540B LORING AVE - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KINHFRLEYDRISCOLL
MAYOR 120 WASHINGTON STREET♦SALEM,X(ASSACHL'SE 1-15 01970
1Et 978-745-9595 4 FAX:978-740-9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION rr��
Location Name: , e r W i rl K��S VOO uitding:
Property Address: 5�o b )�D c, na nv Q,
Property is located in a; Conservation Area Y/N NO Historic District Y/N WQ_
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land v
Name: _ SgrC� fo —)Aecid uco'-
Address: 1 5 ol � CKq I^ S a e,V't F l�
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing i
Renovation Number of Stories Renovated I
Change in Use New 0
Demolition Existing a
Approximate year of ��oo I Area per floor (sf) Renovated g5
construction or renovation New Q
of existing building
Brief Description of Proposed Work:
Q f60-r e x+e1v*6a✓ 6 Co� P2
a r- 5 avivd o.✓fc o P�+.�e
�,pl(ed 'SaNI� V4)Ue INVe
Mail Permit to: 'W1 I pl C K U P
What is the current use of the Building?
Material of Building? G✓fl 0D If dwelling, how many units? W :
Will the Building Conform to Law? I Asbestos? �C
Architect's Name A-
Address and Phone ( )
Mechanic's Name G'��C�� /YIAT/<7 SOA/ [7,�id Cr�/M /6,t/S�I�✓�Tioca
Address and Phone we Hz1 ef1x— ��•
Construction Supervisors License# HIC Registration# /e 8k O 7
oo/6S7
Estimated Cost f Project$� Permit Fee Calculation
Permit Fee $ ZS. ' Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit
Dto_build to t�he�above stated
specifications. Signed under penalty of perjury X
Date -30 -O(Q
N
L
CL
CITY OF SALEM
0TV
PUBLIC PROPERTY
14 DEPARTMENT
KIMBERL EY DRISCOLL
MAYOR
lEO WASHING"L'ON$TREE'f*$Al1iM,MA.SSACHUSETIS 01970
TEL<978-745-9595 ♦ FAx:978-740-9846
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 150A.
The debris will be transported by:
(name of hauler)
The Idebris will be disposed of in :
(name of facilit
/ 4�!
ddress of facility)
signature of permit applicant
�o - 3D -b�l
date
Jr6risaffdoc
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOIL
MAYOR 120 WASHINGTON SIREEr•SALEM,MASSACHOSEM 01970
TEc 978-745-9595 4 FAx:978-740-9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busing``sslOrganizatioNlndividual):
Address: I 5 c ' 54
�1
City/State/Zip- ('�C� � '✓l Phone N: g�► 323 —69 00
:5rc you an employer?Check the aypropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6 ❑New construction
era to ees full and/or art-time).' have hired the sub-contractors SO�nel Woo
?.
p y ( P listed on the attached sheet t 7. Remodeling -,e K{-end co n+e
� 1 am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work righr of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp.insurance required.]
Any:,pplicaot that checks box it most also rill out the section W. Aowiag their worlkMi compensation policy information.
T Itomeuwners who submit this affidavit indicating they are doing all work and then hie outside contractors most submit a new affidavit indicting such.
�Comractors ihat check this box most attached an additional shoal showing the name of the subsontraclors and their workers'comp.polity information.
I am un emnployer that is providing Ivorkers'compensation iasuranee for my employees. Below is the policy and job site
infori n tion
Insurance Company Name: f t £><QYaS
FI3=C �rcerlse- Ib860'( I �Taoob
Policy#or Self-ins.Lice#: Con 54 at 001 bs-I ![moo S Expiration Date:
Job Site Address: _r4.D R r __City/State/Zip: .S� (y? 70
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.'VIGL 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 to$230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
incesliyaliuns ul'the DIA for insurance coverage verification.
I do hereby certiQfy�� und
er die pains a. Id penalties of perjury that rise information provided above is true and correct.
Siu talu e. �117� a1U��1"IGlr�ti� Date: 6/3°LDt
i
F'hnne:i:
Official use only. Do not Ivrite its this area,to be completed by city or town ofjiciaL
City or Town: _- Permit/License#
Issuing Authority(circle one):
I. Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other _
Contact Person: ____._-- _-- Phone#:
Information and Instructions
blassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under 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 a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,parmership,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-contractors)name(s),address(es)and phone mmnber(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 returned to the city or town that the application for the pennit or license is being requested,not the Department of
Industriul 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 Offfclals
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of time affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permiLdicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/license applications its 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 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 bum leaves etc.)said person is NOT required to complete this affidavit.
fhc 011icc 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
Offtce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.tnass.gov/dia