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APPLICATION"FOR:THE REPAIR. RENOVATION. CONSTRUCTION
� DEMOLITION, OR CAANGE OF USE OR OCCUPANCY. FOR ANY EXISTING .
STRUGTURE OR BIIII.DING
„ 1.0 SITE INFORMATION "
Location Name: �,• ; �' Budding:,
RropeAy Address: :
.0 v S�J
'' Property is located in a: Conservation i4rea YM `l�1rf Historic Diaihid YM
2.0 OWNERSHIP lNFORMATIQN ' ' . . ,:. ' '` - -
2.1 Owner of Land;
Name: �,�
� Address: ; �
'`}.�' .1�a.0 �
` Telephone: - 7 - d-�� �' ` ,` < ;-"`
,3:0 COMPLETE 7HIS SECTION FOtt;IAIORK IN�YiR"r�tur BUILDIN6S'ONLY
Add�tion . ' ,� .: Existir�g . -
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,,
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Rer�ovaUon ` N�mtier of Storie„� Renavated
Change in Use ,,; Ngyy
Oemohtron, Existing. : -
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Ajaproxima#e year of= ; Area.per flooc(sfl, Renovated ; .
construction er renovaUon
, of exisbng�tiuifding ; N�
Brief Oescript�on of Proposed`Work
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What is the cuRent use of the Bu�idfng? - '
�Mat�ai of @uilding? " ' If dwe�►ing how many umtsT
� �Asbestos? =
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[ �Wip the Buildmg Ctinfcrm to lav✓t ' ` ° ,
qrchited`s Name 4
� qddress and Phone ` �� f 1
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Wlechanres`Name
>'Address ana Pho�e �. ` r � �: � r
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Constructioe Superv�sors Irceiise# �
Esqmated Cost o�fio�ect$fr'�� ��'•--' Pertnit Fee Cak:ulgtlbn' <�
Estimat�d Gosf X$7151000 Residential :;
z = Pertnd Fee`3���� Estimated-GostX$11131000 Commercial _
� qn Addttionat$5 00 is added as an
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„� ' anil lagibly wnttert to avofd delays m processin9 _ �.
-��: : INake sure that ali flekis are proper�Y , , _
`The unde[signed daes herebY aPP�Y�a Buiiding Permd tti d W tlie abov ,stated
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NIAVOa
CITY OF SALEM
pUBLIC PROPERTY
DEPARTMENT
128WASmmGVwSRESr4SmZK X01970
-M. 978-74S-9595 • Fey: 97&740-9&16
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR suction i 11.5
Debris, and qm provisions of MGL c 40. S 54;
Building Pa<tmt # is issued With the condition that the debris resulting fivm
this work sball be disposed
of in a properly licensed waste disposal facility as defined by MGL 0
I 11, S 150A.
The debris will be transported by:
Y �'C.
Whf;57i✓.r �C d L� —
ll f .�
(name of haalm)
The debris witl be disposed of in:
(name of fm7ity)
(address of facility)
d
due
.,
d .PUBLIC PROPRERTYDEPARTmENT
KWHIE rsYDRLSCOLL -
MAYOR 120 WASM4GTON S1RM ♦ SALW. MASSACHMEns019M -
Tri 978.745-%95,* FAx.978-740-9846
Workers' Compensation Insurance Affidavit: Builders/ContraetorWE1ectricians
Name(Bminess/organinflonttndividual): ,/7 u 5e, /J C.C. yS15-,e %1 a ---<
City/Statemp: �l �f�
Phone #:
2�
Are you an employer? Check the appropriate box:
Type of project (required):
I.❑ I am a employer with
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part time).'
have hired the sub -contractors
7. C] Remodeling
2. El 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
10.0 Electrical repairs or additions
required]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
152, §1(41 and we have no
11 E1 Plumbing repairs or additions
myself [No workers' comp.
c.
12.616'17 repairs
insurance required.) t
employees. [No workers'
13:❑ Other
comp. insmance required.]
'Any applicant the drain bax$t mut also8a amain ention bdow showing d wWmlme zopmatroa porky id.,aion-.. -.
Homaoworawhoslhln this atHdavit indicating they am domgall work andthm hive oattide cantaul m mut m1nait anew dU5 wit:mdimtiag such.
I am an employer that is providiar wor`3rs' compensdian htsutwrtce for try employees Below is the policy mrd fob sue
information _
Insurance Company Name
Policy # or Self -ins. Lie,
Expiration Date -
Job Site Address _City/Sra
Attach a copy of the workers' compensation policy declaration page (Wowing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL C. 152 can lead to the imposition of criminal penalties of a
fine up to $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 5250.00 a day against the violator. Be advised that a copy of this statement nay be forwarded to the Office of
Investigations of the DIA foppisurance coverage verification
I do hereby certify
official use only. Do not write in this area, to be completed by iciV or town offWaL
above is true and correct
City or Town: PermWI icense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityffown 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 hue,
express or implied, oral or written."
An employer is defined as "an individual, parmership, 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."
MGL 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."
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."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes"'ad 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
member; or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is tequired. 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 affidavits &nplete 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 permittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple petmittlicense 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 liceuses. A new affidavit 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
Office of Investigations
600 Washington Sheet
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.fnass.gov/dia