7 HORTON ST - BUILDING INSPECTION (3) 1
EI'TY•OFLEn
PUBLIC PROPERTY
DEPARTm&NT
V+,.c. laosr�o�c,r snor•s�Nwwo,�,nns Ots»
I%&n&a.&..FPS s &UMO
,�rpL�wTION FOR_'ll'� �>rw� R�OVw1'iO1�L_ �_nNarQ>rrr_ rrnnt_
DEKOLI'!'ION. OR CAANGE Of TJ31< OR OCCMNICY, FOR AM ASSIMG
OR MMLMKG
�.o�Irt INFORMATION '
Location Nemse
Prop"In located In a;ConsmaUon Ann YM Hh ode owM YIN
2.1 OWNERSMF INFORMATION
2.1 Owsw of Land
Marne:
Addraa
7 Ho rYm i ST Sa le
TIMIG .
ff
IS SECTION FOR WORK IN!]USMW IL4MMOS ONLY
Exlstirq X Numbs of Starlee Renovated
Change in Use N"
Demolition Existing
( f)
Connsstruction or renovation Area per Aoor a FN@w
enovated
of existing building
adef Oesuipdonn�of Proposed Work:
� ��� Div/ v14/e� �.v�'
--- - ---Mail Permit la ! 42c E W. a , - -
r
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voter r a►a Cunene use at a*Bui bv? /
M,arlat ar eaa a'+ w.+ o L_ It awSWgl6 how nwW
vw un.s�ataro C/np�+�e� Yes A•b••"?
Ard cft NOW
Addrew and Penen!
Madna deo NameAddraw and Phone
License B HiC ReWmidorn s lkaO66?:Sr
Eetlmatd Coat of Project 00®. ar Pena FM
Pemit Fee S Es*natad Coe X$741000 Residential
--- . - Eewnalad Coat X$11/$1008 ConrnedaF---- -
- _ An gpdidprmi SUC U a as an
Admkddm"darpa.
Make sure out AN ti.lds are Poly and mobly wmm to avoid delays In prooaalnp.
The undesi0red do"Eby apply for a Buk"Permit to hM to awe above stated
spedic$WM SWad under Pen+dll Of Penury X-4a�, %L�
Date 3
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.y
Cl1 i Og SALEM
PUBLIC PROPRERTY
DEPARTUENT
..Vs■1 at''�A`Il
�1�..'a t ll 7.�icvr�:iataT�iu:r.fL�vcwu.ills::+�
Tt1lt:YOti7�b+)!I/�f•�tt:9M7a4sw
Construcdos Debris Disposat Affidavit
(reyuircd for all detnaliticn and renovatiom work)
tj=mdanee with the sixth cation of the Sots Building Cod%7SO CNIlt suction 111.5
1)ebri%Ltd do provisiom of MML a 40.S S*
suilft pemg 0 _ _ is issued with the condition that the debris reaping Sum
this watt shall be disposed of in s properly licaased waste disposal facility as dented by MGL e
111.S INA.
The debris will be mutsported by:
SP �
(name of hr AW)
rho&-bds will be disposed ofin :
.-ems, ✓ _���,�,. .
t 141TW o'fxdltyj /I
4
.,r
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ioNar Rt F.Y naMM4.
12C 11/AWIJ%:YOK SMUT a SAtiK X%2 AC7 n.:Q7-IX 01973
ftit 978-743.9593 •F.tx:9M7e0.9946
Workers' Compewatioa.Insurance Affidavit: Builders✓Contractors/Electrielans/Plumbers
anallcant Infortnation '/J� A� /n/• / Please Print Legibly
Name P Ihwaim:sKh;anin,t/ia�lvtmlrvu/llntt: /"I1 C'�Y/l nZrA rJ pl �/yji/
Address: �� 1— rrl di P P_
City/State/Zip: / {' @ - !'hone N:
Are you so employer?Check the appropriate bolt
'rype of proJeet(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New conxtrocuan
ernpluyt:etl(full and/or part-time).* have hire)the sub-culunt:tors
3. L am a sok proprietor or paMer. flared on the attached sheet t ?. Q Remodeling
ship and have m employees Theca waconrraetms have tie Demolition
working for 1ne ill any capacity. workers'coatp insurance 9. ❑Building addition
(I�o workers'comp insurance S. ❑ We are a eorparadon and its !0. Electrigl r
roquirtxl J officers have exercised their ❑ repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repair%or additions
inyself.[No workers'comp. C. 152.§1(4),and we have no 12.0 Raof repairs
insurance required.) r employees (1\o workers' 13.❑Other
comp inwra ice requirlxLJ
*And applicant the chacta aoa el map also fill"dw cajun Iwluwr Amiaa ibAt whoa'amup ftso"pW w.y iotarrs%lia6
I1�0Wlwrs wb s11Am/r hY oflldavy iadicalyra hay H doiq all wwlt and IAW Aye anode cawroams awal sudnil a crew aindevil wiadina such.
