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0024 KERNWOOD STREET - MCCABE PARK a The Commonwealth of Massachusetts r Department of Public Safety \Ia..,IchlnrtIsStme Bwl.bng Code(,SO C.\IR)Setenth Edition /1y11' City of Salem Buildin Permit,A lication for an Building other than a I- or 2-Family Dwelling I fhis 1r lion Fur Official Use Oniv) Building I'enml .Number' Dale Applied: Budding Inspector SECTION I: LOCATION IPeease indicate Black s and Lot a for locations for which a street address Is not available) F�Building � City /To,vn Zip Cade Nameol BuddingSECTION 2:PROPOSED WORK If New Con.strucnun check here Oor checkall thatapply In the two rows below Repair❑ Alteration ❑ Addition❑ Demolition)W (Please fill out and submit Appendix ]) OE Bf Use ClChangeuf Occupancy ❑ Other ❑;Specify: Arr budding plans and/or construction documents being supplied 44-rt of this permit applica lion? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes Cl No ❑ Dncf Des cn pliun of Proposed Work: vl7]' i�d�• ��t � '�f-I�f'] �atr--4N 22XZL2 ` ihSE2 S :COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY [ChecEkChn,,e0i1f,3n Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): )' Existing Hazard Index 790 CMR 34: Proposed Hazard Index 78O CMR 34: SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed fTo'ta'I'Area . FlooWStories(include basement levels)&Area Per Floor(sq.ft.) (sal. it and Total Height(ft.) SECTION Sr.USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ I.2 ❑ 1-3❑ I-�❑ M: Mercantile❑ R: Residential R-i❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ 5-2 ❑ 1 U: Utility I Special Use O and please describe below: S)rcoal U'sr: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ JIB Cl IIIA ❑ Ilia ❑ IV ❑ VA ❑ VB I SECTION 7: SITE INFORMATION (refer to 7t10 CMR 111.0 for details on each itelnl _ Water Supply; Flood Lone Information: Sewage Disposal: French Permit: Debris Removal: Publrc ❑ Chnkit,ndadc FL+oI L„nr Cl Indictee mumnpal❑ \ trench will nut be lJcen,Cd UnFnr... �rlr ❑ required ❑ur trench r rr .i`cafc. I"1%.1te❑ ,,r m,fvnblc Zona•:_ „r r,n .dr•corm ❑ I permit I.encln.eal O _ I Railroad right-of-way: Hazards to Air.Navigation: \1-\ I h.b nr, l ....... -r..,r Il,... \rl \i•p L..iblc❑ L�Innllue„rlhi n.nrp,,rl.Ipi•p r.Kh.lro.l' I. Iltcu' n•a rc„ ar rnpl,-I'd, I . ..i 1 .•,I-vnl i,r elm lJ rn 1,r•,J0 h•.❑ „r.\n❑ lc. ❑ \rr ❑ SECTION 8:CONTENT OF CERTIFICA FE OF OCCUPANCY —� I .to uT r,I 't, . .___ L-c 1,cui%mi I ,,.IJ i,cri Il.n. Ihr i•urLhnq,•,nl.un.ul �PnnLlrr?l.lcrn` �pcai.11 �I iF,ul.tli,rn. ___— —_—_.__—._.—. � a NYC -ro POu6 _ SECTION 9: PROPERTY OWNER AUTHORIZATION ' V.Inx•,uIJ AdJrs•s.ul l'ruperly l>tvnrr I \a mr(I'nnU .\'u.and Street Cii%, Gnvn Lip j I'n 1).vrtc Ut.tier Contact Inlurm.rtwn: fide relephone No. (bustne,j fviephune No. (cell) r ma11 a.l,lre.. If.lpplli.tble, the property it%%ner hrrebs'aulhunzes . Name Street Address City/Tutvn Slate !-Ip In acl on the pn1 ,vrly ntc ner".behalf, m.III matters rclatn a it, work.mthunzed by this bwldm •prrmtl a + ncc.nnm. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (II Nildm•If la.s than 15,0MUcu. in of endued s+ace and/or not under Cunmtnlcllon Con lrul then check heat O and 41 r'wo ern Ill 1) 10.1 Re istered Professional Res onsibIt for Consimclion Control Name(Registrant) relephune No. e-mail address Regutratiun Number 5lrrrt Address City/Town State Lip Dtsclpline Expiration Uatr 10.2 eneral Contractor Cumgrny �r:/7 ^ R� trS©c121f�� 14 / L /5 Namta.