57 LORING AVE - BUILDING INSPECTION . R CTrY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Construedan Debris Disposst Anldsvit
(fayuimd IN all ammatim and em mad"wart)
(a aoconlattcw w id, du sixdt adidam of dw State liiuildiq Codsy 730 C1612 soctian 111.5
oa rit4 tad this provisions of MCL a 44 S 54
awkifi f Pon 0 _ is[no"wi1h dw madWm dst dw debris mmdt as Dos
this war shall be disposed of is a property lieansad waste disposal facility ss defined by MOL a
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The debris will be tfansporWil b
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lnalwa of t+a�tarl
rho debris will be disposed ofin :
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' CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetridalu/Piumbe»
Aonllcant Information Please Prtot Legibty
damettluairsstYOraatsiratioNlrnuvtthmll: / �:(�C)GV`n r)5+t-0C;t cm-)
Address:
city/sumizip:S 0,+
Are yaw as empleyert Cluck the appropriate boa: f
1.❑ 6. o I am a employer with 4. ❑ 1 am a general contractor and 1 project(���
❑New construction
employees(full atuYur pert-tine).• have hire)the sub-contractors
2.❑ 1 am a sole proprietor or Partner- listed on the attached sheet t 7.;E3,Fcmodelin6
ship and have no omployomt Then sab•connxwrs have a. ❑ Demolition
working for toe in any capacity. workers'comp. insurance
9. ❑ Building addition
)Iqo ircd.)workers'carp. insurance S. ❑ We officers
a corhave
exerioncised
and its 10.❑ Electrical repairs or additions
nquiredJ otl'teers have cxercwcd their
).❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.(Ko workers'comp. a. 152.444).(4).and we have no 12.❑ Roof repairs
insurance required.) t employces.(A'o workers' 13.❑Other
comp rs insunce required.)
•.v,q+Mhcam ter chucks bate ea map also lie uu1 the saetraa twinge sharriaa rAer wurkaw'aimppaaduw pduy ia6amatiodl
'I l�wnata who submit al/anldwu indk mS May i a d v%as work sad thata bite aatdda cownumn ms. .ubmil a maw amdavd"adina vwh.
4(•a rw n that chak this box otter attadtrl tee addaianal)sat umwity tee name arthe submcantracam and lair wurkm'corny.pdicy mrbnnat{ua
/urns an employer that&providing workers'compensatoa hrsmeance for my employees Below is the pulley and Job sUe
inform"I"
Imurance Company Name: --- -
Policy a fir Self-itu. Lie. M: _ .. _. Espirauon Date:
Jub Site Address: cayrStateizip:
attack a cupy of the workers'compensation policy declaration Page(showing the polity number and expiration date).
Pai lure to wcum coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one-year imprixomncnt,as well as civil pcnallius in the form of STOP WORK ORDER and a fine
of up to i250.00 a day against the violator. Ike advised that a copy orthis slawnwrit may be forwarded to the OOice of
lug:,ngmants ul'dw DIA for insurance covcra;u vcriftcatiun.
i der hereby terrify under the airs and nattks ujper a thW the informaden provided above is/JFNO gad correct
D
ate• (` Z I//)l /(7 O
PN -,.3-S 3 5�
U/Jkia!are aal/t AO mat write is this area.to be coarpleted by e4 or rewn olf d-idd
City er 'fawn: Pcrmit/l beast e
Nsuing Aulburity (circle one): --
t. Retard of Iteaith 2. nuawng Department 3. City/rows Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Cuulael Person: _ Phone p:
Information and Instructions
Massachusetts General Laws chapter 132 requires all employprovide service wor v t' com meager tion for heircontr ct of hue.
pucluaar to this,hatute,an ea/foyee is def rred as'...every person
°%pressor implied,oral a writted"
ashtot5ltie�cesP01if10O at other Val estiry,ar any two or mots
.AA esirpbyw a dsfieed as"u isdnriduN.parmlrshiR or the
Of the foregoing engaged is a joint satetprio,and ischtd'prg rot legal representatives of a deceased employer.
association or other legal treaty.employing empbyesa However the
receiver a dude of as indivi in g o rmsrshnp. as end who resides timmis.or rho of the
owner of s durelting heroes oho a trot mac toes three opwirematioureari
dweUung house of another who
rho employs perstms m do maiarcnance,construction a repair work no such dwelling house
or at the grounds a building appurtenant therm sbsll net because of soeh ew#brj tea be deemed to be an employs."
