11 HORTON ST - BUILDING INSPECTION - --- I he (',)1unl,nlssrallh I,I \IJ,,.uhu,a•u,
li„arJ „I Hillidul: 8tr_ul:ul,mN and SIandjijs I I IIZ
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i I}uilJin_ I'ennil :\pPlic.tU,1n To C„nN!ruci. !te;air. Itcnm.Jr /h l)enn,li,lr It
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I•- - I Sect it at F tr ()t hit.dal l',e Unly -----__- .-
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.SF.C"1'ION I: .SI IT INFORM % HON
1.1 Pn peri. \ddn s: L 1 !,scours Map & Pary l Nod liar.
� I
FI I.1 I h O ai ,VptYndl ,IRu a, _-y
for
I operty Dimensions:
.,mng Y)I,In:I Pnp,wd l ,r L r ..._L I,y I-i _.. .._-_ l i��w dt. ills
1.5 Building Setbacks (ft)
irrunl Yard —F I ar -n--y H -; Y:uJ -- -1
. .R eyon J —r FnntJrJ i Rc:u n', Pru,IJcJ r3•. 'uurJ + PI , 1
1.6 \Warer Supply MG I.L. 40, §s.tr I 1.7 Flood "Lune Information: 1.8 Se..uge Oispusal SyN u
I Zone'. Outs;ue Flood Zone I ;
Puhltc O Pn,ulr. O — A1un clpul 0 On-nc jiIpo:ai D
sa,: t )N 27 P?wpER'1"e' OWNFR:iII1Pr
. Ea_ I ION 3: DESCU;P MN OF PROPOSED WORK'icheck all that apply)
Ne•.e Existing BmiJilg C I i:'a a:.t Ouupied0 rRelsln,(n) 0 ! :i'ertrnmt.O
D�mnin;un >7 A.ce, ,,,l v I}:dg O Nun e`1r of Urlit _ rr-^ Other Cl 1pcc ! -_ - --
r} I)I npnon kit Prup ised
I 1r. n
SECTION J: ESTIMATED CONSTRUCTION COSTS —
Ilan Esnmaled Cuets: - Official Use Only
II.abor,md Materials) I _ --- ---.—_--- -- _-.- .- .
I Hill Jim! ) (. Built ing Permit Fee: 'S_-- Indicate hit„ lee I, Jena nuncJ.
--- — Standard Cilylfuan Application Fee
F2. I;Iet.tr1LJI ) : O focal Prn)ect Cn,t (hem 6) a nndt;pherinhing 5 ' Other FeeschanlcJl I li\':1C) i --
! � .\teehJnic.tl IPirc —
�u , ne,.t, ni ! � flgJl :\I! Fee, )—_ __--
_-o-._-- � wm —I ( hr.:k No l heal. .\nwunl- l .t,h \immill
h total Project Cost- C3 J-- p Paid to Full 0 OutNl_InJ:Ily 13.II.m,e I lcc'
SECTION 5: CONSTRUI 'riON SERVICES
15.1 Licensed Construction Supervisor tCSI.)
N :I ,II ('S I. 1lo Idrr
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1\ r. Di,.0 noun
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iP Rc,iJ:uli.rl S��LJ I irl IS_uuiin`\�L�I
r5.2 R istercd Ilom In ruvemenl Cuntructor I IIIC) —
fit('Air[).1t. .Naitrr or JIKQ Regl,trint . 'anle Reguu alum Nuwhrr
' Igl r�'�� frlrphone
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(NI.G.L. c. 152. § 25061)
Workers Compensation Insurance affidavit must be completed and ,ubmnted with this application. ICulure to pro,lde
this affidavit will result in the denial of'the Issuance of the building permit. _.
Signed Atfidavit Attached? Yes ......... No .._. ..-. ❑ - - -
SECTION 7a: OWNER AUTHORIZATION TO BE CONIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property herebv
i
authorize c<� _ to act on my behalf. will -
relative to w•.n Is authorized "s building permit application.
Signature to,, r Date
SECTION/7b: OWNEW OR AUTHORIZED AGENT DECLARATION _—
1, /,31 ,4 �p w...,., as Owner or • K r zed Age herchy declare
that the statemenis and information on the foregoing application are true and accuraie, ti�r e-best-of my knowledge and
behalf O AD`—.
