175 LAFAYETTE ST - BUILDING INSPECTION crn' or. S_v1.1 ::v1
NT
APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT 1 AND 2 FAMILY DWELLINGS
IN1PORfANT: Applicants must complete all items on this a e
SITE INFORM TIO
Location Name Building l�(�\ ��r� v ,A
Property Address
Map#
Located in: Conservation Area Y/ Historic district Y
Use Groups
(check one)
Residential (3 or more Units) R2
Type of improvement Residential (hotel/motel RI _
(check one) Assembly (churches) Al _
New Building_ Assembly (nightclubs etc) A2_
Addition Assembly(restaurants, recreation) A3
Alteration / Business B ✓�
Repair/Replacement ✓ Educational E_
Demolition_ Factory (moderate hazard) Fl _
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard H
Accessory Building Institutional (residential care) 11
Other(describe) Institutional (incapacitated) 12
{pmV\ 3-'-rNC - Q- Institutional (restrained) 13_
�O CX lt: ,CF Mercantile M
Storage (moderate hazard) Si _
Storage (low hazard) S2_
OWNERSHIP INFORNIA'f10N(Please hype or Print Clearly)
OWNER Name
Address
Telephone—I06\ ae\
DESCRIPTION OF WORK TO BE PERFORMED ` S;K&�
\`S\S�0.\� VNPL.1 [�1� 1 1 1vd��OlJ O..h� ��C�c� �•N,'��\ 1
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Fs'rIMATED CONSTRUCTION COST Q-:c)o
CONTlL1C1'OR INFORINATION
Name Sew,
Address \� L.CtX\Q.e
Telephone D:8\160 \(',
Construction Supervisor's Lic # C s S
Home Improvement Conn actor#
ARCHITEC1YENGINEF.R INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x z40/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury �—✓Signed -9 �/Date \
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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rn.978.745-9595 • 1'.vc: 978-74C-A4e
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 ChtR 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 properly Licensed waste disposal facility as defined by v1GL c
I It, S 150A.
The debris will be transported by:
(name of hauler)
Hie "Icbris will be disposed of in
Innr:frof Iry)
e�locstc�� t�o.
s
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Vlanuc 1_'0 WAS I I IN610NS I R EE i s SAIEM, NlASSA(:III si_rnJ1970
"i'rf: 978-743-9595 ♦ Fsx: 978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name IBtisincisrnrganizatiordlndividual): _ L 4`,\e,..g EY\4 SY; \I
City/State/Zip: •C�a \� �— Phone #: —IS \ Q'-C C)DO �
Are vo%ou an employer? Check the appropriate box: Type of project(required):
1.JJ `lam a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).` have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub-contractors have 8. ❑ 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.] officers have exercised their 10. Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LD 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' 13.1 rl t9ther�fSk�.�
comp. insurance required.]
`Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy #or Self-ins. Lic. #: : 4-C`QL L('A L\L\ Expiration Date: 1 )g c
Job Site Address: \_C " \N_j, e�N\ City/State/Zip:
Attach a copy of the workers' compen a on policy declaration page(showing the policy number 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
tine 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investieations of the DIA for insurance coverage verification.
I do hereby rertif tut der the p/ti s/aJnd penalties of perjury that the information provided above is true and correct
Sin uurz
J//i/ // Date \a o `J
�
Phone ' --l$� -I
Official use only. Do not write in this area, to be completed by city or town official
Citv or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Alassachusens General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an empluree is defined as "._every person in the service of another under any contract of hire,
express or implied, oral or written."
An engrloyer 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 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."
- NIGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
1 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."
t\ Additionally, MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomrance 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-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 retumed 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 permidlicense 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
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 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia