - 79�/• Are you an employer?Check the appropriate box: 1.® I am a employer with 4. I am a general contractor and I Type of project(required); employees(full and/or part-time).* have hired the subcontractors 6. ❑New construction 2. I am a sole proprietor or pastries- listed on the attached sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me m any capacity. workers'comp, insurance. (No workers' comp. insurance 5. ❑ We are a corporation and its 9• ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp, c. 152,§1(4),and we have no 12.[0 Roof repairs- insurance required.]t employees.[No workers' comp. insurance required,] 13.❑Other. fAny apPamnt that checks boa#1 must also fill out the section below showing the4 were'coin Homeowmn who submit this affidavit indicating ate doingall pia policy infmam im tContnutm tial cheek this box must attached an additional sheet tbo gain the name off the rub.con � must submit e ,c a0ldavii y inform such, tractors and their evohm'mmp.pofiry inforautloa, lam an employer that Is providing workers' ampensadon insurance for my employees Below is the polity and Job si4 information / Insurance Company Name: /r /Gt�j 6 Policy#or Self-ins.Lic. Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers'compensation policy declaration page(showing theo P licY 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 s 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$250.00 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 Ido hereby certify under t pains and penalties of perfary that the information provided above is dire and coned Sianature: Phone C F cial use only- Do not write in this area,to be completed by city or town ofJ7ciaL or Town• PermitlLicenseng Authority(circle one): oard of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector ther Contact Person: Phone#• Information and Instructions to txa.� . _.. requires all employers to provide workers' compensation for their emp Y 152 re P of hire Massachusetts General Laws chapter q person in the service of another under any contract , Pursuant to this statute,an employee is defined as"...every pe 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 to i deceased employer,es. How or the receiver or trustee of an indivithral.Partnership'association or other legal entity,employing employees However the and who resides therein.or the occupant of the owner of a dwelling house having not more than three apartmenb work on such dwelling hoose dwelling house of another who employs persons to do maintenance,construction or repair to be an employer." or on the grounds or building appurtenantthereto shall not because of such employment be deemed MGL chapter 152,§25C(6)also states that"every state or local licensing agency ummold the is uance r renewal of a license or permit to operate l business or to contract buildings the applicant who has not produced acceptable evidence of compliance with the insurance coverage required.- applicant Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth evidence of compliance subdivisions th�o1D�nce enter into any contract for the performance of public work until accep have been resented to the contracting authority." requirements of this chapter P Applicant Please fill out the workers' compensation affidavit completely,by checking the boxes that apply rt your situation and.if 1 sub-contractods)name(s),address(es)and Phone nttmber(s)along whit their certificate(s)of necessary,supply with no employees other than the insurance. Limited Liability Companies(LLC)or Limited Liability n insurance. (LLP) members or parmcM are not required to carry workers' compensation ubmitted If an LLC or LLP f lnd 4v� employees,a policy is required. Be advised that this affidavit may be submitted tnd o the the affidaDepartvit. Accidents for confirmation of insurance coverage. Also be sure for the permit to sign a license is being requested,�o t Department of should be returned to the city or town that the applicationquestions regarding the law or if you are required to obtain a workers' Industrial Accidents. Should you have any qn es should enter their compensation policy.Please Dell the Department at the number listed below. Self-insured companies self-insurance license number on thea line. City or Town Officials eparnnent has Provided a space at the bottom Please be sure that the affidavit is complete and printed legibly. The D of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicappant. Please be sure to fill in the permittlicense number which will bei as a reference number. in addition,an ar,need only submit one affidavit indicating current that must submit multiple permittlicense applications in any given Y in policy information(if necessary)and under"Job Site Address"the applicant should write"all locatioonsrovided to or town)."A copy of the affidavit-. has been officially stamped or marked by the city or town may p applicant as proof that a valid affidavit is on file for future permits or licenses. A new afidsva must be filled 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 brim leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigation would like to thank you in advance for your cooperation and should you have any question, please do not hesitate to give us a call. The Department's ess,telephone and fax number. This Commonwealth of Massachusetts Department of Industrial Accidents O®ce of Iavesdglitions 6W washingtnn street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www mm.gov/din