600 LORING AVE - BUILDING INSPECTION (3) What is the aurent
use of the Building?
i •- � �,„; If dwelling,how many units?
Material of Building? �G
Wilt the Building Conform to Law? Y--C-4n Asbestos?
Architect's Name I l� o✓�f d ( S<-
L Gi S (9Y ? v 'f s -F
Address and Phony
CorJ�-
MechaniWes NarrN
Address and Phone A G.v
Conalruction Supervisors Ucense 5 C S O S"? ?93 HIC Registration d L y �'A l�_
Estimated Cost of,Project i I—) 0 o Permit Fee Cake Won
Permit Fee: � Estimated Cost X$7f411000 Residential
Es*m ted Cost X S41/=1000 Commerolal'— —----..
An Additional $5.00 is added as an
Admir.atrativo charge.
Make sun that all fields are property 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 perjury ,
Date q 112,l
C
Crrrop-SAALKIM
PUBLIC PROPERTY
DEPARTMENT ja
, �
SA&&W,%fAifAQILShTit 01970
M745-95"•FAe M740.9{N
APPLICATION FOR THR REPAIR. RENOVATION_ CONSTRUCTION,
DEbIOLTTION.OR CHANGE OF USR OR OCCUPA=N[v_ FOR ANY EXISTING
STRUCTURE OR BMDIKG
1.0 SITE INFORMATION ..
.
Location Nang ilding:
Prop"Is located In a:Conserva*n Am Y Hlemrla pishlct Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: L L G
Address: Goo 9 /- c
iq-)o
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXiaTjW BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing I o
Approximate year of Area per floor (sf) Renovated ! oS
construction or renovation
F
existing building New
ef Description of Proposed Work:
J)
ek,K-0- ehcy 1oV otij / Ce'/ ,eAio � P , t
--- ---Mail Permit to: ode T U kP
".CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\Etta qt IIc ww".-;.ONS RUT.3\t.11,St.\CiU:2n ak 11)i:9J�
TO:vn74sems .F..x 972-74G944
p _
Construction Debris Dlsposat Affidavit
(required for all demolition mul renovation work)
In accordance with the sixth edition of the Stan Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40.S 54;
Building{ Permit N _ ._ is issued with the condition that the debris resulting from
this work shall be di ed of in spos a properly licensed waste disposal facility as defined by%4GL c
111. S 130A.
The debris will be transported by:
Utame of luuler)
fhc debris will be disposed of in, :
taarne of I'aaAty)
♦ j.l.IbiJ . :Cpl.lC..l;a.IC3A9
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MUM RUY URIX:ULL
MAvtat l2C WAsru.%G rote STREET 4 SA1P34,MASh'AC[n%-1'l3 0197'J
'rra:978-743-9395 •FAX:9M74C•9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADalicant Information / '/ /, Please Print Leeiibly
NamC tduciiw.WOrgani:atioMlndivtduon: l..�t�r a2 14- Pi df �+f111 to,& A oIle /6w4�t r- ,J/
Address: SS cCx r 4a Ldif 14 Z v A
CitylStatclZip: L 019101 Phone
.Err you an employer? Check theappropriate box:
Type of project(required):
1.(el am a employer with 24 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have. hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. : 7. Remodeling
ship and have no employees These subcontractors have S. 0 Demolition
working for me in any capacity, workers'comp. insurance. 9. 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its
j required] officers have exercL%cd their 10.(a"Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 1 I.®'Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.j t employees. [No workers' 13.0 Other
comp. insurance required.]
'Ally applicant gut checks boa p1 most al:w lilt out the wman bciow slwwiag their wurkays'cumpcntwtiun policy inr,,rrrstiu0.
'1l m lwnon who submit this affidavit indicating they am Joins oil work and ahem hire outside cwnt.4mm matt submit a new altidavil indicting catch.
�Cuntrxntars that chuck this box must attached an additional Aloes 4towing the new of the sub.contracton and their workers'comp.policy infiwma itm.
I am an employer that Is providing workers'compensaton insurance for my employees. Below is the polity and P alit ob site
I
f I
ins ormution.
Insurance Company Name: --
Policy N or Self-ins. Lic.ij: __._. ... ._.__ Expiration Date:
Job Site Address: CityiSlatuZip:
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
fins up to S1,500.00 and/or one-year imprisonincnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Ime,ngauons of the DIA for insurance coverage verification.
I do hereby certify under die pains and penuldes ofperjary drat rile information provided above is true and correct
Date' 9 //Z/O7
Uncial use wdy. Do not write in this area,to be completed by city or town oJ17cial
City or Town: __. _ Permit/License g
Issuing Authority (circle one):
I. Board of Iiealth 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: -- Phone N:
` Information and Instructions
hlassachusets General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employe is defined as"...every person in the service of another under any contact 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,patmerstup,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."
btGL chapter M.§25C(6)also stares 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 is 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 contact for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contacting authority.-
Applicants
please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply stab-contractor(s)name(s),address(es)and phone numbers)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, arc 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 dale the•affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial 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 a ro !isle line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the 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 permitilicense number which will be used as a reference number. In addition,an applicant
that must subunit multiple permit/license 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 that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
1'hc 01,titc of lovesti..ations would like to thank you in advance for your cooperation and should you have any questions,
please do nut hesitate to give us a call.
The Depantnent's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
Licensa CONSTRUCTION SUPERVISOR
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