13 MALL ST - BUILDING INSPECTION CrrY of SALEm
PUBLIC PROPRERTY
DEPARTUEM
>L�u• tDGL ev::osti7LQ•&WN.MAILM2wat0b::0
TU;IW4&4M•f.%=9 804900%
Construction Debris Disp"st Affidavit
(require! Got all danoGtion and removad"wort)
to xconiance with the sixth edition of the Stun&dldh*Coda.7SO CUR section It t.S
Debris.ud die provisions of MOL a 44 S Sk
Building Pon nnit• _ is isssted widt dw condidon that the debris ra dtkS <t m
this wort JWI be disposed of in a property licensed waste disposal facility as dented by MOO a
11t.S15"
The d&H6 will be=nsported by:
tnuw arhawdo
rho icbriswill be disposed of in :
�3'.dZP �20iro
t a+rne ur rx,t,tyl
e
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4
CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.talaratAY Ine9t:Ula
M.vYaa I3C WAttaNUTIO aSMUT a SALZK M.%9JACIIs701'1301973
T1J:978.7419593 a F.sx:97a•74p9a46
Workers' Compensadoa losuranee AlMdavit: Builders/Coatractors/ElectridaiWPtumbers
Annllcant Inrormadon Please Print Legibty
Name lauaimss!(kaalli:attoNlndnr tdlmlY• r�/l/Q-��517` -5 ���C C(/ 4(1
Address: � / S%
Cit lStatrlZi d e 0a�1�
Y p Phone q: if 02 `, S^ X/
mix-
.are you as employer:'Cheek the appropriate boar
Type of projtaee(rogalreln:
I.❑ 1 am a emplayatt with 4. ❑ 1 am a ycnlnal contractor and 1 6. 0 New cmisvuetiaO
2.entpluycaa(full and/or parL-umc).a have hired the sub-comractors
l am a sole proprietor or partner. listed an the attached sheet. t 7. ❑ Remodeling
ship and have no employees Them have a ❑Demolition
working far me in any capacity. workers' comp. insurance. q
❑ Building addition
[No workers'comp insurance S. ❑ We tiro a corporation exercised
and its 10.❑Electrical repairs or additions
nquirlxLJ ot7lcers here Oxcrcisal their
3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.❑ Plumbing repairs or additions
myself.[No worker'comp. C. 152.§1(4).and we have to 12.
❑ Roof repairs
insurance requircd.J i cm loycc&p. insurance
[Now quirod. ] 13J. .❑Other /��' 0,7�
comp inwrsnce requirwl] n
AIp,PPIWam nr eAMta ban el mum Ww till out The White Iwbw laorioa their cootie'wmPrWi,m jw iuy io6wmiou
l k. wlwa who submii Mir anldavu indkatbg they am daitry as.wit one Mat hire aladda caar="M emu.wbmil a eew amJavil Wi wino"a.
C'amrull.ra that Awl die bm mum saaehol an addntiom I Jwe.Mowing Me nap alto W&Mnamem sad Ijus,wudted aarlp,policy inl6ne dm
l alto an employer that b providing workers'rorapenradoo insurancejor lny 0,11TAyees Below Is the pulky und/ob anti
illfallwar/llR
Insurance Company Name:
Policy M or Scif-ins. Lie. A: _ .. EApirauon Date:
Jub Site address: CllylstatuZlp:
.attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure w wcom coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
rime up Its S1,500.00 amVor one-year imprisonment,as well as civil penalties in the form Ora STOP WORK ORDER and a rice
of up to S250.00 a Jay arainst the violator. Be advised that a copy urthis slatcment may be lurwarded to the Office of
Iue a.ngjimns oi'thc DIA for insurance covara;c variflcatiun.
l do herrb7 certify under_^-pains and penuilks of perjury that the infwwat/nn provided above is true madcorreeL
rMn•u7: �6'A- � 9Y � ��a2
O/Jlrial use om4t, De wet write/n Mir arre,to be rawplef d by elly Or town o/Jle i`id
City or Town: _ PcrmiVIJcease g
Is gsuin .aulhurily(circle oue): ——
1. hoard of Malik I. Huddling Department J. Cityrfoen Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Gauacl Person: _ Phone M•
Information and Instructions It
,%11,jaachusetts General Laws chapter 152 requires all employersto p rhea�u�e of another kind"compensation for nnead of Idtheir �
pursuant to this statUld,an emp&Y a is defined as"...every person
.%press or implied,Oral or written."
