101 MARLBOROUGH - BUILDING INSPECTION IT`
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED �t
Location of Building 101 A )-bo ZovQ+
Building Permit Applleation F
(Circle whichever applies) R f, Reroof, l stall Siding,Construct Deck, Shed,Pool
Addition, tcration, Repair/Replace,Foundation Only, Wrecking
Other. t
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings: ,
The undersigned hereby applies for a permit to build according to the following specifications:
Owneri Name: PA-T L R I O N Contractor. N llm e -Dig oT
Street 1 W A AA L60RO -i-kity Suut'�y5 CTEi .el;NW06DCity Lk)0r<Ce5'F(1
State Phone 6-)$) 74 5- 1 Q SD State Phone tl?9)
Architect: City of Salem Lie# G
Street City State uco HIP# t L(�l) q 3
State Phone ( ) Homeowners Exempt Form __yes
Structure: (please eir ) Single Farniiy iviuhi Family 401her
Estimated Cost of Job S t
Will building confirm to law! yes no 1 '
Asbestos?
_ya ,./ no
Description of worst to be done:
Dnwia Submitted: es no Mail Permit to:g U
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Signature of Application,SIGNEO UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO Bi OMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: PemdFN Zoning M WAAI
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Permit fee S
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CITY OF SALEMv MASSACHUSETTS
,., ' PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
FAX (976) 740-9846
STANLEY J. USOVICZ. JR. ,
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition
of Building Permit# , all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,S150A-
The debris will be disposed of at: CFS' -
Location of Facility
o
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
6xv�j CN Hots
Name of Permit Applicant
ko ryle 'De'eo-r
Firm Name,if any
Address,City& State
The above statute requires that debris from the demolition,renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL ca S 150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dta
Workers'Compensation Insurance Affidavit: Bugders/Contractors/Eledricians/Plumbers
Applicant Information Please Print I.e ibly
Name (Busmessiorgar&Atlonanaivith t]: 46M2 ^I)E, Po-1-
Address: S T _
City/State/Zip: \K)�ZCFS N z < Phone#: Ot' —5 —IS-7 Co Co
Are you an employer?Check the-appropriate box: Type of project(regaired4):
LO I am a employer with X y 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors 7. Remodeling
2.❑ 1 am a sole proprietor or partner- . listed on the attached sheet t ® �8
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9 ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions
required.] officers have exercised their
3.01 am a homeowner doing all work right of exemption per MGL I I.❑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.❑ Odter
comp.insurance required.]
Any applicant tlrat chedrs box#1 Trust also fill out the section below showing ttrek cwrkm'compasetion policy rofmmatiom
Homeowners who submit this affidavit rodicetmg they are doing all work sad then bue outside coottedors roust submit a new affidavit mdwating such
,ontraclots that check this boat must attached=additional shad showing the name ofthe sub-contractors sod tick workers'rnmp.policy iofoTmetioa.
am an employer thw is providing workers'compensation insumwe for my employees. Below is thepolicy andjob site
for
murance Company Name: 1 1vS��. Or
olicy#or Self-ins.Lie. #: !aGt Ci 4—7 9 Expiration Date:v 1=0isca
rb Site Address: City/Stale/zip:
ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
inure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tie up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
'up to$250.00 a day against Ste violator. 'Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the DIA for insurance coverage verification.
fo hereby certify under the pains andpenables ofperjury that the information provided above is true and correct
fmatu e: Date:
tone#•
Official use only. Do not write in this area,m be completed by cky or town o,QFeiai
City or Town: PermWUcense#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
w
Massachusetts 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,partnership,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 15Z §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-contractoi(s)name(s),address(es)and phone number(s)along with their certificates)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 retuned to the city or town that the application for the permit or license is being requested,not due 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 Depar anent at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line
City or Town Oflichda
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 die applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit 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 filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(ie. 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 numbs.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
:vised 5 26-05 wwwmws.gov/dia