1 LAURENT RD - BUILDING INSPECTION �'� ��Qi' �L1l.i'.�� —'___ ,
��' � ��4(� PUBLIC PROPERTY
`� DEPr1R'I71�IIENNT
�,.m�„o.�. .Z, ��1
a1.�.�ac ,�ow.w,ix�c�r�s'�a�r. •
�ur�,�f.�ttnaf�st�'rs 01970
_ 14L 9?6�7i5-9595�FNL•9767i0�9l46
APPI.ICATION FOR THE REPAIR. RENOVATION. CONSTRUCTION.
DEMOLITION. OR CAANGE OF USE OR OCCUPANCY. FOR ANY EXISTLYG
STRUCTURE OR BUILDING
. 1.0 SITE INFORMATION � J
Locadon Name: / L cP U�'�e Buildtng:
— -prpperty Addtess:��u i'e�i . �i — ---- --- ------
property is bcated in a;Conservatbn Area YM�Hiatoric DIsMd Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land �
Name: ,�( !'e��i . ,eY—
Address: f� C/'d uJ� �4 y
�b e ea �. c��P�.s
Telephone: 8' - � /./ZZ
3.0 COMPLETE THIS SECTION FOR WORK IN ��aT�N� BUILDING9 ONLY
Addition ExisGng fp vµ� �
Renovation �,/ Number of Storfes Renovated
Change in Use New
Demolidan ExisYing
Approximate year of � Area per floor (s� Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: ��d f�o c��
cur��S ,
I`�er7��;an � .�'t q �e o�1c �oon�� fw� _ /��,-� c�r�oe �
in wo
f s-oe rns_ /j/ew 7:'/e a � K;�`clt-c� 4 �qo,64'l`��6d
-�'/nor�s_ �� �tf' fif� w Q l(s_
e c t-tl ' Q ���'i��✓l�c�� �C/-�d'io l'>
- - ---- --
--- _
Mail Permit to: Cj" oa� (/'�"
What is the current use of the Building'r c 3
Material of Building? r f wo K dwelling, how many units?
Will the Building Conform to Law? U <S _ Asbestos? /1 cJ
Architect's Name _
Address and Phone
Mechanic's Name
Address and Phon
Construction Supervisors License # C Z % dl9 i l HIC Registration #
EstimatedCost of Project $ -GC' Permit Fee Calwiatlon
Permit Fee if�'�/ D� Estimated Cost X $71$1000 Residential
-- - - - - Estimated Cost X $41/$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 stated
specifications. Signed under penalty of perjury X
Date Z":' -0-7
Nevar n DRISCOLL
MAYOR
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120 WASt1JGT0I.n STREET a SALEM, MAMC M -UM 01970
TEL 978-7459595 • FAX 979.74049846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben
Name
City/State/Zip: S4Ic /Wer.
10/97d Phone #: % %6L
771-,C2-06
Are you an employer? Check the appropriate box.
1. C1C3Tj
I am a employer with 4. I am a general contractor and I
1 e
pe of project (required);
employees (full and/or part -tune).*
have hired the sub -contractors
New construction
2.9,1 am a sole proprietor or partner-
listed on the attached sheet, t
7. ® Remodeling
ship and have no employees
These subcontractors have
9. ❑ Demolition
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
S. ❑ We are a corporation and its
9, [] Building addition
required]
3. ❑ 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
10.0 Electrical repairs or additions
11.❑ Plumbing repairs cc additions
myself. [No workers' comp.
c. 152, §1(4), and we have no
12.C] Roof repairs
insurance required.] t
employees. [No workers'
13.❑ Other.
comp. insurance required.l
1 1
;AnY APPS tht cheek. box el mut"w out the rection below shoving took wait== eompm11gfan OoReY int=estine l
t ttameowmra ado submit fhb must au they nd dotng all Astir anti thin etre ootids cmtrserors mut Admit a mw atedsvit Indenting Ara
rConbutoe spat cheek fhb bin must r=etied ao ddirlooal dte=ahowing the 010111 of dw 51640uhuten sad their workers' comp PoNey Warosdow
I am as ensioloyer that Isproviding workers' compensadon insarence for
information my rmployeta Below hr tlYe polity andJob sire
Insurance CompanyName:�ct7%4/
Policy # or Self -ins. Lic. # Expiration Due:C37
Job Site
City/State/Zi • /Ws 5 O 19 l]
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requited under StxKioa 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fixe
of up to 5250.00 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 ander flu pains and penalties of pedujy that the information provided above /s hue and correct
n. -..-n
WAW
-.9Zdt±o
OJJlelal use on1A Do not write in this area, to be completed by city or Www ojJlciaL
City or Town: PermittLicense #
Issuing Authority (circle one):
1. Board of Healtb 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone
i
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Purwaut to this statute, an coapki ee is defined as "...every person in the service of another under any contrail of him,
express or implied. oral or written
o is defined as "an individual, parmetship, association, corporation or other legal entity, a any two a won
An onapf ye► and includingthe legal representatives of a deceased employet, or the
of the foregoing engaged in a joist emtesprise. m sibs legal entity. employing employees However the
receiver a trustee of an individual, partnership, a� who resides therein. a the occupant of the
owner of a dwelling house having not mac than three apartmentsADAon such dwelling have
dwelling house of aoothar to to do maintenance, consuucuOn � to be an emp Y "
or on the grounds a building who employs
shall not because of such employment to a
MGL chapter 152, $25C(6) also states that "every state or local licensing agency shag withhold the issuance or
renewal of a Vectraa or permit to operate a business or to eosstrue bumdinp t• the eommeawealth ter sty
appmeast who has not produced acceptable evidence of compWaes with the insurance coverage required.
MGL chapter 152. $25C('1) states "Neither the commonwealth nor any of its political subdivisions shall
Additionally. performance of public work until acceptable evidence of compliance with the insurance
rata into any contrail far the to the contracting authority."
requirements of this chapter havvee bion
een presented
Applicanq
affidavit completely. by checidng the boxes that apply to Your situation and, if
Please fill out the workers' compensation s of
1 sub conaaetor(s) name(°), ad&e*cs) and Phone numba{s) along with their certificates )
necinsurancessary.
supply
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) widt no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC a LLP does have
employees, a policy is required, Be advised that this affidavit may be submitted to the DepsRment of industrial
Alae be sure to sign and date the atndsv% The affidavitdavit should
Accidents for confirmation of insurance coverage-
that
the city a town that the application for the permit a license is being requested, set the Department of
be returned ed
Industrial to e citts- Should You have any questions regarding the law a if you am required to obtain a workers'
Compensation policy. Please call the Department at the number listed below. Self-imumd companies should enter their
City or Tows Otticials
Please be sum that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
out in t
of the affidavit for you to fill he 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 inference number. In addition, an applicant
that must submit multiple per=VU ense applications in any given year, need only submit one affidavit indcating currant
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in __(city or
that has been officially stamped
or marked by the city a town may be provided to the
town)." A copy of the affidavit
affidavit is on file for future permits or licenses Anew afudsvir must be filled out each
applicant as proof that a valid
year. Whom a home owner a citizen is obtaining a license a permit not related to any business a commercial venture
(i.e. a dog license Of permit to burn 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 question.
_,--. A^ nnr hesitate to Rive ns a call
The Depar-=cnt's address. telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Once of linvestegrttione
600 Washington street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
• a;
1�'!l>� • lYo�Y�lYoa�nOtf'1•
IVUM74L4M • PAS M74&"
Cow&ucdoa Deeds D4pad AfiMawit
(e•quind 8sr >� dwslidos sd r•ewades went,
is a000sdmoa wide the" WWOM a[dW Sten SWIdW$Coft 780 CDR seedow 11 t.!
p" sd dw pswAdam of UGL a446 S SM
�Adbdwmh"be disposed offs s ppb geed wwadisOoed aoedmdot do dshsia reeby U 8wet
sl dtditt� z. deAaed bylitf8. •
t tt. s tsaw.
Tha dd ria win bs "mpostd ilp
ll�,Y,LC,-u,
gammmalles"
The dobria will be disposed offs:
�r�/�5��� Cart`✓��f
(same of faailihr)
s )O A-1-4 4 4 t�q�e.'�
(addnn of Mei lO
/- jel- d 7
dare
lawk As