asimeinti m'omporstion or other legal entity.or any two or more
,n rrrObydr u defined o eta ia�vidwal.PatR to ere or the
Of the foregoing engaged in a joint enterprise,and including�legal representatives of a deceased emp y
association at other legal entity.employing employee& However the
receiver at ttuwe+of an iudividng no
and who resides thaeir4 air the oecupane of the
owner of a dwellting house bavieg not emote tbsa theca apartments
dwelling house of another who employs persons to do maintenance.cunstruction or repair week d>o web dwelling hare
or on the grounds at building appurtenant&WM shall not beesum of such employment Ire deemed to be an employ«•"
.ktGL chapter 15Z 42SC(6)also smuts that 'avery state or Beal ueensWE agency star withbelld the beuam or
b operate a business or b construct btsildlnP)n tbd cemmeawes"for any
renewals •Ikense e: Parmaed�aptable avidene s of comprises with ebe iaenrsnce coverage required."
apppcestt wits boa eat prod of its political subdivisions shall
the commonwealth nor any
enter Additionally.MGL chapter 153.42 a ofPtes blbliic wwoesh until acceptable evidence ofcotttplinace with the insurance
mate into my contract far the perf
requirements of this chapter have been presented to the contracting auahorily."
Appliesats
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation sad,if
necessary.supply ante eentracuorls)namels),address(es)and Phone number(s)along with their cartificas)f than the
insurenca. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employ
members or partners,am not required to carry workers'compensation insurance. If an LLC or LLP does have
employees.a policy is required. Be advised that this afRdevit may be submitted to the Department of Industrial
go. Abo be sun to sign and dale the amdavlt. The affidavit should
Accidents for confirmation of insurance covers
be returned to the,city o town that the application for the permit o license is being requested, sot the Departtent of
lndusrial Accidents. Should you have any questions regarding the low 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 Officials
ricase.hoc sure that the affidavit is complete and printed legibly. The Department has provided a speed at the bottom.
of the affidavit for you to fill out in the event the Offeet of Investigations has to contact you regarding the applicant.
,',case be sure to till in the pormiulicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permiulicetse 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 o licenses. A now affidavit must be tilled out arch
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e.a dug license or permit to burn leaves ere.)said Person is NOT required to complete this affidavit.
I'hc I,)tIiCC of ltri'e1(haUani would hate to thank you in athvance for your cooperation and should you have any questions,
;iicaoe do not hesitate to give us a call.
The Departments address, telephone and fax number.
The Commonwealth of Massachusetts
Depatment of Industrial Accidents
oMm of Iarasdpden
600 Waahin6tar Street
Boston, MA 02111
Tel. 6 617-7274900 ett 406 or I-977-MASSAFE
Fax 0 617-727-7749
jcvi>cd 5-26-05 www.mm.goV/die
oar o
Construction Supervisor License i. , License: CS 30055
° .g. Birthdate 8/12/1939
E1[pifation: 8/1 212 0 0 9 Trp 1907
�/ w�, ' Restriction: 00 .. .
VINCENT S BROWN-
57 WALL ST - �L. �•
Minns cone.+ ... ...._._
EITrOFS-ALES
PUBLIC PROPERTY
I's DEPARTMEL T
Kl.%Q FJLEY ORMML
�Iwva� 130 WASI NGTON b-MEEr• "LEK Mmucmulls 01970
Zta:97 US-95" • PAX 976.7409646
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY yasnN
STRUCTURE OR BU"ING
1.0 SITE INFORMATION
Location Name: auilding:
Property Address.'/ 3
Property is bested in a;Conservation Area Y/N_/�[ Historic Olstrict Y/N IfI6 _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: � ,�
Address:
Telephone: 4' j
3.0 COMPLETE THIS SECTION FOR WORK IN PYtATiNA BUILDINGS ONLY
Addition Existing
Renovation NumbStories 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:
Dire i>< /�/�I
— Mail Permit to:
What is the current use of the Building?
Material of Building? Z�� �< any units?
If dwelling. how m l
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( 1
Mechanic's Name G ` z` �j�o 41
Address and Phone
Construction Supervisors License 0 13 OD 6 5 HIC Registration#
Estimated Cost of Pr9jed to x Permit Fee CakwladOn
permit Fes$ Estimated Cost X$7/$1000 Residential
�L2---
Estimated Cost X$11/$1000 Commercial An Additional $6.00 is added as an
Administrative charge.
Make sure 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 / Z d�
N
YOi1
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