16-22 NEW DERBY ST - BUILDING INSPECTION 7 City of Salem Ward
APPUCATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCT
IMPORTANT•AppMcw*to complete aI Ram.In socflai 6 K aR N, and M.
L Air&OGigM SHEFGtMN OW_A&D R"Lf r2✓sr lL- LL AffW KM Yr or°siw�T _
OF 9Erwe� L GJf AM 4JA1r#/ + ✓
BUMMING onse LGT
LOT
suso"b0N LOT BLOCK SUE _
M. TYPE AND COST OF BUILDING -All applicants complete Parts A -D
A. TYPE OF IMPROVEMENT D. PROPOSEp USE-FOR"DEMOLBXW USE MOST RECENT USE
1 ❑ 11aas a+dWq fly elosaaaldwdW
2 ❑ AddM9 (H Maid."enr.numb.dnew 12 ❑ Ow rnW 1110 Mkww.Lraarllwrl
/iou+(n0 uro any,in adde4 y a pert a 13) 19 ❑ ON.CK a9rr nelpbul
13 ❑ 1lad.mpe WnYy-Fn1r num01
3 ❑ Aa.atbn(sw 2 aOoN) of uNr 20 ❑ lnduetr
21 ❑ Parkkq plat
1 Ratak rePleoemerra 11 Q h1ri.M hurl, Una a domebrY- 22 ❑ Savlb er I .span 9.4
Eirr numb.dunp ___.____
s ❑ wr.cJcirq F muManley r.euenert enr ra,nr. 23 ❑ Maoi+.:wraorr
of unib n buddbV in P11 A 13) is ❑ Olga
9 Cl t�q(Mbwdm) 2/ ® olMa beret praleeeilrl
18 ❑ CarpaA 23 ❑ P1tle ulay
7 ❑ Pw-mm orgy 28 ❑ saMd- Mom 081.e*=36orr
17 Q cow_sPaNy 27 ® s1er.R n.rc
a.OWNERSF4P �Ji iarta,gY1ra
8 K Pn Mi vale(lndduaL corporation.ro pmft Ze L
inalaulfom etc.) 29 ❑ OOr-spw.&V -
9 O PL"ie(Fed11.S%dK m local gDvwmrmd - .—
C_COST (CYrYI canal Marsei0.eY1.Ossvbe it deri peooaad u d budangiL ap.bad pr000m q pftm
WcJrba chan%rurlAy buerJrq 1 hoapaat sw^mrry whad secondary schoot coos
I a Coal of WNW,arnera Is Parod+fal scJ+od parklrq 9era9a for deperYrrra�rR rend aAloe tMidaq,o8loe tx+edr•�
at ndw&W oMmL Y uN al"Adirq du&*q Y b"N chlged ~propowd uea.
7p lea bathed NO nor nasal d , c�—
inrhaa0oue COW
'JL S C N'��I`
a Erctrlcal_.--.-_-............----_----__...._....__....__. rw
a P1ur b,q ._......--...........
r�ol/E �r
4 Odrr teterabr.etcl..----------------- '
11. TOTAL COST OF IMRIOVEMENT QU V" (Ivv`•'-�/ - - ,
OIL SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Paris E -L.; demolition.
cam to on Parts J 6 AI aH others ski to IV
E. PRINCIPAL TYPE Of FRAME F. PRWFAL TYPE OF HEATH FUEL a TYPE OF SEWAGE COMPOSAL L TYPE OF MECHANICAL
0 Ma vy(waf�) 33 a c /0 ❑ P bk o/pmar dd V.V
.hno
C] of
J2 ❑ S6tcMa1 e1M1 37
❑ ELc�eY I1 ❑ Prover laspaa wst slcl 44 ❑ w as ❑ -r.
