255 LAFAYETTE ST - BUILDING INSPECTION CITY OF SALEM
• PUBLIC PROPRERTY
DEPARTMENT
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MAYCRt l2C WA1HL\uf/NNSTRUT a SALF.1t,MAssAcllt:ar.'t'tc0197V
Mr :971-74S•9595 •FAX:9M740-9s46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aimlicant Information Please Print Leeibly
.lame tSuailwsVOrgmizatiot✓Individual):/��Address: / e17 /`diceC /¢titom_
City/Statdzip: r���10�117 . /L//}SS Phonek:
Are you mployer? Check the appropriate box: 'type of project(required):
I. am a employer with 0—'-- 4. ❑ I am a general contractor and 1 6. ❑ New construction
employc"(full and/or part-time).' have hired the sub-cuntractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : 7. ❑ Remodeling
ship and have no employom These subcontractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.[1 Electrical repairs or additions
required] officers have cxcrcL%W their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.j t employees. (No workers' 13.❑ Other
comp. inwrance required.)
•Airy apptieettt nut chocks bos el must also All nett the states Loluw showing thoir wwktas'cumpanaWiwt pulicy infurmutium
' 11 m ,,mass who submit this aflidavir indicating I"am doing all work and then him outside contrauon must submit a new affidavit indicaing suck.
:Cuntrx;utra this ckvck this bet mast attached an addilitiul J►xt showing the nattw of the iubionlractm and their wurkan'wrap.policy informatio.
loin an crrtployer that is providing workers'compenmdon Ltsurance for ray employeex Below is the policy and job site
information.
Insurance Company Name: rY ez.-t ._. f//. /�[ ge/`''ca� o•
Policy is or Self-ins. Lic.M (�G ' cv KSSP r77_ __ -- Expiration Date: -A O -
Job Site Address: Cityistate/zip:
attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure w sucure coverage as required under Section 25A of�IGL c. 152 can lead to the imposition of criminal penalties of a
lino up to S1,S00.00 and/or one-year imprisomncnt, 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 011ice of
Invc,ngaiieets slate DIA for insurance covcrayc verification.
/do hereby certify w er the pains rest u fi of crjury that the inforrnullon provided above is true list correct.
tii •:vttnrc' Pair..
Phimca 7
official um only. Do not nvrite in this area.to be completed by city at-town a/j?ciuL
City or Town: _ Permit/I.Icense
Issuing Authority (circle one):
1. Board of ucalih 2. Building Department 3. Citjlrown Clerk 4. Electrical Inspector 5. Plumbing inspector
6.Other
Contact Petsow ._ _ __ Phone p:
CITY OF $ALEM
PUBLIC PROPRERTY
DEPARTMENT
111 6r''OE:M:V I L
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Tra:VS-745-15" •F.\x:97 AC,9s4L
Construction Debris Disposa[ Affidavit
(reyuircd for all demolition uxl renovation work)
in accordance with the sixth edition of the State Building Code, 7S0 CMR section It 1.3
Debris, and the provisions ofMGL 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 e
1 It.S 150A.
The debris will be transported by:
(stama of haul
The debris will be disposed of in
wume of'iaUlty) /
i..d.:rexq Ali t6ci14y/
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i
EIT7C-OF En
p PUBLIC PROPERTY
07 4X6jEPARTb1ENT
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0"-' T 1;976-7ii95"*PAAZ 9M740484 01970
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: Building:
Property is located in a:Conservatlon Area YIN_ 4�Historic District YIN�G
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: 5
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK.IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated qr
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Mai!Description of Proposed Work:
-----Mail Permit to: �/; O• r r`� vim_
",at is the current use of the Building?
Material of Building? If dwelling.how many units?�--
Wlll the Building Conform to Law? Asbestos?
Architect's Name
Address and Plane
e `fcY ou .ter
Mechank's Name ZL
� /�1 rit
Address and Phone X
Supervisors License i1 0 7 6V�� HIC Registration
Construction Superv'
Estimated Cost of Project S U60 Permit Fee Calculation
Permit Fee i y Estimated Cost X$7J$1000 Residential
..-.__ __.. Estimated Cost X$11/$1000Commercal----....----
An Additional $6.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the abov to
specifications. Signed under penally of penury X
Date
96
a