- P`r.tm (fie nnsi l�L@rstyirojiun /� License No. and Type if Applicable G l l�� Street Address City/Town State Zi k7YZ/ p Telr hone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT IM.G.L..c.152-q 2SC(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit.submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) =S �( 1. Bwlding S OV % Building Permit Fee=Total Construction Cost is (Insert here X 2. Electrical 5 appropriate municipal factor)=§ 3. Plumbing ; i. Mechanical (HVAC) 5 Note:Minimum fee=E (contact municipality) S. Mechanical (Other) S Endow check payable to 6. Total Cost S 0V (contact munict alit )and write check number here SECTION 13:SIGN TORE OF BUILDING PERMIT APPLICANT v •meting n,1 c below. I hereby alteSI under I e pains and penaltie,of prrjury that all of the Information o tntained in this pp c Own I> r I a I.Iccu Ite to the best of my knr vledge and Understanding. I'r.1 nnf .Ind . n n.nnr _— Ualr �Ilrct 1J.Irt•" ('Ift ; Ginn .— -- SLI(r Gp L//w0 I \lunicipal Inspector to fill out This section upon applicati n approval: \dine tie cT�- �a CITY OF Sm-EN1, ANSSACHLSETTS BuLLOLNG DEPARTMENT • Ia?R,']' 120 WASHIINGTON STREET, 3'FLOOR T1E1_ (978) 74S-959S F.4x(978) 7504846 KI.NBERLF-Y DRISCOL.I. THOMASST.PIERRa MAYOR DIRECTOR OF PUBLIC PROPERTY/auI .DL\GCOSLAIISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A i Iicant Information Please Print Le ibl Nalne(Busiox•s Orginiratiomindividual): '� Q Address: 2 ( V— Lf r,� City/Statcaip: Phone Ar �ye employer?Check the appropriate box: 'type of project(required): 4. ❑ 1 am s general contractor and 1 b. New construd:tion 1. aemployawith ❑as(full and/or part-time).• have hired thesub-camractors 7. ❑ Remodeling 2. am a sole proprietor or partner- listed on the attached Acet. ship and have no employees - These sub-contractors have g. ❑ Demolition working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition No workers'coon insurance 5. ❑ We are a corporation and its l P• 10.❑ Electrical repairs or additions required.) officers have exercised their },❑ 1 am a homeowner doing all wont 6 P right of exemption per MGL I I,[] Plumbing repairs or additions myself.(Na workers'comp. c. 152,$1(4),and we have no 12.❑ Roof repairs insurance required.)i employees. [No workers' 13.❑ Other comp.insurance required.1 -Any applicant dw daeW box al ow ales rill out the searion below showing their nrorkmn compensation policy mfannatiun. s I LvmdNrnxxs who winnil this atfiditvis indiearins they are doing all work and then him ounldecanlntaors maal submit a new afrdavit indicting such. /G�r•—N 'O,nawaors that Omit this box most attached m additiornl sheet showing the nano otdho sudeontnctore and thalt wurkm'mmp.policy intomannon. 1.1 ND I am on employer that lap compensarlon brsrtrance for my employer Below Is the policy and Job site information. �v(arLk/emirs 1 Insurance Company Name: t "�._.__ 1 ��JfCs1r.�Gie ` � Policy p or Self-ins. Liis N: Expiration Date: Jub Site Address: I Li�.C- �/�,+xc+'_� `t, City/State/Zip: AV 67.1 Attach a copy alike workers'compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A ot•MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Oflicc of Investi is ofthe DIA t rin ante coverage vcrificuliun. /do/ereby c r y raider a /ns and li nalr/as of perjury Ntaf the btjurmutlan provided o e/ve it t sae and correct. 1 Phone A' Qljftid toad may. Oo not write in this urea,to be completed by city or town ojjkiaL City nrTown• ---- _ Permit/i.lcense71n.soector IssuingA Whorily(circle one):1. Board of Health 2. Building Department 3.Cityrruwn Clerk J. Electrical Inspector 5. 