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18 LEMON ST - BUILDING INSPECTION T � What is the current use of the Building? Material of Building?` `_�\ �� If dwelling,how many units?� Will the Building Conform to Law? Asbestos? Archited's Name Address and Phone ( ) Mechanids Name - b Address and Phone- 1 t Construction Supervisors License -3 HIC Registration# \ \� Estimated Cost o Project s " oa Permit Fee Cak Won 7 1000 Residential Permit Fes s� Estimated Cost X$ Is - -- - - - Estimated CostX st11$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 — Date Q-X N i s SI 9 \ 0 � a O > � 3 C11 1 OF- t PUBLIC PROPERTY DEPARTNI&NT KL.mFJLSY��wvvt u.voa taowtivUN=*snFXr• •,& • cstrrso1970 TM M74 5 -9s"•FN¢M74"M APPLICATION FOR THE REPAIR RENOVATION coNmucnom DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY FMSTI NG STRUCTURE OR BUILD 1.0 SITE INFORMATION Location Name: Building; Properly le bcated in a;Conservation Area YIN Hlstario DlsMet YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: 3 Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISI rs BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per Floor (so Renovated construction or renovation of existing (wilding New Brief Description of Proposed Work: -Mail Permit to: - - CITY OF SALEM ;'t PUBLIC PROPRERTY O� DEPARTMENT 120 WAS]8Nli:OKS1REET•SALI°N,MA<s.\Cra 'Li-iS:191: Tn:978-7454595 #FAX:978.744:-9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# _ is issued with the condition that the debris resulting from (his work shall be disposed of in-a properly licensed waste disposal facility as defined by MGL c I11.S 150A. The debris will be transported by: S�V� (A- mac Iname of hauler) Hia debris will be disposed of in s C? 4-N C� (oame of facility) gad:rca. �I tuc ilty) �Ialelul't.)t IJ(nlll a1)p.l� .1t ,:1IG CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT SIX1nERI.Ey DRM:OLL MAYOR 120 WASHING I ON S'rtri:LT •SAt k\4,MASSACH[SIA*IS C 197 TLr:978-745-9595 0 FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers r ilicant Information Please Print Le ibiv NaMe Ito /O oar iatioMndividuel Address:�M e r City/StatcLipS��--- O\y in Phone Are you an employer?Check the appropriate box: 'Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am it general contractor and 1 6 ❑New construction _ of Flo cot full and/or art-time).' have hired the sub-contractors © t Y ( P 7. ❑ Remodeling � 1 am a sole proprietor or partner- listed on the attached sheet. : 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.❑ Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions 3.El am a homeowner doing all work S P P' myself.[No workers' comp. c. 152,y 1(4),and we have no 12.E?Roofrepairs insurance required] t CITlployecs. [No workers' 13.❑Other comp. insurance required.] 'Any applicant trial checks box#1 most also rill out the senior W.ow showing their workus cumpensation policy information. 'I tomeuwo,"who submit this a fPdavir indicating they are doing all work and then him outside contractors must euhmil a new al'tidavn indicating such. �Comracntts that check this box must attachod an additional xheel showing Inc name of the subcontractors and their workers'comp.policy information. l aot un curployer that is providing workers'compensation insurance for ary employees. Below is the policy and job site iufornratian. Insurance Company Name:____ __.._.----...-----------_--__--- Policy ti or Sclr-ins. Lie.f: -- ------ Expiration Date: Job Site Address: City/State/Zip: :\ttach x copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up m$230.00 a day against the violator. Be advia:d that a copy of this statement may be forwarded to the Office of Investigations ol'the DIA for insurance coverage verification. Ida hereby cc tify under th m and pemdtics of perjury that the information provided above is true and correct. Siennure: Date: Official use only. Do not uvire in this area,to be completed by city or town officiaL City or Town: Permit/License#-------___-----.-----.. .- -..---_--_-- Issuing Authurity (circle one): 1. Board of Health 2. Building Department 3.City/foan Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact PcrSoIl: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an empluree is defined as"...every person in the service of another tinder any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in ajoint 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 that 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 members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have employees,a policy is required. 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 rehmied 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 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 to contact you regarding the applicant. Please be sure to fill in ibe permit/license number which will be used as a reference [umber. In addition,an applicant that must Submit multiple penmio'ficense 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 townl."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 licenses. 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 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 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 Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia