15 LEACH ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTUENT
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Construction Debris Dis"llat+ Affidavit
(required Far an danotidaft and 80pvOdom wort)
In mconianee w ith the dxdt edition of do Sets Suildiot CW4 730 C1►11 smdm t t 1.3
Daw*urd dw provisions oCNGL a 40.S Sk
8uildiq Permit• _ is isatted wiry the eoodidoa On the debris realdns ftarts
this wort shall be disposed of in a properly licensed wasts disposal &dHty as defined by SIDS.a
ltL. 515"
The debris will be transported by:
tname of hauled
i
rhe:kbds wilt be disposed orin :
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Worker•Compeawdea Insurasee Alltdavtts BdldWWCosd'ae%rdEj@ daaa/phanpart
Aaalkant Informadon Lyi Print t
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VatnC tutaMeaUogr;raaewlnJww4ralr.�_•r•Q Ca•-,,� tz..rq�1-e ��erer rr` cp�� iYIC
City/Stuivzip: Z e vp , o t5 rt ,'Bono N 9 7 8— q
Ara you u osapArir?Clwek tbo approprlab bom
1.0 1 am a employer wick ♦. [3 1 ant a Jeneral conuaciew and 1 Type orprolaee(ttequirvo
employoea(full muVor ptn-tims).• have hired the sub-contractors 6 0 N m comamtotias
2.0 1 am a sole proprietor or partner, Used on the atgwhed shoat 1 ?. 0 Ramodsling
ship mad have no employees Thews haw g 0 Dernalidos
working for me in any capacity. CA .camp,Irourenca. A
(ne workers•coat a, Insurance S. We am a corporation and Its 0 wag addities
required.) often,have oxercisod their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of axamptim per MGL 11.13 Plumbing repairs or additona
Myself(iris workers'tamgt. a 132,f 1(4),and we have no 12 Roof rcpoin insurance requko&j t employees(A'o workers•
comp insurance rcquitsxl l 13. Odw
'Ath+rPheast atw eI ' eaa et net alas tta ma ato saa;aa wow A"thdr ttwmtos atw(,snadtta pywy iaarertisa
'nlurrrtWt�a who tueatls oils.nu.ls Indisuma'airy an doiyl so wmk tea iris aiw a
nr
ounids sawwow tl wertth a a.w mtYvis inJlariryt vt,i
('anvx+ws do okra!raga kaa tors amsdrtl r atwlsisesl Am%hWairta the news Onto m il►cono mma aN#hair wamhw•comit•Owk7•
one nw 001PAYer this,b pro v/ roar workm I compenradew bus enjarefer my earp/oyees Bdow b
In urance Company Namr� r�S�S e .1v sk+r Avst e
Policy 1t or Self-ins. Lie.0, - •- Expiration Date:
hub Site Adth-so: �� � � S� Citylstat&Zip: Sl.vtfi
Attach a copy of the workers'compensation pulley declaration a b \Q
P as(showing the policy number and csp(rmtius date}
Failure tv x:cure eoveragf as required under Soctiea 25A ufMGL c. 152 can lead to the imposition of criminal panaltiea ofa
sin.up ut 51.500.00 and/or ote-year imprismm�cnt,ar well ar civil pettaLies in the form of a STOP WORK ORDER and a riot
-if uo to i250.00 a Jay agairaa the violator. lie advised that a copy urthis slaWmi nt may be turwarded to the Office of
Inr,,ng;muntts of t 1 ut,ur .x awcra�t:scrirtcatiun.
/Je hereby reni onJer mar Ind ptnu/tks e/pedary that Me!%rwW/os p vrufed ebaw is Irmo mad correeR
T .
U/J4•id ear emr/jt /Je env wmtiii/w th4 creels Io�coarpkrNby c/yor antes 75- Plumbing
City or rows: PermiVlJeenmlauing Auiburity (circle one):1. Iloartl of Ilralth 2. Building Department 3.City/rown Clerk 4.Electricaector
6.Other
It C„tttact Persott:�_ _ Phone q:
Information and Instructions
152 requirell all employe=to provide workers' compenastioe for their employem
userts Gcneraj Laws chapter
m iy�j ee is deRnsd ae`..svaY pares in the service of another under my conasee of bin.
or; od,oral or,rritoes'
eapress assoeiad tY
M om ondos or other lead daft.army two or coon
to owpoorw
dr��is a isdhridsl* legal:representatives of a deceased Mployer.of the
bWava
receiver or tame of as ,&,,id"L partnersb*&Noc'ahaa or otdw teal wtitp.a &gWits C tla occu ofthe
ri rota man the.tlna and whra enidss therenr,err the aoetrPast hour
dwelle S�of a bouseM&a employs perso"to do mai b8sr m c�mpa or repair �der.
err btaildiM aPPv:�[hereto sdt�set bsesttss of smlt argtloytsmt "
�art the�� tM 4stusee d►
hiGL chapter 152.425C(6)also grata that-OVW7 state W Meal Measdst annoy dM wkMWM
rate chapter
d a Ynnas or Pttrsk b oparaM a bsaMeaa K m eosah'net bttNdlsgs b the cypeswee"fee salt
wlm bell set produce at a evWw�seam� Poll"sub dhrdsieas shall
ptPditiueslly.Mt7L chapter 152.42SQ7)start s 4N*idter
rnoar Mks asY contract fat the pe rMwasce of pubhio`Mork until aeeepwbM evtdsmn of corsplirsce with the insurance
requirementsof this chapter
have bees prserued s tits cantraednt audloe[tY-®
ApPArsap to our sitttatios sad,if
affidavit eompktraly by checking the boxes that apply Y
Please Bit out slt addrea(s)sod phase number(o)along with their certitfeato(s)of
necasasy,s** oaes(LLC)of limited Liability Pattner�(LLP)with so employees other then the
tssurasim Limited &b not required ce�Y whim.a iosurance. If as LLC or LLP dos have
member.or psrtsers. =iced fM advised that affidavit may be submitted to the Departm ent of [ndumial
that this
employed+•a policy is req o f irtnatanod eovdrd[R Ahe a sun s allot sad due the ufndaviL Tlw affidavit should
Accidents for cmrstatiot tlt the applicatien for the permit or.licenn is being requestsd. not the Depaetoent of
be returned to the city err taws that the low or if you an required to obtain a workers'
lndur[rial Accitlents Shaul you have any queeriod regarding y is,haald toter thtev
c duswisl A policy,please plt the looput ost tt number listed below. self-issured com sg
telfinwrattp keens rrumbar os die
City or Tows Oak" ..
1e ib Tbt Depnatate hss Provided a gasp at the bWtoM . .
P0.are be sun that the affdivit is complete and p?inted' i Fj: IieW.
of the affidavit far you to fill out in the ducat the Office of Investigations has to contact you regarding aPP
t•Icasd 'an applicant
be surd to till in the purmitlticense number
m any
�u wed only submi as a reference t one affidavit iandicating current
that must submit multiple permiytieenw applications
polity information l if rtecesary)and under"Job Site Address"11 2PP witantshould)wrie"all loucioar is__Petty or
ma
rownh•"A copy of the affklsvit that has been officially stamped
the city or town may be provided to the
each
applicant as proof that a valid atfidavi is os file for future loan nk not related to any busim"os at licenses. A now affidavit r commercial filled
lvventurd
year. Where a hone owner or citizen.
obtaiaisg a license or pen
(i.e.i dog license or Perm*to bum laves sot.)said person is NOT required to complete this affidavit
fhc t.)ftix of lnvestiPtiurut would like
w there*Ynu in advance for your cooperation and should you have any questions.
ploaae du rwt hesitate to give us a can.
ThePkpwtmrnt's address, telephone and fax number.
TM Cofnmonareaith of Massachusetts
pepatbmeot of lndusaial Accidents
t n%*of Is"dIP&M
6O WUNDSM Street
Bad^MA 02111
Tel. Al 617-727-4900 cd 406 of 1-877-MASSAFE
Fur M 617-727-7749
;tcv iacd 1-26-05 www.man.gov/tom
CITrOFgxLENT f
PUBLIC PROPERTY
DEPARTIMEINT
KmOSERLEY DPIV:H L
MAYOR 130 wV WNGTON SrtErr 0
may.5fn,,tAaust�Ts 01970
TM,979-745.95"*FAX 978-740.9846
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: \ L-C-&CH Buikfing:
Property Addresr. \s lie9r-
S}
Property Is located in a; Conservation Area Y/N h Historic Oh&kx Y/N Y\
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: pj--\r4P .
Telephone: 919 — -)4(F
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) Renovated
construction or renovation
of existing building New
Sri& Description of Proposed Work:
yCQA 141t2.QS
Mail Permit to:
What is the current use of the Building? _A-Qa4,\-
Material of Building? >!✓� If dwelling.how many units?
Win the Building Conform to Law? Asbestos? r.
Architect's Name �^
Address and Phone
Mechanic's Name � Jam` _ I
0�
Address and Phone �n"^�CQ 1
Construction Supervisors License# OD 8339 HIC Registration# 1
Permit Fee CalcuWW
Estimated Cost of Project S
9
Permit Fee i � '� Estimated Cost X S7/51000 Residential
Estimated Cost X$11/$1000 Commercial An Additional $5.00 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
�P/ it to bulb io above stated
specifications. Signed under penalty of perjury X
Date
4
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