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10 INTERVALE - BUILDING INSPECTION (2) What is ttie current use of the Building? Material of Building? lvbtl0 It dwelling.how many units?_ — WiY the Building Conform to Law?xt%— Asbestos? D Ardtiteas Name Address and Phone l ) Meehanles Name Address and Phone l ke Construction supervisors License it HIC Registration g Estimated Cost of Projed S g Permit Fee Calculation Permit Fee S--- =�� Estimated Cost X$7/$1000 Residential --- - _ Estimated Cost X S41/i1000 Cammerdal---- -- - - - An Additional$5.00 is added as an Administrable dtarye. Maly 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 psdurY X 4_ Date 0 0 N s � 0 s Z %) a Y! O y ygg Gr 3 EI'1"StOF - _ PUBLIC PROPERTY DEPARTMENT u..eEn�v owu�u N"Yoe 130 WAMWGF(W sFUW•SaAft V'.WA61LSl79s01970 T%L-VWUSAS93•FAZ M740.9" APPLICATION FOR THE REPAIR RENOVw'rwoN CONSTRUCTION, D&MOLITION.OR CHANGZ OF USE OR OCCUP n Cy FOR ANY EXISTINQ STRUCTURE OR BUR nn_vr_ 1.0 SITE INFORMATION Location Name: /eD — y Va, I je 8utidtng: g e 5 4 jK C.- -- Property Address�- -------- - -- -- Property Is Located In e:Conservation Ares Y/N Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land kr ,L �S Name: KJ-jGTr, ifv 14 r Address: 10 yn%�✓{'a 1 Telephone pp 3.0 COMPLETE THIS SECTION FOR WORK IN MUSMING 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 SEW Description of Proposed Work:n IL-e-en0 to--/ -j0%h ✓yn>©V0 ------------- Mail Permit to: 10 h,-P 0 4vr e ✓ - CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT n1NOF RIEY ORIS OLL. MAYOR l2C WASHUNC17ONSTRIM-r• SAIEs1,MA5%AClnster1sGl9TJ Thu:978-743-9395 0 FAX:979-71G9816 Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers Applicant Information Please Print Leeibly NaMC(f;u<im.WOrganizationtindiv,duui): J t tM.11 1 V tr`C�a 1 Address: G Le e- A?�l //i�h Rd. city/srace/zip: W Ol J1/ Phone #: q7 - 3 3(W - e%10 7 Are you an employer?Check the appropriate box: 'type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-timc).• have hired the sub-contractors �� ,� _.®'fant a sole proprietor or partner- listed on the attached sheet : 7• @31COmodelmg ship and have no employees These subcontractors 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 10.❑ Electrical repairs or additions required.) officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LC3 Plumbing repairs or additions myself.(No workers comp. c. 152,§1(4),and we have no 12.❑ Ruofnpairs insurance required.] t employees. [No workers' 1341-1 Other comp. insurance required.] •Any applicua that eludes boa nl must ago fill wt the action below 4l iag lhit wwkua'eompena 6o pulicy in6,rna1iura 'Ilomonwnsn who submit this affidavit indicating they am doing all wore and then hire outside eonitnmon must.uivnit a new affidavit indicating sttch. �Connacu,ca that chuck this bon mutt anaclmd an alditiond A m showing the name or rho sub-coatradom and their workcna�comp.policy inf«matitm. l am an employer that is providing workers'compensadon insurance for my employees Below is the policy and job site infornnutiun. Insurance Company Name: _.. . Policy#or Sclf--ins. Lic. #: _._ Expiration Date: Job Site Address: CityiState/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A uf.%,IGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment, as well as civil pcnallic:s in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of luv .%w,ations ul'ihc DIA for insurance covcragc verification. i do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si•�,:uuro' Dar . D 7 Phone : q7 q 3 5q 9 V Orjcial use only. Do not write in ddr urea,to be cootpleted by city or town offlci&Z City or'rown: Permit/License#_ Issuing Authority (circle one): 1. Board of licahh 2. (Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: __ Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, eapress or implied,oral or written." :Vt employer is defined as"an individual,partnership,association.corporation or other legal entity,of 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 have 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." AtGL 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 in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required:' Additionully. 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." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)narne(s),addresses)and phone number(s)along with their certificatc(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 arc 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 OMC1215 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicense 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 affiduvit is on file for future permits or licenses. A new affiduvit 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 Ot'ice 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®ee of investigations 600 Washington Street Boston, MA 02111 Tel, # 617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT I2C W.t9RV::ONS.IEET a 1UtU,atMi.\t::u *-i is%91C TEs:v7s.7+sl5vs a F.%x:9M7469e44 Construction Debris Disposaf Affidavit (required for all demolition aril renovation work) In accordance with the sixth edition of the State Building Code, 7S0 CDiR section I I I.S .� Debris, and the provisions of M. GL c 40, S 54; Building Permit N _ _ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c l 11. S 150A. The debris will be transported by: (,!ante of hauler) I'lic debris will be disposed of in G, /Vf Adl l uamr ui iat ilrty)_ gad.: ei\ oi CuiLlp ,