gG 33 ❑ RO-Wlm d meets 38 ❑ Caal K TYPE OF WATER SUPPLY
31 ❑ Other �h 39 ❑ Ottw-spscdy 12 Public M pmar ca•nplry WA dra es an erM 47
38 ❑ fye 17 ❑ •�
❑ 'sr(weA corm)
GAS-L-- D• ,D�GI�n��� L✓hG�v 2�.�"b� -
I DOWNSIor0 M. DEMOLITION OF STRUCTURES:
a %Ardw Cot sewrA
,a "'M sa," n.,,e k o us Has Approval from Historical Commission been received
a tma b1SW W e,wv for any structure Over fifty(50)years? Yes_ No—
Dig Safi Number
so lay WW yea 16 R
IL am OF piF-ST<RM PAAFlNO SPACES Ped Controt
51 Erckaw _-.___....___....._...___._.____..____._..
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED
Yes sz aAAoo.._.__.._._.._._.____.__._........_--
c fnAL euaOSrW O Water
� rrltr
ElecEric
Sa ErcioWd _.__._.------ Gas
Fve___—___..__..__ Sewer: -
s+ "nO"d DOCUMENTATION FOR THE ABOVE MUST 8E ATTACHED
P.,er.._-._._._..._....___.. BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes— Now (ff yes.please endow docurnentatbn horn HisL Con.)
Conservation Area? Yea—_ NO (B yes,pie ewe Order Of Conditions)
Has Fire Reventicn aPpraved and stamped Plans or applications? Yes— NoY—
Is property located in the S.RA district? Yes— NOS
Comply with Zonktg7 Yeses— No— (If no,endear Board of Appeal decision)
Is lot grandfathered? Yes-- Noy-- (if yes, submit documentatlonfd no,submit Board of Appeal decision)
If new construction,has the proper Routing Slip been enclosed? Yes— NO_
Is Architectural Access Board approval required? Yes— No� (If yes,submit documentation)
Massachusetts State Contractor Licensee Cps 30 3 Iq Salem License e
Home Improvement Contractor e [ Homeowners Exempt form(d applicable) Yes_ No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX (e)MONTHS OF ISSUANCE OF BUILDING PERMIT
,n'A M an extension is necessary. Pie emit
CONSTRUCTION IS TO BE COMPLETED,BY: J y in writing to the Inspector of Buildings.
V. IDENTIFICATION • 7o be completed by all applicants
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Eryrrr Y
I hereby certify that the proposed work 13 authorized by the owner at record and:hat I have bean authorized by the owner to make this application f
as his authorized agent and we atee to conform to all licable laws of this jurisdiction
Address Application date
SgraNre of applicant I
DO NOT WRITE BELOW THIS LINE
V
I. IDATION
FOR pEpART1�AEHr USE ONLY
umber Use G,oup
2) r]jp` Q`� 19 Fee Gn39
ssued
Laacilm
Build 2
P+amMFee f // ar„p,,,CY�
Certificate of Occupancy f
Drain Tile
Plan Review Fee f
7rRE
NOTES AND Oats• (For department use)
S d
C .S
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by. Completed by. --
- l
A ZONM PLAN EXAMWERS NOTES
DISTRICT
i
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SITE OR PLOT PLAN •For AppNeant Use
O N
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\L`. 'K I_': W A911N1;.0 :S:RcET • SAt:w1, MA11 V -t( +L f1N
-rF1.978-N5-*)595 • !Ax: 978J4G9646
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of I1GL c 40, S 54;
Building Permit p _ _ 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
I11. S 150A.
The debris will be transported by:
(,V QS7e "
(name of hauler)
Hie dcbris will be disposed of in
CITY OF SALEM
3 i, ? PUBLIC PROPRERTY
DEPARTMENT
RIMURLEY DRISCOLL
MAYOR 120 WASHINGTONSI'REET • SALEM, MASSACHUSEITS01970
TEL: 978-745-9595 ♦ FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �1 Please Print Leeibly
Name (Business/Organization/Individual):
Address: k�:OLAG
~Gi3�r
Phone#: Ct2b 31L( - (844
City/State/Zip: lv -
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
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 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
officers have exercised their l0.❑ Electrical repairs or additions
required.] o
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ 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' 13.0 Other
comp. insurance required.]
"Any applicant that checks box#1 most also Ell out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name: r AIN- GS�[�
Policy#or Self-ins. Lic. #: 0 00f x 28- /I t 0sW� l7/Expiration Date: /� � — � �4
Job Site Address: NLlaz ( ( 57— City/State/Zip: MA-
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
fine 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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under t pains a enalties ajperjury that the information provided above is true and correct.
Signature . G 2 Date'
Phone#: A �701-011
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. 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 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 152, §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-contractor(s)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 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 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
(i.e. 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 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
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia