10 LYME ST - BUILDING INSPECTION PUBLIC PROPERTY
` DEPARTMENT
1 IMMAIEY MSI:OLL
MAYOR M WASHINGTON S7REEr '*FAYC.79-74 CHt;Stl-rs 01970
'I�l:978-745-9595 �F,VL•97&7i0-9&I6
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: b Building:
Property Address:
G
Property is located in a; Conservation Area Y/tV Historic District Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 0/4n/t �r�,✓� p �
Address: `Q G ,1HnZ 3-7-
Telephone: !e� 7V 172—
3.0 COMPLETE THIS SECTION FOR WORK IN EX II �C,,WING 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: ,
Gu + LC I ?C< N VL - w cGv i �/�✓ �����r� /L
Mail Permit to:
What is the current use of the Building?
Material of Building? y!u"� ! �^ ¢— If dwelling, how many units?
Will the Building Conform to Law? �/.!//
Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
<u w
Address and Phone �J� �! Lie CJIi
Construction Supervisors License# lzq%`7 2� HIC Re 9istration tt
Estimated Cost of Pro ct$ �G(7U'Cv Permit Fee Calculation
Permit Fee$ I' Estimated Cost X$71$1000 Residential
Estimated Cost X$1141000 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
specifications. Signed under penalty of perjury
Date /� C
�I0
o
� N
+ ^J f 00
t
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
RBNBERLEY DRLSCOLL
MAYOR
120 WAsHe4GTON STREET*SAtEM,MAMCHusETTs 01970
TEL•978.745.9595 ♦FAx:979-740.9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aooifcant Information Please Print Le iv
Name(BusinessiorganiraaonRndividusi): �a� 1679 J12:1
Address:_ �Lr_ 5, /11/
City/state/Zip: 3FG/� "L CL�'3 Phone#: / /��� /�
Are you an employer?Check the appropriate box:
1.❑ I am a Toyer with 4. Q I am a general contractor and I Type of pr ect(required):
ePtillbyees(full and/or part-time).• have hired the sub-contractors 6. ❑ w construction
2. I am a sole proprietor or partner- listed on the attached sheet. t 7. Remodeling
ship and have no employees These sub-contractors have S. Q Demolition
working for me in any capacity. workers'comp. insurance,
[No workers' comp. insurance S. 9. ❑Building addition
p ❑ We are a corporation and its
required.] officers have exercised their I O.Q Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myself. (No workers'comp. c. 152, §1(4),and we have no 12.Q Roof repairs
insurance required.]t employees.[No workers'
comp. insurance required.] 13.Q Other.
'Any applicant that checks box#1 MUM also till om the seedon below showin chair possatlon policy informed=
t Homeowoms who submit due aRidevit indicating a waken'com
tCoatrsctars that cheek this box must attached an additional sheet eho awm the name of the cub n-eon nd dian him ooisWe t on moat submit a new aRidavrt mNcadoR wch,
acton and their waken'comp,policy inforraadan.
am an employer that Is providing workers'compensation insurance jot my employees
injarmatian. Below is the pollpolicyand Jab site
Insurance Company Name: A� r
Policy#or Self-ins. Lic. #:_�ll� �7i� ( �i C, ¢`f/Z�, / y
Expiration Date: / 0/1
Job Site Address: Ci /State/Zi
tat p: .2L+- / '�//FJ
Attach a copy of the workers'eornpeasattoa policy declaration page(showing the poBcy 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 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the O
Investigations of the DIA f ' urance coverage verification ffice of
/do hereby ce rtder the pa' dip aides OfRerfary that the information provided abov Is tru and correct
Si a r �` v �� D t w UC
Phone#
Official use only. Do not write in this area,to be completed by city or town oJJlcial
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
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employ'
contract of hirer,
pursuant to this statute,an employes is defined as"...every person in the service of another under any
express or implied,oral or written.
or
An employer is defined as"an individual,partnership.association.corporation or other legal entity,or pay two r t more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased empToyer,or the
receiver or trustee of an individual,Partnership,association or other legal entity.employing p However the
house having not Mort than three apartments and who resides therein,or the occupant of the
owner of a dwelling to persons
to do maintenance,
construction or repair work on such d'e�g hO18e
dwelling horse of another who employs
mp ys Pew
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 15 ,§25C(6)also states that"every state
2 e or local licensing agency shall withhold the issuance or buildings in the commonwealth for any
renewal of a license or Permit to operate a business or to construct
applicant who bag not produced acceptable evidence of compliance with the insurance of its 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 contract°r(s)name(s),address(ea)and phone number(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
Be advised that this affidavit may be submitted to the Department of Industrial
employees,a policy is required
f insurance coverage. Also be sure to sign and date the affidaviL The affidavit should
Accidents for confirmation o
be returned to the city or town that the application for the permit e license if you are eregquiirreed tv°obtain a workers' of
Industrial Accidents. Should you have any questions regar g should enter their
compensation policy,please call the Department at the number listed below. Self-insured companies
self-insurance license number on the a line.
City or Town Official
Please be 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 applicrence number. In addition,an ant.
tions m any given nt.
Please be sure to fill in the permit/license number be used as a ven year,need only submit one affidavit indicating current
that must submit multiple permit/license appcant
ddress"the applicant should write"all locations in (oily or
policy information(if necessary)and under"Job Site A
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 a 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 vuzh --
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of investigations would like to thank yo
u 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
6W Washington street
Boston, MA 02111
Tel. #617-727-4900 ext 406 Or 1-877-MASSAFE
Fax Al 617-727-7749
Revised 5-26-05 wwwxaas3-g0v/dla
CITY OF SALEM
PUBUC PROPERTY
DEPARTMENT
wws t3o�r�twtwtan sus•s� o�s�o
Tau W&USAS9ti•F.uo W&740.9"
Consimcdon Debris Disposal Affidavit
(required for all demlidoa sod movadan wads)
In acmdmae with dw sitct6 edition of dw Stets Building Code,780 CMR section 111.5
Debr*and dw pmvisions of MGL a 40.S A
Building Permit N is ism"with that condition that dw debris rasuldng 4om
chic wo*Shan be disposed of in s pnopady liamaad waste disposd hd tr as defined by MGL a
1 11.31Jt)A.
The debris will be transported by:
(s.ms a[esd.r)
The dabris wiU be disposed of in
e
(nams of&edit»
z ("draa of heility)
� � d
sisoas,rs of pamsit appliead
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dart