63 LAWRENCE ST - BUILDING INSPECTION EITY-OFSXLEi -
' PUBLIC PROPERTY
DEPARTMENT
I:I�WERLEY DPIS(:ULL � ���j
MAYOR 120 WASHINGTON STAFF[•SALEK MANSACHl Ytl1501970
TFt:979-74S-9S9S 0 FAX 978.740-98"
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: C. Building:
Property Address: ( _:' yv-� k yl-A Q 9-7 D
property Is located in a; Conservation Area Y Historic District
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:Address: (0 Lemma)
Telephone: — _7j47j U
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) FNe
ovated
construction or renovation
of existing building
Brief Description of Proposed Work:
Mail Permit to:
r .
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors Lice se# HIC Registration#
Estimated Cost of P of Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit ild to the above stated
specifications. Signed under penalty of perjury X
Date-Rc-
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r CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KnreERtaY Da6COl1
MAYOR
IM WA4@1GTMSTaI n•ULEK MAMCWJWM01970
TEU 971W45-9595 a FAX:M740.984
Workers' Compensation Insurance Affidavit: Builders/CoutractorsMOttrlcia=Mlumbets
u AQdcant Information Plea n
Name 3-Ts o,t C o
Address: 21 l qi �tyt,ce I'L
City/Stawzip: Sc/1 erv. rh c Q4 P 0 Phone
An you as employer?Check the appropriate boss
1.❑ I am a employer with 4. TYP$of Project(required):
❑ I am a general wntractoc and I
in Yen( and/orpast-tip).• have hired the stdsconnacters 6. ❑New construction
2. I am a sobs psoptietor ar partaar listed on the attached sheet= ?. ❑Remodeling
ship and have no employees Thee wb-coatncsosa have 8. ❑Demoliti�
working for me m any capacity. workers'comp,Insurance.
[No workers'comp.insurance 5. ❑ Wa aro a cosporstioxi and id 9. ❑ ding adtims
re ] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption Par MOL 11.❑Plumbing repairs or addition$
myself.[No workers' comp. c. 152, $1(4),and we have no 12 Raof
mWing
Insurance�d l t employee.[No workers' ❑
comp, insurance rcquised] 13.Q�OtherRMa& t:sal
'AnY W VHOW thd eha ks ban NI mug an nil nut ft Iselin briar d owl tlWr warkq'ooe�m�{w� y
rCoaaaemm tlrttlrt Ws has mwt soueha " al dote$aE vak and rhea tdn aaubb waaaemn mmt wbmh a taw anldrvY .add(ttoeal swu rhorm$ohs meat ofdm mbccaus o and dW*aarloaa'�, fidbrnudm
Pam an employer that 1r provldlnd workers'compeneadom inaurance for my
informaakxa employees Below L the policy and Job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address
CirylShte2ip:
Attach a copy of the workers'Compensation policy declaration page(showingthe
Failure to secure covers as Po�Y number and expiration dab).
coverage required under Section 25A of MGL o. 152 can led to the imposition of crmiaai penale oPa
fine up to S 1,500.00 and/or one year i nimsonmrnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day againstthe violator Be advised that a copy of this statement may be forwarded to the Offic
Investigations of the DIA for insurance coverage veri e of
fication
f do hereby csidA ander the pairs and penaldn of perfurp that the j in o madon provided above is vue and correct
Signature: ! �� Da e t—z? r—a&
Phone#:
1OJjkial as*only, Do not write bs this area,to be completed by city or town 0QklaL
City or Town PermiNLieeme#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Clrylfown Clerk 4.Electrical Inspector 5.Plumbing Iuspector
6.Other
Contact Person
Phone#:
I.
information and:%structions
Massachu tts General Laws chapter 152 requites all employers to provide workers' compensation for their employee.
Pursuant to this statute.an enplopee is defined as"...every person in the service of anodes under any coursed of bits.
express
Or implied.Oral Or written."
other legal entity.Or any two Or more
An employs is defined as"an individual.partnership. 08-cotVorsdaft or ofof a deceased emPleyer.Or the
of ties foregoing enpged in s Joins and 1OC�the� loy;ng employees. However the
of m indtvidira4 pstmashipt association or other o resides tploy*herein.or the ooeupast of the
receiver or trustee hoarser ham not more tl�three apartment
owner of a dwelling to do maiot�ao�.motion Or repair wort on such dwelling httuea
dwelling boom of another aloe arnPloYa Aso shall not Weause of such employment be deemed to be an employer."
or on the grounds Or building appurt�
6 also states that"every state or local neeadag agency shag withhold the lasuanee or
MGL chapter 152.$2SC( ) Pe"a a busmen or to construct bulWlogs V the commonwealth for say
acceptable ev use's oI eomptlaace with the lasuranu coverage regt�"
reeewal o[•nattee or permit to 0
appneast who bas not Produced states"Neither the commonwealth tier any of its political subdivisions shall
Additionally.MGL cbsfor t e p fotma>) le evidence of compliance with the inauanae
anycanted for the performance of public work until acceptable
entof this chapter have bien presented to the contracting amhonty"
ue9
Appl{eanu the boxes that apply to your situation and.if
ssition affidavit completely,by checking
Please fin out the w� �s)��s).add and Phone number(s)along with their eertificaoe(s)of rhea the
necks ranges(LLQ or Limited Liability Partnerships(LLP)with no amployen other
to carry worker'eompmsstioe insurance. If an LLO or LLP doer have
members Or P�erns tent advised that this affidavit tray be submitted m the Department o4 Industrial employees.a policy is requited coverage. Alm be ans a to sign and date the affidavit. The affidavit should
Accidents for
confirmation of insurance Should Yen have an qu*M or
license is being requested,not to
Department
to returned the city Or town that the application for the permit to obtain a workers'
Indu regarding the lea if you are required should enter their
t ati'ial��nt' at the number listed below. self insured companies
compensation Policy.Plea can the Department line
self-insurance liceom number on the a
city or Town Ofclalo
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 m contact you regarding the applicant.
Please be sate m fill in the an applicant
petmittficense number which will be used as a mferencenly anumber.one n a d iti indicating cnsOrm
that must submit multiple permiNlieense applications e A any given year,need hoar in
policy information(if necesmry)and under"Job Site Address"the applicant should writ"all maybe locations d°r
or marked by the city Or town maybe Provided
town)."A copy of the affidavit that has been off skimped Or licenaea Anew afidavu must be filled out each
applicant as proof that a valid affidavit is on file POr fiitare permitsnot rotated to any busmen Or commercial venture
ear.Where s home tweet Or citizen is obtaining a license s Perms
y u NOT required to complete this affidavit
(i.e. a dog license Or permit to burn leaves ere.)said person
ou in advance for your cooperation and should you have any questions,
The Office of Investigations would lilt to thank y
please do not hesitate to give us a call.
The Department's address,telephotm and fax tiu nber.
The Comm avieslth of Massachusetts
IN Department of hAlahisl Accident
o8[ee of Invesdgatlone
600 WMIliugtOn sheet
Boston,MA 02111
Tel. #617-n74900 W 406 or 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26-05 WWW mass govidler
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