Print Name
Signature of Owner,—)r Authurrted .>gent Date
ISi med under t1)e acts and penalties of (u I
NOTES: -
l. An Owner who obtains a budding permit to do his/her own work or an owner who hires an unieen,lcncd runt)-•n for
(not registered In the Home Improvement Contractor (HIC) Program), will wit! hace acces, to me •uhinatwn
program or guaranty Lund under M.G.L. c. I42A. Other important mfurmanon rat the HI(• Program and
Construction Supervisor Licensing WSLi ran he found In 780('MR Regulation, 1 IO.126 and 1 ll) RS. ic,pecmch
When substantial work is planned. provide the information below�
r,Ital llr n rs area l Sq. 1'I.i I mcludi ng garage. tinuhed ha,etnent/atnrs. deck, ,Ii poi:h l
Gross to mg area I Sq. Ft.f Habitable rosin ci lum
Number M lueplaccs Number m hednlums
,Nunlbet ur hmhloum, _— - Numher tit Il,1lrihalh,
f%Ire of 11e,uing ,%,tcm Numhc•r td Jcs k,/ pt t,hc,
I spa �Il .ra�hng ,v,mm —_—_ I[nJuseJ
i ?. Tucd Prnjert Square Footage' may he substituted fur rot,l Project Cu,t.
CITY OF SALEM
_SL
' PUBLIC PR OPRERTY
'-,; DEPAKTMENT
�v..
Construction Debris Disposal Affidavit
(I'CLluirCd fix all demolition and renovation work)
In accurdance N%ith the sixth edition of the State Building Code, 780 Cb1R section 111.5
Debris, and the provisions of b1GL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11. S 150A.
The/ 7
debris will be transspporteed by:(name ut hatter)
I he debris will be disposed of in :
(name ut laeihty)
laddres,ul Iacility)
r
1�gnalure u(permit applicant
CITY OF SALEM
j PUBLIC PROPRERTY
DEPARTMENT
\lAI1K I'. \C�.\�i \�li� '\S;!tt I • S.\I C\i, MA"A' I I 'i I :, :
ii')i ♦ 1'\\: 77S-'4:-')84r,
\N'orkers' Compensation Insurance Aflida%it: Builders/Contractors/Electricians/Plumbers
A folic ant Information Please Print Legibly
\:Illle l liu;Itic" I)[g.uu Zat om IIldl\iJu.d is �� � c'K ✓ "�V"L'•t f -
C'ityst:ltc/zip: / r4"Ile sr, J Phone .#:
.\re you an employer:' Check the appropriate box: Type of project (required):
1.❑ I am a employer with 4. ❑ 1 :un a general contractor and 1 6. ❑ New construction
PrIlto ees(full and/or ant-time).' have hired the sub-contractors
P Y P" 7. Remodeling
' 1 .nn 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. y, ❑ Building addition
No workers' cum insurance 5. ❑ We are a corporation and its
r P 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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' 13 ❑ Other
comp. insurance required.)
'�\Iiy•�pplicaut that checks box NI must also till out the section below showing their workers'compensation policy information.
t I lonicowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:c,oaraclors that check this hox must attached an additional sheet shoving the name of the sub-contractors and their workers'comp.policy information.
/am un employer that is providing workers'compensation insurance far n+y 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). 1,
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a tine
of up to S250.n0 a Jay against the violator. Be advised that a copy of this statement may be tm-warded to the Office of
Inh d.ti¢ations of the DI:\ tor insurance covcrtge verification.
/ /it hereby certify;.t drr/lyo pain. and lwisal ' _af perjury that the information prow
above is true and carrre•t
� C�
�icr:nure: Utrc ��L / F-
111'. 1 > S4 S l t> 7( (r
01ficial use only. Do not write in this area, to be completed by city or lawn officiaL
('its or I o%\ n: - — -_-- --- Permit/License M ----__----__--
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. 01her
Contact Person:__._------ -- one _.
Information and Instructions
\I; N�achusens General Laws chapter 15' requires all emplu\ers to pros ide workers' compensation for their cnlploNees.
PLII Nklain to this stuute, an emjdi ree is dclined as ".. c%en. person in the scn ice of another under any contract of hart, ,
e\press or implied. oral or is Linen.-
. .\n enildorer is dCfined as "an mdis:dual. p:mmcrsh:p, association, corporation or other legal enti"r. or any two or more
tithe foregoing engaged in a joint enterprise, and n1CILld111g the legal Lepresentam es of a deceased employer, or the
I cccicer or trustee of an individual. partnership, .issociation or other legal entity, employing employees. I lowever the
,ors ner of a dwelling house having not more than three apartments:old who res:des therein, or the occupant of the
duelling house of another who employs persons to do nlaintrnance, construction or repair work on such dwelling house
or on the 11ounds or building appurtenant thereto Shall not because of Such employ ment be deenud to he an employer."
\IGI_ chapter I5-1, §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 in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, SIUL 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 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-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
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 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 pemut/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, a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The ()Ifice 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.
I he Dcpamnent's address, telephone and tax 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
Rc%iscd 5-10-05 Fax # 617-727-7749
www.mass.gov/dia
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