0039 1/2 MASON ST - BPA-09-471 IV
AI'YLICA110N FOR YL:1N H VNIINAFION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT I AND 2 F441ILY DWELLINGS
--- --- - -
INII.ORI ANT:ApphCanln must rum drtr all items on th in to•c
SITE INFORMATION
Locution Name ,i_ ,•_T_C3T�,^lilitz .__......."_.-- .
Property Address C37 /ot JCJ/tl_U�1�1 ',
%lap u
Located in: Conservation Arca YM . __--_.:.Historic district Y:'N
Use Groups
(check one)
Residential (l or more Units) R2 /l
Type of improvement Residential (hotel/motel RI —"�_
(check one) Assembly(churches) Al
New Building ...... Assembly (nightclubs etc) A2_
Addition Assembly(restaurants, reacation) A3_
Alteration L(_ - - - - ,--:thsiness R
Repair/Replacement— • Educational E_ ti
Demolition_ ,Factory (moderate hazard) FI _ \
Nlovc;Rclocatc _..— Facto w ry"(lo ltautrd). F2_
Foundation Only-......_--�_— -'. 'High Hazard I , . 11
Accessory Building Institutional (residential .:are) 11
—
other(dcscribc) _.- Mnctitutional (incapac i tilted) 12
Institutional (restrained) 13
.Mercantile M
Storage(moderate hazard) S I _
Storage(losv hazard) S2_
011 VF:RSI111' INI-0101:\I 10N(Please t)lx tor Print Clearly)
OWNI:R Name ,fir
yr
Address �
t telephone q 8•-7yq- 046 _ --------!
DES( IIaIlO.V OF Y)It "TU I'k.NFUww111CU
neitA; ifvlLY AMA4Z TO GTZ�P / S/1 NCE
a
- L'U.N'1'&\C'fb'k'IN6'OR�7,\"1'IUN ^� \7�
Name�t7C�\\ .` 1 O(2/L��T' i
Address I I 77 W�-PR- "IZCl mar e P fop.
Telephone 1)81-G2S)-80N8
Construction Supervisor's Lic # rg5m)
Home Improvement Contractor #
ARCIII'I'EC"I'/ENGINEER INFORNIAT�I((�N
`Name —lF(.�f f�/�a�}a It-
Address
P•n_ �,� f ALa/d, AAA (0/990
Telephone q98-Ti4 S354
Mass. Relaistration # -SaCjlf
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
• COMMENTS 46� • /1
2a a
The undersigned does hereby attest that all information stated above is trite to the best
of my knowledge (order the penalties of perjury
.Signed vs
Date
3
CITY OF SALEM
PUBLIC PROPRERTY
,ter_ DEPARTMENT
\L11,`H I`� \\ .�,I II?:� ��1I!u t ♦ S.�I i fit. \L1••.1� I; ,r I :,_19—
frl :
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
k 1plicant Information
Please Print Legibly
N.Illll t liusmos t tr�anliauon Inds,idu.11 I: ✓/1' °e 135
Address: 415 h�aSON S72E�'T
City Statc'Zip: �SA 1,)57k 1vtA 019?0 Phone #: 97t4'�4<</-0485
Are you an employer:' Check the appropriate box: Type of project(required):
1-9 I din a einplo)'er with q 4 ❑ 1 am a general contractor and 1 6. ❑ New construction
em lu ees (full and/or art-time).' have hired the sub-contractors
P )' part-time).*
?.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7.-Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition.
working for me in any capacity. workers' comp. insurance. y, ❑ Building addition
No workers' cum insurance 5. ❑ We are a corporation and its
re p 10.❑ Electrical repairs or additions
reyuired.J. officers have exercised their
I ❑ I 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 12.0 Roof repairs
insurance required.] f employees. [No workers' 13.[E:lOther
comp. insurance required.]
*Any applicant that checks box 41 must also till out the section below showing their workers'compensation policy information.
t I lonmowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'Gump. policy information.
/um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
infornrution. /'
Insurance Company Name: y'teVy � 1&b4 9 U27?S' 5"M-� C641A4
Policy # or Self-ins. Lic. #: 12-08 Expiration Date: IO .Z5-
�3'2`Z, S �tA ol9�6
Jub Site Address: ACON �� CityiStatelZip:
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 MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S I.500.00 and/or one-year imprisonment,as well as civil penalties in the firm 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 Office of
hi%c>tieations of the DIA for insurance co%crage verification.
i du hereby certi/i•under the pains and penalties of perjury that the itijitrtttution provided above is true mid correcL
�r1 n:lltlyd:
[)are
1'Lone = '
01,14 ial use only. Da it write in this area, to he conipleted by city or town officiuL
Cin or Tuan: --- -- -__ .._._- _--_ Per initil.icense #----_—_ _—_--
Issuing .%whority (circle one):
1. Board of Health 2. Building Department 3.City town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other --
Contact Person:------------- -__---._-- Phone #:--___ --
e '
Information and Instructions
\I:15ea Chu,CuS General I_ ms chapter Li' regiures all cmplosers to pro%ide workers' compensation for their entploti ees.
]'Ilr>ti.tt to tlt is ,cu tire, an eugr10t•ee is .IetinCd as '•_.e'LCry person in the Service of another under any Contract of(tire,
evprcSs or implied, oral or written." 11
An enrP ip-ver is dcrined as "an indis:dual• partnership, association, corporation or other legal entity. or any two or more
of the foregoing engaged in a joint enterprise, and uteluding die legal representatiNes ofa deceased employer• or the
rcCe:%cr or trustee of an :ndi%idual. parntership, is,0ciation or other legal entity, employ itg employees. l lowever the
ou ncr of a dwelling house has ing not more than three apartments and who resides therein, or the occupant of the
d\u Cllinu house of another who employs person, to do maintenance, Construction or repair work on Such dwelling house
or on the _rounds or building appunenant thereto,hall not because oFsuch employ nwnt be deemed to be an employer."
\I(il- Chapter 152, §2500) 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 eoruruonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, NIGL chapter 152, j25C(7) lutes"Neither the commonwealth nor;my of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
reguiremCuts 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-contractors) name(s), address(es) 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
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 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 appropriate 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.lny5stiy8-bons has to contact yuu`•regarding the applicant.
Please be sure to-fill in the permiulicense number which will be used as a reference number. In addition, an applicant
that must Submit multiple permit/license applications in anygiveri,year;need only submit one affidavit indicating current
pol icy;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 the 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
o'c. a dog license or permit to burn leaves etc.) said person is NOT required to complete this atfidavit.
I he ()tfice of Investigations would like to thank you in advance for your cooperation and should you hate any questions,
please do not hesstate to give us a Call.
Ilse Department's address, telephone and faux 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
Kai iced 5-'6-0 Fax # 617-727-7749
www.mass.gov/dia
VDAC
THIS IS A QUOTE , NOT A POLICY
WORKERS COMPENSATION
HT-TMRDAND
EMPLOYERS LIABILITY POLICY
QUOTE PROFILE — VERSION 01
POLICY NUMBER: (6S60UB-95231-17-6-08)
RENEWAL OF (6S60UB-5478C87-9-07 )
INSURED'S NAME AND ADDRESS
WORKERS COMPENSATION
CROWN AUTO BODY SUPPLY LLC INSURANCE PLAN
45 MASON STREET A/R (WCIP) # MA
SALEM MA 01970
POLICY PERIOD FROM: 1 0-25-08 TO 1 0-25-09
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 70G7
PREMIUM DISCOUNT NONE
0900-20 EXPENSE CONSTANT 338
TERRORISM 163
TOTAL ESTIMATED PREMIUM 7568
TAXES AND SURCHARGES 445
DEPOSIT AMOUNT DUE 8013
Employer's Liability BI Limit: $ 1 00000 Each Accident
500000 Policy Limit
100000 Each Employee
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
Adjustments of Premiums shall be made ANNUALLY
Deposit Amount Due: $ 8013
POLICY NUMBER: (6S60UB-9523L17-6-08)
DATE OF ISSUE:08-29-08 WC ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: GERALD T MCCARTHY INS 73MBB
>' = CITY OF SALEM
y y. f.
=r Ay l= PUBLIC PROPRERTY
DEPAR`IMENT
Construction Debris Disposal Affidavit
(required 1br all demolition and renovation work)
In accordance pith the sixth edition ofthe Slate Building Code, 7S0 CINR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11, S 150A.
The debris will be transported by:
NN tiW IA96 4S640 (d4572r 1/C.
(nJn1C u(hauler)
I he debris will be disposed of*in
7c.
(name of tacil
//0 !�xFoM I'a9,4r-
I?OWL.�YN AW, QN969
Iaddrens o(Iacililvl - -
L
a ❑alurc of permit a plicant
,lale