207 LORING AVE - BUILDING INSPECTION (2) What is tM current use of the Building? 12,a
Matarld of Building? It dwelling,how rnanY units?
WIa to Buk*V Conform to Law? Asbestos?
Ard-cods Name '
Addreas and Phone
Modwi 's Name
Address and Plana A-I 7, S7 la ,.,
HIC 8 a
Supsry isors t.icertee 0_ - Registration
EslYnafed Coat of Projad_
' Parma Fee Cale hdOn
Permit Fee S ' O Estimated Coat X=7/:1000 Residential
Estimated Cod X i11/s1000 Carnrnarraa4----
An Additional$5.00 a added as an
AdministraWo charge.
Make sure that all Aelds are properly and legibly written co avoid delays In processing.
The undersigned does hereby apply for a Building Pemdt to build to the abcvs stated
specftatkms. Signed under penalty of perJurY
Date a 7
I
N
s
� s ••
CITY OF SALEM
ow
PUBLIC PROPRERTY
DEPARTMENT
d AI I;i X I k.Y!`tuA:011.
MAYOK 11C W.\51aX(�iON SYAEET $dLP\1, �1.UiA(:FfLtill li C197C
Tt r:978-743-9595 • Fax:978-74C 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
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 1.50A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(lame of facility)
wog C>°5�
.Iaddresn of f:,eilily) .
--....-. . �-Swr-'4)'m' ppiiu it --
� ' �� --
:ate
\ the Uommonwealth of Massachusetts
Deparlment-of Industrial Accidents
Ojfice Oflnvestigations
600 Washington Street
Boston,_MA_0211-I-
ura www.massgov/dia TOh1TC Of TI[JlgtpII
' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/ OU—Irlrs
A licant Information
Name (Business/Organization/Individual): Please Print Le ibI�}�
Address: !12L
City/Stale/Zip: ,A 7n!-t Ic—� r
Phone #:_ S—t S -5t6t —�jZt l
Are you an employer?Check the appropriate boa:
1. I am a employer with I() _ 4. I am a general contractor and I Type of project (required):
employees (full and/or part-time).' have hired the sub-contractors
2. I am a sole proprietor or partner- 6' r��N� construction
e ]fisted on the attached shave 3 �• I_I Remodeling
ship and have no employees These sub-contractors have working for me in any capacity. workers' comp. in 8- Demolition
[No work surance
ers'comp. insurance 5. ❑ We are a corporation and its 9. ❑ Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work
mysyself right of exemption per MGL 11.❑ Plumbing repairs or additions
insurance e e 1equired.] t. have no
workers' comp. Tight
'152, §1(4),and we
employees. [No workers' 12.0 Roof repairs
'any applies that cheeks cornP insurance required.) 13.0 Otber
box Nl must also fill out the maim below showing their workers'co
aii
t Flnmeowneis who submit the eltidavit indicating they art loin all w sa'ion
iContracmrs that check this B work and then hire outside eonima Try mfomtattoa
box mu attached an additional sheet shoa•rng the name of the sub-coniraRors midair w,p �.
must baut a new affidavit
indicating such
I am an employer that is providing workers'compensation insurance or m CO1Op.1io1KY mformattoa
hiformadon f y employees. Below is the policy and job site
Insurance Company Name:
� Or
Policy#or Self-ins. Lic. #:_ a�112n�
Job Site Address: Expiration Dater
City/StateJZip:
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 penalties of a
fine up to$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 maybe forwarded to the Office a
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pain and penalties ofperjury that the inform:::::::::ation provided above is true and correct
Si afore: _
Date:
Phone#:
F
only- Do not write in thv area,fo be cam toted b c
P Y ity or town offictaL
n: Permit/License#
ority(circle ooe):ealth 2. Building Department 3.City/fown Clerk 4. Electrical inspector 5. Plumbin Insg pectoron:
Phone#:
i GrITUFSc�E;`
PUBLIC PROPERTY
0(4 7xj DEPARTMENT
IU.�OIFr nr ovwrn
�NAtuaasr'rn 01970
114 M745-" !0 FAX V&?M M
APPLICATION FOR THE REPAIR. REIVOVATItON_ CONSTRUCTIOM.
DEy[OLITION. OR GRANGE OF USE OR OCCUPANCyv Fog A.Ny EJOSTING
31RUCTURZ OR BUILDIN -
1.0 WN INFORMATION
Location New BuildhW
Property Addrssr- - . -. . _ . ..
o-7 bc,0
Avg
Property is bested in a; Ana YM HwAft Dlstrlat YIN
[Address:
.0 OWNERSHIP INFORMATION
J Owner of Land _
elephone: 7 S
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
ffAppwr�oxlmate
Existing
of Area per floor (sf) Renovated
ovation
New
Md Description of Proposed Work:
- - - --Mail Permit to: