6 LYME ST - BUILDING INSPECTION EI`T' -OF'gXLE
\\ JOU-61j7 PUBLIC PROPERTY
DEPARTMENT
K1%(HFA[6Y OR15U)LL
MAYOR I20 WASHINGrON S7RFEr♦SAL.EK MASSACHLSEI-M 01970
TEL-978-74S-959S♦ 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
Location Name: Z Si Building: //V o5'e
Property Address:
Property is located in a; Conservation Area YIN Historic District YIN C>1
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN Of ISMNG 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
Brief Description of Proposed Work:
c
Mail Permit to: % C�a
What is the current use of the Building? 'm v
Material of Building? If dwelling, how many units?-
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
i /.Z YES
Construction Supervisors Lice HIC Re9stration#nse#
Estimated Cost of Project '-"V Permit Fee Calculation
Permit Fee$ < 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 to build to the above stated
Xspecifications. Signed under penalty of perjury ��,�'
Date
of
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CITY OF SALEM
PUBLIC PROPRERTY
��. DEPARTMENT
KDABERLEY DRISCOLL
MAYOR
120 WAsHNGTON STREET♦SALEM,MAsSACHusEk7S 01970
TEL•978-7459595 ♦FAx:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information a Please Print Leeibly
Name (Business/Organization/Individual): J9�Z7r� `/ �Py
Address:
City/State/Zip: Phone #: f7ef- 77Y— 0��'y
Are you an employer?Check the appropriate box:
FORemodeling
project(required);
1.❑ I am a employe with 4. ❑ I am a general contractor and I
employees(full and/or part-time).' have hired the sub-contractors struction
2.U.I am a sole proprietor or partner- listed on the attached sheet. t ing
ship and have no employees These sub-contractors have onworking for me in any capacity. workers'comp, insurance.[No workers comp. insurance 5. ❑ We are a corporation and itsaddition
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' J/
comp. insurance required.] 13.0 Other__!
•Any applicant the cheeks box#1 must aim fill out the section below showing their wrorkan win / �—
t Homeowners who submit thin affidavit indicating _ prnwtion policy infarrnatioo.
indicating such.
=Contractors that check this box must attached an additional sheet showing the name domg all work and then of the sub-contractor and thei outside contractors must r woorkes'coa now in.P li information.
P Policy
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name:C
Policy#or Self-ins. Lic.#: �_ Expiration Date: G ,P—U ^O
Job Site Address: C `L,w o City/StatelZi :_ Si9�.t
AttachP
a copy of the w pY piker compensation olio deck �P policy declaration page(showing the policy num
ber tuber an P �7' d 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 S 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
fdohereoy cerd under the pours an penalties of perjury that the information provided above is true and correct
Signature cz-,6/
Phon
Official use only.::::,:n :7,:writeto be completed by city or town officiaL
City or Town• Permit/License#Issuing Authority1. Board of Healtt 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person-
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers erYPerson
Provide
sseervvice of another under any contrace-0 ensation for their employees.
pursuant to this statute,an employee is defined as"...every pe }
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,partnership,association or other legal entity,employing employees. However the
house having not more than three apartments and who resides therein,or the occupant of the
owner of a dwelling
dwelling house 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 as 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 acceptabl 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-contractor(s)name(s),address(es)and phone number(s)along with their ce of
rtificate(s)
insurance. Limited Liability Companies(LLQ or Limited Liability Partnershipsi (LL. Ifan)with
or no empldoesees other than the
members or partners,are not required to carry compensation
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
permit or the lacense or if you are required to obtain a is being requested,not,the partmkme t of
Industrial Accidents. Should you have any questions
the number listed below. Self insured companies should enter their
compensation policy,please call the Department at
self-insurance license number on the appropriate line
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
the Office of Investigations has to contact you regarding the applicant.
of the affidavit for you to fill out in the event
Please be sure to fill in the permitilicense number which will be used as a re In addition,an applicant
reference number.
that must submit multiple permittlicense applications in any given year,need only submit one affidavit in
current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town). wn may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affifidavir must be filled out each
a license or permit not related to any business or commercial venture
year.Where a home owner or citizen is obtaining
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office 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
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
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KID^' �'�D�tfO011
MAvd 136 97Aaanmcm blase•SAI 9— MAssA[3tl:ssrts 01970
Constmedon Debris Disposal Affidavit
(required f)r all demolition and renovation work)
i,'n accordance with the sixth edition of the State Building Code,780 CMR section 111.3
Debris,and the proviaions of MQ.c 40.9 34�
Building Permit# is issued with dw condition tint the debris resulting first
this work shall be disposed of in a properly licensed waste disposal &duty as defined by MQ a
IL1.S130A.
no debris will be transported by.-
The dcbris will be/dispoossed of in:
(name or racility)
(addtsss or facility)
sipaalra orpcm*apyt cant
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CERTIFICATE HOLDER _. CANCELLATION
=.IN" 3NORADAMOF THIS ABDUE DESrROID POUC193 W CANCELLED BEFORE THE EXMRATO
DATE TH"WP.THE Wd RUNG MURERMLL ENDEAVOR TO MAIL 10 DAYSVARRIER
For infOrNatiOI�I purposes only. NOTIM TO THE CMMRDATE HOLppL MAMm TO THE LEP1.WrPALMETDW�sNALE
Please contact Agency for D
individual Geri:„:fi Oate. IMPOSE NOOBUGATM OR UAWL"YOF AW RIND WON TINE INSURER,ITSAGENTSOR
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AUTHORMO RI3p®ENTArryE
ACORD 25(2001108) Deniel .1 mb"ley
0 ACORO CORPORATION 1983