6.Other Cuntagi Person; _ ._.. . . Phone to: Information and Instructions Massachusetts General Laws chapter 1 i2 requires all employers to provide workers' compensation for(heir cntployees.,. Pursuing to this sutirte, an emplotve is defined as".,.every pcaxon in the icivice of another under any contract of hire, %press or Implied, oral or written.- .\n employer is defined as"an individual,partnership,associanon,corporation or other legal cnnry, or any two or more ..t (he foregoing engaged in a Joint enterprise. and including the legal representatives of a deceased employer,or the i ecciver or uus(ca uI .n uadividu.il,piumcrship,associatioa or other Icgal 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 buuse 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." %IGL chapter 152. ¢25C(6)also states thug "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 wlro has not produced acceptable evidence of cumpllance with the Insurance coverage required." Addinunally. NIGL chapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall ' enter into any contract for the performance ul'public work until acceptable evidence of cumpliunce 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-contractors)name(s), address(es)and phone nunrber(s)along with their cerrificatc(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employers 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 sire to sign and date the affidavit. The affidavit should he 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 u 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 applicant. Please be sure to till in the permit/license number which will be used as a reference number. in addition,an applicant that mint submit multiple pennitilicease 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 (i.c. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. I It,; 01 lice of InveNligatlons would like to dlank you in advance fur your cooperation acid should you have:ny questions, please do not hesitate to give us a call. The Mpartment's address, telephone and fax number: The Commonwealth of Massachusetts Depament of Industrial Accidents OPHee of lavesHIIatlons 600 Washington Street Boston, MA 02111 Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE R:.tied 5-_'ti-05 Fax #617-727-7749 www.mas3.gov/dia CITY OF SAI.E.NI, NL-kSSACHusETrs • BI:ILDLNG DEPARTM&NT 130 W."HLNGTON STREET, 3 °FLOOR TM (978) 745-9595 FAX(978) 740.98U KjA(BFRr FY DRISCOLL ;MAYOR THomu ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUIIMLNG CO%LNIISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.5 Debris, and the provisions of MGL c 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signatu a of permit applicant dat Jebnaalf J•k i GANSENBERG CONSTRUCTION I 21r Lincoln Rd.pppp Salem Ma 01970 978-335-4742 #cs092108 PROPOSAL SUBMITTED TO: hie 159161 WORK PERFORMED AT NAME: Doug Bollen Macabe ramp DATE OF PLANS: ADDRESS: Kemwood st TBA PHONE: 978-744-0924 We hereby propose to finish the materials and labor necessary for the completion of- Demolish and remove existing shed. (all electric by city) Rebuild 8x8x8 shed with 1 door facing street, 1 sliding window facing parking lot and 1 double hung window opposite door Exterior—T 1/11 siding and pine trim Roof to be rubber Clean grounds of debris All materials are guaranteed to be as specified, and the above work to be preformed in accordance with the drawings or specifications for above work, and completed in a substantial workmanlike manner for the sum of ******** $4,900.00 ********* $ 2,400.00 deposit to deliver materials. 2,500.00upon completion Submitted by _Date Note-this proposal may be withdrawn if not Accepted within 14 days ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment to be made as outlined above. Signature Date --Iq b3ao