MGL chapter 152.42SC(6)also srstas that-every seats or Meal Uassbf sleety shag withhaY the issuance or
re" a operate a bustaca or to construct buildings to the eommonweakh for any
appittrst s%•o ba r a Per>reed acceptable evidence of eoapdsna with&be irrawanee coverage required."
A&Wi4 m woe has sat peed _
Additiaonlly.MGL chapter 132.;25C(7)statea'TJsither the tanaotwealthvidc anynce�"I political cotoplihhace wi �nsurancei
enter into any contract for the performance of public work until acceptable
ter have been presented to the contracting authairy."
requirometus Of this chap
Applksss
Please rill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and, if
necessary.supply stbsontractoc(s)112011e(s),address(es)and phone numbet(s)along with their cenificatc(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees Other than the
members or potmcrs.ate 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 policy
i requdon of insurance coverage. Also be sure to sign and date the aMdavit The affidavit should
be returned to the city or town that the application Cor the permit or license is being requested Department the pspsrent of
industrial Auidenu. Should you have any questions regarding the law or if you era 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 member on the appropriate line
City or Town Offkisk
please be sure that the affidavit is complete and printed legibly. The Department has Provided a space at Bret bottom
of rho affidavit for You to fill out in the event die Office of Investigations has to contact you regarding the applicant
Please be sure to till in the pormitfliccnse number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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
.town)."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 ghat a valid affidavit is on rile for future permits or licenses. A new affidavit must be tilled our each
year, where a home owner or citinca is obtaining a license or permit tot related to any business or commercial venture
(i.e.a dos license or permit to bum leaves ere.)said Person is NOT required to complete this affidavit.
I'hc�h fix of Investigations would Cute to thank you in advance fur your cooperation and should you have any questions,
leaje du not hesitate ro give us a call.
The 0.partment's address. telephone and fax number.
The Con=onwealth of Massachusetts
Department of Industrial Accidents
omen of InvesdPdaaa
600 Washington Street
Boston, MA 02111
Tel. M 617-7274900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
2cvi�cd 526-05 www.man.govkGa
- — CITY-OFSXLETNI — -
PUBLIC PROPERTY
DEPARTMENT
.Ursa 130 WAUUNC"5-rUm.3Qk7y.MAtSAOlL.3t'PfS 01970
To-97L745-9S".Fex:976-740.98"
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: Building:
Property/Address:
157 S
Property Is kidated in a: Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.i Owner of Land _
Name: A'l/15
Address: ",YN1" — VA*A 21 A 1
'5/r 7 ^r2j)12/1- G! N13�✓l l S
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIINL3 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
&ief Description of Proposed/Work:
�G h/��e/ � 7`✓j 7i��r� S �li�rer�c.e �oa�t {�'�C'e'T%�5 �iul
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- Mail Permit to:
What is the current use of the Building?
Material of Building? k B�G�L If dwelling. how many units? G
Will the Building Conform to Law? Asbestos? N
Architect's Narnili �
Address and Phone' i; J ✓ ( t )
Mechanic's Name
Address and Phone ^ Esc oT em
Construction Supervisors License 0 ?G�Z HIC Registration aY
Estimated Cost Pr ' S_q64Z)_00 Permit Fee Calculatlon
Permit Fee i — Estimated Cost X$7/$1000 Residential
Estimated Cost X 511/$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 penally of perJury XY, /
Dat .
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