446 LORING AVE - BUILDING INSPECTION CITY-OF SAL
PUBLIC PROPERTY
I
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WAMINGrON b`IREU SAtrtr,MtisAcxt;stI'rs 01970 -
TM-97&74S-959S 0 F=978.740.98"
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: f� d,2 Building:
— Property Address:-- ---- -- -
Property is located in a;Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone:
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 (sn Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building?
Material of Building? If dwelling.how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name A25 /^
Address and Phone 7� ,Edu) E— R f�
Construction Supervisors License# -Q�'/3 HIC Registration# 00 ?-7
Estimated Cost of Project Permit Fee Calculation
Permit Fee $ Estimated Cost X$7/$1000 Residential
-- -------
--- -Estimated Cost X$14/$1000 Commercia -- -- - -
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 e s led
specifications. Signed under penalty of perjury X
ate / 3
of
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
�.�traacou.
MAYOR tM mA20=rot,u STREET a SArM4,MAStAQR)g-1-tg 01970
TtL M743A39S a FAx M740-n"
Workers' Compensation Insurance AiBdavit:K. BuilderslContractersMecti{claayplum
Anoiicaut Informadon Please Priest f .bers
hr
NamelBusinesUo�Yaa;auoortndi//v��;AW): //��j —
Address: tCrJCc� Q.*
awstatem • l% _ Phone#:_ 33-f-- /3 _
An yo employer?Cheek the appropriate test
1. am a employer with 4. ❑ 1 am a general contractor and t �of proleet(required):
employes(fWl and/or part-time).• have tired the tatbcontractaa 6. ❑New eeomttetion
2.❑ 1 am a Bole proprietor or partner- listed on the attached cheat i 7. Remodelins
ship and have no employees These have 3. ❑Demolition
worling for me in any capacity. workers'comp, inaaranee. 9.
(No workers'comp.insurance 3. ❑ We am a corpmadon and its 10 ❑ ad
required] o@tcas have examined their ❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions
myself.[No workem'comp, a 132,;1(41 and we have no 12
insurance required.]t employees.[No wmrkem' ❑
. Root repairs
comp.insurance required] 13.0 Other
fAoY applicons duo chorus tws et now also w ere the section blow,showing auk wakons
HounawssmwbopAmk"affldovkWdco&s dry a tkdsg d wok sod gno hhe nsW&uo amli khnoloaft s"ffideey tConaeaws dot cheek thin has mat aasehsd m oddwoonl,test showing as same ord s and thatr waken•eamR
fan an emp/oyer that 4 provN&S workers'compearadoe L-Vumme for cry emp/oyeea Bdow b the poiley and foi star lnjormaafaa - -- - -- -
Insurance Company Name: A
Policy M or Self-ins.Lie.M_ �7 `3�d`2 Expiration Date: ^3 I 'O
Job site Adds. �{Sl� �d��/LJ�, G4—CJ city/stawz;p �f�
Attach a copy of the workers'compensation polky declaration page(s[towhrg the potley number and expiration dab}
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to die
fine up to S 1,500.00 and/or one-year im rmpositi�°f criminal ltenaltiea of a
y prisonmeny.as well as civil pezWt'es in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance crags verification.
/do hereby es /j.ands penaidss of 4147 that the in/ormaaton provided above 4 arts and correct
_ — 23 —
Phone M:
OQ?ela/ass on/yt Do net write in this area,aD be complete/br cbr o►aowa o,Q'$loL
City or Tows Permit/License M
issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone 0:
Information and Instructions
Masi=husens General Laws chapter 152 requires all employers to provide workers'compensation for their empl@YOc$,* .,
Pursuant to this stsaets,an ewofoyee is defined as"...every person in the service of another under any contract of hit%
express cc implie4 Ord or writtoa"
aswdsd^Corporation or other legal easily.Orany two Or mom
An saePloytr is defined as"an individual,P�n�R representatives of a deceased empktyer,or the
of the foregoing engaged in a joint enterprise.and including the legal represm However the
association or other legal entity.employing employees. o[the
receiver or trustee of individual,parttiera the and who mudea tbeseia,or the occupant
owner of a dwellini not mere thin three apartments a wodc an such dwelling home
dwelling lion of amothac who employs P�to do maintenance.suction reWit
or on the grounds or building appurtenant thereto shell not because of such employment be deemed to be an employer•"
er legal agency shag withheld the bsuastee er
IS 2SC(6)also states that every state licensing commonwealth far any
MGL chapter 2.$ tee a business or to construct buildings in the eo
renewal of a o has
or perusal �able ev��of exmpWaee with the Insurance coverage req°ierd"
applicant who has not produced feeept sum"Neither the commonwealth nor any of its political subdivisions shall
Additionally.MGL chapter 152.performance
with the insruaaee
_�.,,��.�ce of public work until acceptable evidence of compliance
enter into any contact fat die
requirements of the cbapm have bien presented to the contracting audtontY'"
Applicant
Please fill out the wodcere compensation affidavit Completely,by checking the boxer that air c to your (s)o rem and.it
s nama(e),acid<ess(es)and phone numbers)along with their certi8eate(a)of
necessary.Supply sub cons ) or Limited Liability Pacmers UPS(LLP)with no employees other than the
insurance. Limited Liabilitynot d insurance. if an LLC etc LLP does have
members or per, to worku§ c11vit May
be
a policy is regiured. Be advised that this a8idavit may be submitted to the Department of Industrial
�loyr' of insurance covenga Abe be sure to sign sad date the affidaviL The affidavit should
Accidents for confirmation application for the permit or license is being requested,not the Department of
be returned to the city Of town that the dte law Of if you are required to obtain a worker'
Industrial Accident. Should you have any regerding
compensation Policy,plan"tall aloeDquounent
at
the
numb listed below. Sett-insured eompanias should enter Chair
self-iosimmen items°number on the
City or Town Of»dsd
complete and printed legibly. The Department has Provided a space at the bottom
Please be sure that the affidavit is comp y fP�na PP
of the affidavit for you to fill out in the event the whit of Investigations has to contact er re a licanL
Please be sure to fill in the purnittlleense number which will be used as a reference number. In additiom,en applicant
that moat submit multiple Permiviieense applications in any given year.need only submit one affidavit indicating currant
policy information(if necessary)and under"Job Site Addreu"the applicant should write"all locations in_—(city°r
or marked by the city er town may be provided to the
town)."A copy of the affidavit that has been officially stamped ts cu licensee. Anew drvic must be filled ewe each
afu
applicant as proof that a valid affidavit is on tale for AlumPermi not meted to now
business or commercial venue
year.Where a home owner or citizen is obtaining a license a a prim
any
(i.e. a dog license er permit to burs leaves ate.)said person is NOT required to complete this affidavit
The Office of invesdgadoos would like to thank you in advance for your cooperation and should you have any questiot
s.
Please do not hesitate to give us a call.
The Depactmens's address.telephone and fax number.
The COMMOnwcath Of Nasal htisetb
DVUMNM of ln&4tiMa1 Accidents
oft*d latvesdgatlons
600 WLAMOMM Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26.05 wwwawwgov/dia
CrrY OF SALEM
PUBLIC PROPERTY
DEPAXrUMNr
MAWS
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