23 HORTON ST - BUILDING INSPECTION I_ + V
PUBLIC PROPERTY
DEPARTMENT
M(SER.Er,ORWOL.
MAYOR ,/O� 120 WASMNG w SlUsr f S"XK MAMAUitStl'rs 01970
TEL 978-74S-9S9S•FAX M740-9846
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION "
Location Name: 3,a5 h Co r-,k ;. Building: rz
Property Address: 3 \ 1 SI-
Properly Is located in a;Conservation Area YIN N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land } 0-le-ph Lo F 1 `
Name:
Address:
Telephone: R 18 83 i}y 5
3.0 COMPLETE THIS SECTION FOR WORK IN FY I IIGSiZI G BUILDINGS ONLY
Addition Existing
EenovatioEnEj E-�
Number of Stories Renovated New
n Existing
ate year of Area per floor(sO Renovated
on or renovation
building New
ription of Proposed Work:
--,- -- C!-tva - - --- -- --�'1 �-�- � I--�'i�\try-� . -------- - --- - ----
Mail Permit to• s•1-�� �a ,\�!�� -- —\ -�-�o=_-- ----- —
What is the current use of the Building?
Material of Building? ) If dwelling. how many units?
Will the Building Conform to Law?
L5 Asbestos?
Architect's Name
Address and Phone
Mechanic's Name � �� '-�)(--C So CY V%,
Address and Phone
Construction Supervisors License# 01-a 6f3�t HIC Registration# j`���
Estimated Cost of Project$ 57226 Permit Fee Calculatlon
Permit Fee$ ,3 S 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 to build to the above slat
10
OF
specifications. Signed under penalty of perjury / �
Date
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CrrY OF SALE.M
PUBLIC PROPERTY
DEPARTMENT
Kt�sast.a9 osuoott;
Wirol t��AfiaatbZOrt tirsaR•S4�JfAY�Ott'flCR 0191*
Construcdos Debrb Disposal Ailtdavit
(required tar all dsmobdon sod moonalm work)
in accord@=*with dw sixth edidon of the Shot Building Codas,7W CMR section 111.5
Debri4 sod dw provisions ofMGL a 44 g 5 4
BuildtM Penn&d is immM with dw coodidoa that the debris m=Wog bod
this war AM be dispoaad of in s properly bmted wasq disposal btdlity as defined by MOIL s
111,s tsa.
The debris wiD be transported by:
(.sass ach dlu)
i
The debris will be disposed of in:
I�-�CS`� t�S'tCs-e CG�-ti
(am of heilit»
SCA \NA I�
(uldnsa of haility)
sisaaatts of permit�pplicaat
due
.'etn.allJua /
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KAIBFRLEY DRLSCOLL
MAYOR 120 WASHMTON STREET•SAtEM,MASSACHUSE'T0 01970
TEL.9M745.9595 •FAX:978-740.9846
Workers' Compensation Insurance Affidavit: Bullders/Contractors/Electricians/Plumbers
Aunficant Information t Please Print LeAbly
Name(Business/OrganivitiottMdividual): \�G`1sl'S-ICc u.�C\ •• � l` y2c,�., cl
Address: U`. o� —70-\''
City/State/Zip: J ��t%� Phone#:
Are you an employer?Check the appropriate bow Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contactors 2.❑ l.Cf 1 am a sole proprietor or partner- listed on the attached sheet t 7. �q,
Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity,
nnntee�99qi workers' comp. insurance. 9. ❑Building addition
[No workers' comp. insurance 5. We are a corporation and its
required.] ` officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.0 Other
*Any applicant that checks boa el must den all out the section below showing their workas'compmaarim policy information.
t Homeowners who submit this affidavit indicating they ore doing all work sed then him outside coutracto s must submit a new affidavit indicating such.
tContracton that cheep this boa must sttached an additional sheet showing the name of the sub•eontnetors W their workers'comp.policy informadoo.
1 am an employer that Is providing workers'compensation insurance for my employees. Below Lf the policy and Job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Add b Site
ress: �-? _ t� � I ELnel
-- —� City/State/2ip: S
Attach a coP trrthe-workera^tomPensation PalBc declaration page(showing the poBry7umrer=
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$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.
/do hereby certify. der the paint and e af�s ojper/try that the information provided above Is true and correct
Signature• Date 1 l —1 cc,
off vial use only. Do not write in this area,to be completed by city or town ofJlclaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to Provide workers compensation for nerve ployem
of hire,
Pursuant to this statute,an employee is defined as"...every person in the service of another under any
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 occupant of the
dwelling house of another who employs persons to do"+�tenance,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 152,125C(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,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 with the insurance
requirements of this chapter have been presented to the contracting authority."
e 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),addresses)and phone number(s)along with their certificates)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 rerumed 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 permit/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
appiicant as proof that a valid affidavit is on file,for.f iture perr�it&or t censes. .A new afudavit 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 bum 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
O®ce of Investlgadons
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.man.gov/dia