'C.nursmw thin ckadt this has mist 302dwd an additional Am%hewyy Me nacre etnle and Ihow workers'crap.paiie r mPormarim
/am an employer that it providing workers'campenradon Insurance for my employees. Below is the pulity and Job life
lafarmutwn,
lmurancc Company Name:
Policy a or Self-iris. Lic.0: Ercpiration Date:
Job Site Address; City/statuZip:
.%ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiratiun date).
Failuro w sccute coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties ofa
ri ne up to 51.500.00 and/or one-year imprisonincne,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up m 5250.00 a day against file violator. Ile advised that a copy of this slawaunt may be turwarded co the Office of
lus•cangauuns of due DIA for in.urarcc aivcragc vcrifrcatiun.
i du hereby certify made op n and n�/f1/�'s of per ry that the it armation provided above is true and correct.
,i•:,:,n,ra: -. --,/`LG+�6 Date
Ptu wa a:
=(circleoisa):
un/yc no war write is/his area.to be comp/etedily c/ry or fawn oJJli-Ild
n: Permit/IJecaseM____. _. .
purity (eirde else):Health 2. Building ncpartment I City/fora Clerk a. Electrical lospecfor 5. Plumbing Inspector
son: _ _ Phone p:
j .
Information and Instructions
Massachusetts General laws chapter 132 requites all employers rovide in the service workers'another under compensation for filer
ile r et of employees.
e
Pursuant to this statute.an ess<feles is defined as"...every person
eaptcss or implied,and or written."
No ese &Yff is deuced as"an io�vidud,psrtmship.asseeoama.corporation or other legal entity,or any two a more
of the foregoing engaged in a joint earetpriaa,and including the legal representuives of a deceased employer.or the
association or other legal wtitY.employLag employees. However the
receiver a dmismwells g o individual,psrtnust than and who resides therein.er the of the
owner*(a dwelling bother having not mare done three aparo work on such dwelling house
,,welling house of soother who employs persons to do maintenance,constructionor re pair
or on the grounds or building appurtenant
thereto shall no because of such employment be deemed to be an employer."
AtGt chapter ►52 #25C(6)also tittles tbat"every state or local licensing ageaey shag withhold the issuance or
too rate•bust or to construct but~Is the cotamosweslsh for say
renewal of a license or permit�� operate
t ebie evidence of compliance with the insurance coverage required."
apptleaat who has net prodnor-any
;dtiihienully.MGL chapter 152.312SC(71 states iJaidter the conunottwealthvirieace f compltuuace with eY insurance
enter
contract for the performance of public work until acceptable "
enter into any ammborm
requirements;of this chapter have been presented to the contracting ry
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)names),address(as)and Phone numbers)along with their cenificatc(s)of
insurrnea Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the
members or pactaars.are not regal red to carry workers'compensation insurance. if an LLC or LLP don have
employees.a policy is required Be advised that this affidavit may be submitted to the Department of industrial
ould
Accidents for confirmation of insurance coverage. Also W sure to a is heir tnd date he uesa4 not the Da affidavit. The tpareaoendavit st Of
be returned to the city or town that the application for the permit gal
Iadustriul Arxideats. Should you have any questions regarding the law of 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 Iine•
City or Town Officials
Pleasc 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.
11Icase be sure to till in the pefmniviicense number which will be used as a reference number. In addition,an applicant
,hat must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating wren
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
rownl."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 now affidavit must be filled out each
...— .�:
year. Ri+h"ere 3 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 ere.)said person is YOT required to complete this affidavit.
I'he Of tier of Investigations would like to thank you in advance for your cooperation and should you have any questions
picric Jo not hesitate to give us•u call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
DepaMcnt of Mdtisttid Accidents
Onus of Iwesttptle"
600 Washinglon Sheet
1loM%MA 02111
Tel. #617-7274900 ext 406 of 1-877-MASSAFE
Fax N 617-727-7749
2evised 3-26-05 www.mass.gov/dia