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6 HORTON ST - BUILDING INSPECTION What is the current use of the Building? Material of Building? If dwelling,how many units?_ WIII the Building Conform to Law?1 Asbestos? Architect's Name Address and Phony ( ) Mechanic's Name Address and Ptwns 3�t : Construction Supervisme Vcanse s U b `t�5r e�HIC Registration 0 L v y rc 3 Estimated Cost of Pro Permit Fes Calculation Permit Fee i- Estimated Cost X$7/:1000 Residential Es*natsd Cost X S41/$1000 Commwcia4----- - - An Additional t0.00 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 Penn bu to the above stated under penalty of Perjury « � Signed s iflcatkuu. ig Peo Date �a I 4 �d� o � � N o L a Erry-OF PUBLIC PROPERTY ` DEPARTMENT N.%pvwev ONSCA" Hwroa 130 WAwvNG cw+h'n u•SALjft%L%uAcM_%--j-M 01970 IVL'97L74&""•FAW M74G.9ay APPLICATION FOR THE REPAIR. RENOVATiAN ICONSTgUCTjorj, DEMOLITION,OR CHANGE OF USE OR OCCUP WY FOR ANY EXISTING STRUCTURZ OR BATULDVIG 1.0 SITE INFORMATION Location Narrler a p Building: -- - .. --- PropsrV Is located In a.Conservation Ares Y/N Historic District YfN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: S- Telephone: 3.000MPLETE THIS SECTION FOR WORK IN EX181 G BUILDINGS ONLY Addition Existing Renovation ✓ Number of Stories Renovated Change in Use New I Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New 86ef Description of Proposed Work: j�� �T�- ��� reed ed: - /�E � T /� P�IiS t g, 1/ �"-yS . �ST /9e c rT Um era,r e6 S ---- - -- Mail Permit to• 1/ CITY OF SALEM (: PUBLIC PROPRERTY DEPARTMENT T 81ataFRIElf Ditt-WOL1 M.vvo R l2C WASIV%GTON STREET' •SAtw",MASSACI u.:ui t is G197'J TE.I.:978.743-9593 •FAX:97M•740.9846 Workers' Compensation Insurance affidavit: Builders/Contractors/Electricians/Plumbers Anglicaut Information Please Print Le ibl NatTtt: tHucitw;xs/OrganizatioNlndivtdual): Address: City/slare/Zip: Phone #: .\n you an employer?Cheek riseappropriate bo Y x• 'type ot project(requlrcrl): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction employe"(full andlur part-time).• have hired the sub-contractors 2.❑ I am a sole proprietor or partner. listed on the attached sheet. 7• ❑ Remodeling ship and have no employees Thera 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 _ required] offices have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per N4GL 11.0 Plumbing repairs or additions myself [No workers'comp. c. 152,§1(4),and we have no 12.❑ Ruof repairs insurance required.] t employees.[No workers' 13.0 Other comp. insurance required.] 'Airy�pplicwa o,at checks boa el must also lilt out the aactian below showiaa their worktas'cumponsariwr policy information. ' 1 Wtnvowncra who submit this amtlavit indicating they are doing on wart and then hire outside cuntracton must.uhmit a new amdavit indicating arch. �Contrxwn that chock this box must attached an additional Ann.hewing that name of the sub-comraaon and their wurkaii comp.policy information. /ant an employer that Is providing workers'cmnpensndon Insurance for try etrplayees. Below is the policy and job site iufurination. Insurance Company Name: Policy As or Sel4ins. Lic.#: _.. .__._ Expiration Date: Job Site Address: CitylslatuZip: .\arch a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure w secure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a 6ne up to S1.500.00 and/or one-year imprisomncnt,as well❑s civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. He advised that a copy of this statement may be forwarded to the Office of htn rsngations of the DIA for insurance coveragc acritication. I da hereby certify under the pains and penalties ufperjury char rise information provided above is true and correct tiig:ruuro: Date• Phure is t Official aye only. no nor ivrire in ibis area,to be completed by city or town ojjieiaz City or Town: Permit/License ll Issuing Authority (circle one): 1. Iluard of health t. Building llepartment 3.City/fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: __ Phonc #: Information and Instructions Massachusetts General Laws chapter 152 requires all employttoprovide the serworvicekers' compensation any ctheireet of hire Pursuant to this statute,an employee is defined as"...every person etpress 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,pentncrship,association or outs legal entity,employing employees. N of the 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 is the commonwealth for any applicast 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 fill 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 maybe 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 approLnate 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 till in the pennitllicense number which will be used as a reference number. In addition,an applicant that must subunit multiple penmitilicense applications in any given year,need only subunit 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 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 burn leaves etc.)said person is NOT required to complete this affidavit. 1'he Olticc of Investigations would like to thank you in advance for your cooperation and should you have any questions, please du not hesitate to give us a call. The Departunent's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Ottilee of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 Revised -26-05 www.mass.gov/dia CITY OF SALEM a' s PUBLIC PROPRERTY DEPARTMENT I2C WA!9aNt::0vS:aEET •5.atry,\tauuau u i is7:91: Trt:9M745.9595 •F.%r:97t.74C-9646 Construction Debris Disposal Affidavit (required for all demolition atul 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 property licensed waste disposal facility as defined by \1GL c l 11. S 1.50A. The deb ' will be transported by: (name of hauler) € The debris will be disposed of in i V In:1(I1C Jf IaC 11 lly) {4Ii Stti L elom — - uahne: CONS f=TION Wa .. antx©t ' � i[ rrt S Y' k S 129 s C f4 I i