4 LORING AVE - BUILDING INSPECTION p
PL`BLIC PROPERTY
DEPARTMENT
KIMB JUSY DLLS[WL
MAYOR 130 WASWNGTON J'7AEEr 0
S-=M4 AUsACHM7'rs 01970
Tm-97e.74S•9S"•FAx M740.9"6
APPLICATION FOR THE REPA_UL RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTLIRE OR BUILDING
1.0 SITE INFORMA710N
t Location Name: s.2 Building:
Property Address:
s
Property is bcated in a; Ccnssrvaty0n Area YIN Historic DMict Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ^
Address:
i 6
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition qExisting
Renovation Number of Stories
Change in Use
Demolition
Approximate year of Area per floor (sf)construction or renovation
of existing building Bdef Description of Proposed Work:
Jq
Mail Permit to: �$ _ �4 k�, 1,97
What is the current use of the Bui ing? �P
4� ®� if dwelling,how many units?
Material of Building? a Asbestos?
Will the Building Conform to Law?
Architect's Name
Address and Phone
Mechanic's Name L
Address and Phone 3R
Supervisors license# HIC Registration i1----
Construction 60, � Permit Fee Calculat w
Estimated Cost of Project 5 --
Pertnit Fee$� Estimated Cost X S7IS1000 Residential
Estimated Cost X$"'$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 perjury6
Date—
/ I
o
N
a
0
O
0. O. . ----- -- - - ---___.- -
` CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KAtaER[PY DRISCOLL
MAYOR
120 WASHINGTON STREET•SAr M,MAySACHVSE CS 01970
TM 978-743-9595 0 FAx:978-740.9846
Workers' Compensation Insurance Affidavit: bera
Builders/Contractors/mectrlcisns/Plum
Applicant Informatio Plea Print Legibly
Name(Business/Organixation/individeal): !H -I-�
Address:
City/State/Zip: Phone #: 9 7T-- '?46 7 41 7
Are you an employer?Check the appropriate box:
I.
❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required);
employees(full and/or part-time).• have hired the subcontractors 6. ❑New construction
2.1Z I am a sole proprietor or partner. listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These subcontractors have
8.
❑Demolition
working for the in any capacity.. workers'co ty instrance.
mp
o workers' 9. Buil[N rkers' comp. insurance 5. ❑ We are a corporation and its ❑ �g addition
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption
myself aDP l�MGL 11.❑Plumbing repairs or additions
y [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers'
comp. insurance required,] 13.❑Other.
�Y ePParant dui checks box al must also all on the section below dowmg their worker'compensation policy Warm
im
Homeowners who submit this affAwd iMieatina they am doing all work and than hue onside Contntoon to submit s new
rContrscfon that check this box must atnched se addldo nl sheer showma the new of the sub-contncton and their woken•
MEey mfavutloa
am an employer that Is providing workers'compensation
injormanon. insurance for my employees. Below is the poBry and Job site
Insurance Company Name:
Policy#or Self-ins. Lic. #:
Expiration Date:
Job Site A ddrese: City/State/Zip:
Attach a 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 penaltiea of a
fine up to S 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$250.00 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 u er the pains and penalties ofperfttry that the injormadon provided above is true and correct
Sitmat_M
Phone
OJJlelal use only. Do not write in this area, to be completed by city or town oJjlclaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• Phone*
Information and Instructions
person in the service r another under any contract of hire. .
to provide workers' compensation for their employees.
Massachusetts General Laws chapter 152 requires all employers t
pursuant to this statute.an employee is defined as"...every
express or implied,oral or written."
An tntQloycr is defined as"an individual,partnership,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,assoc tac°n or other legal entity.employing employees. However the
owner of a dwelling hwtse having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs Persons to do mainwnanc0.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."
d the issuance
MGL chapter 152,§25C(6)also states that"every state or total tract buildings
agencdings iin the oimmolnwealth for any
renewal of a Menu or permit to operate a business or to construct buildings
applicant who has not produeed acceptable t �Neither the commonwealth nor any of its political subdivice of compliance with the insurance coverage sions shall
Additionally,MGL chapter 152,§ ( ) public work until acceptable evidence of compliance with the insurance
enter into any contract for the performance of p
have been resented to the contracting authority."
requirements of this chapter P
Applicant
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to Your situation and if
name(s),addresses)and phone number(s)along with their eertificate(8)of
necessary.supply sub conaact°r(s) Partnerships LLP)with no employees other than the
insurance. Limited Liability Companies(LLC)or Limited Liability P
members or partner,are not required to carry workers' compensation insurance. If an LLC or LLP does have
r
employees,a policy is required' Be advised that this affidavit maybe submitted t sign and o the he affidavit.
ffidamen _
Accidents for confirmation of insurance coverage.
Also be sur for the permit orolicense is beingtrequestedvnot the Department of d
be returned to the city or town that application required to obtain a workers'
Industrial Accidents. Should you have any questions regarding the law or if you are req should
enter their
compensation policy.please call the Department at the number listed below. Self-insured companies
self-insurance license number on the a
line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has Provided a spacegardine bottom
of the affidavit for you to p ormittlicense number which will be used as a in the event the Office of Investigations reference number to contact you s In addition,an applicant
Please be sure to fill in the pe applications in any given year,need only submit one affidavit indicating current
that must submit multiple Pe rmitllicense app
policy information(if necessary)and under"Job Site Address"the applicant should write"all locationsrovided to(the or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be p
applicant es proof that a valid affidavit is on file for futtm permits not related to any ;illness or commercial veamm
year,where a home owner or citizen is obtaining a license or permit
(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
Ogee of Investigations
600 Washington Street
Boston,MA 021 It
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia