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3B NIMITZ WAY - BUILDING INSPECTION
i JdaP+Es OVED $Y T44E UINO GRANTED CITY OF SAtEM No. � 12/14/.0'7 a Is ftopoty Loomed in Location o! 3 B 'N i m i t z Way rh•Frlrtorlo.Diebld? Yee No � �x irui];dlraa Salem MA •0193 0' , Y Plapwb LooMed b go Cgl naft0 Arm? - Yet_No Bu1LDINa PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, 'Shed, Pool, RepaldReplace Oth install replacement windows PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCf111111" TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following 31:190cations:- Owner's Name Camille Nichols 2 Lodge Road Address & Phone, gw'aMnc�n+ + arts ni any ( 781) 596-1 72R - Archkect'e Name -- Address& Phone L ) Mechanics Name Frank F . Obey y! 81 Centre Street Address & Phone Lvnn . MA 01905 (781 ) 599-1353 t bI .•'� What Isv*pupaedbuwW res.identiit . b McMW d q q wood Ma d"i 6-9.foe how many bmYw4 o-��+r. � r Wtr wig 0 Worm to Iwrr yes 4 no Eyyeyb soft. $ 1— , 5 0 0....000 Cay WN""o N A aft Llow" 0 CS 027156 1103699 �1 Signature of Applicant ti{ SIGN40 UNDER THE R�F i ! OF PERJURY DESCRIPTION OF WORK TO BE DQNE ( Installation ofn�ew replacement iwindows MIIILPERMITTO' auni.11e Nichols z+. . ti 2 Lodge .Road' Y* Swampscott, MA 01907 r b R"1 No. APPLICATION FOR PERMIT TO LOCATION PERMIT GRANTED %ZC A O"Fo ECTOR O UILDINGS s _ 1 -e 6 Board of Buildinq eqqulations One Ashburton Place, Ism 1301 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 06/24/1941 Number: CS 027156 Expires: 06/24/2008 Restricted To: 00 FRANK E OBEY 81 CENTRE ST LYNN, MA 01905 Tr. no: 26531 Keep top for receipt and change of address notification. DPS"CAI 0 50M-04/05PC8698 o ui mg egu at ns a�ha n One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 103699 TYPe: Individual Expiration: 7/9/2008 FRANK E. OBEY Frank Obey 81 Centre St. Lynn, MA 01905 Update Address and return card. Mark reason for change. -' Address ! Renewal Employment Lost Card DPS-CA1 0 50M-05106-PC6490 PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM, MA O1970 TEL. (976)745-9595 EXT. 380 FAX (978) 740-9646 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 constriction 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 12 Swampscott Roadr Salem, MA 01970 Location of Facility 12/14/07 Signature of Permit Apphcaat Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Frank E.-Obey Name of Permit Applicant Frank E . Obey , General Contractor Firm Name, if any 81 Centre Street , Lynn, MA 01905 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 cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. The Commonwealth ofMassaehusetts • Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 lei, www.mass gov/dia Workers' Compensation Insurance Aflidailit: Builders/Contractors/Electricians/Pluinbers Applicant Information Please Print Legibly Name (Business'Orgaruzation/Individual): Frank E. Obey, General Contractor Address: 81 Centre Street City/State/Zip: Lynn, MA 01905 Phone #: 781-599-1353 Are you an employer' Check the appropriate box: Type of project (required): I © 1 am a employer with 4 4. ❑ 1 am a general contractor and 1 6. ❑ New construction cmployees (full and/or pan-time) ' have hired the sub-contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7 ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10 ❑ Electrical repairs or additions 3. [11 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.] t employees. [No workers' 13 ® Other windows c')mp insurance required.] '.v y applicant that checks box a 1 must also fill out the section below showing their workers'compensation policy information I liomeo v.ners who submit this affidavit indicating they arc doing all work and then hire outside cxontruciors must subunit a new afridacit mdicni ing such. Contractors that check this box must attached m additional sheet showing the name of the suh-contncturs and then workers'comp policy mtonrwnnn. i am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site information. Iastuance Company Name: A.I .M. Mutual Insurance Company Policy a or Self-ins Lic. #: VWC 600461001 2002 000 Expiration Date: 1 2/7/oFl Job Site Address: 3B Nimitz Way City/State/ZipSalem, MA 01970 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 foe up to S1,500 00 and/or one-ycar 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 Investigadons of the DIA for insurance coverage verification. l l do hereby certify under ins land penaities of perjury that the information provided above is true and correea Signature: �7i/ ( C(�//L'yJ Date 12/14/07 Phone #: 781-599-1353 Of tcW use only. Do not write in this area, to be completed by city or town official City or Town: PermitfLicense # 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 ana 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,partnersbip, association, corporation,dr 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-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'iequired 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 slue to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/liceuse 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 pemiit not related to any business or commercial venture (i.e. a dog license or permit to bum 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 EITy_olr PUBLIC PROPERTY DEPARTI4IENT MAYM , vIwSMINL�q 5[wfier 0 3At�MAgAQIISYTIS 0,970 17s:M743-901•FAz 97s.740960 APPLICATION FOR THE REPAIR. RENOYATION. CONSTRUCTION, D&MOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Nang /G sum kw Property Address:---- Property is bcmw In a.Cons VatlOn Ares Y/N /o Hist ft District Y/N ko 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land O f✓o�! i . Name: C i C o [ Address: FO Telephone: g s g 2 3.0 COMPLETE THIS SECTION FOR WORK IN E KLSIDW BUILDINGS ONLY Addition Existing Renovation Numbe, mica Renovated Change in Use Now Demolition Existing Approximate year of Area per floor (SO Renovated constructlon or renovation /® �� , New of existing building / j Britt Description of Proposed Work: ----- ---Mail Permit to: 4 006 F lZ SGJHMC'SCoT% c---r q o - - What is the curr ent use of the Building? Material cf Building? �✓c c /�ti�`"� `Z If dwelling,how many units? V q WIN"Building Conform to Law? Asbestos? Architect's Name Address and Phone ( 1 Mechanic's Name Address and Phone Construction Supervisors Ucenss g HIC Registration g Estimated Costt Of�Project S vpo Go Permit FN Calculation Permit Fee: Estimated Cod X$7/51000 Residential Estimated Cost X$11/$1008 Carnmercimt-------- - An Additional $5.00 Is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit rtoto th ve stated specifications. Signed under penalty of perjury J ate �I N s �� a s - - CITY OF &XI.EM PUBLIC PROPERTY DEPARTMENT Kl 101cv p�w•n,, MAYOR 130 WASHINGTON$nlM•SALE SALEK MASSACHLSEM 01970 lai 979.73S-9S9S• FAY:978.740.98.16 HOMEOWNER LICENSE EXE.MMON Please Print Date 7 0 7 Job Location 3.13, N,1 ^ , "r Z w A y i�,i a .a.v Upnjc Home Owner Address '2— 0 0 Gk• 130, Home Owner Telephone ? �r S9 4 I ? 2 Fl Present Mailing Address 2 4 n r,>6 r r2o 0i 90 The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire who,does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official,on a form acceptable to the Building Official, that he/she be responsible for all such work performed under the Building Permit. The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner"certifies that he/she understands the City of Salem Building Department minimum inspection procedures and requiremerA and that he/she will comply with said procedures and uiremen HOMEOWNERS SIGNATURE APPROVAL OF BUILDING INSPECTOR j' v� See other side for state code CITY OF SALEM PUBLIC PROPRERTY DEPART-VENT ..ua:r.r er• aa.a�rl \LMYt lD('�.19rN::Ji►3 BELT 3.\li f1.�.NY\l.�a,l tl\i:9r Tat:YTNWtSs�f•F.\:�97fJ�69W —;r Construction Debris Disposal Aft1davit (required for all demolition and renovation work) in accoadutce with the sixth edition of the State Building Codsi, 7110 CUR section 111.S Debris,pad the provisions otvtGL c 40.S A Building Permit N _ . _ is issued with the condition that the debris resulting from this work shall be disposed of in a property licettred wasp disposal facility as defined by%IGL c !l 1, S 150A. The debris will be transported by: rv"en��s3�3 Ca , C� t namt of trwtar) fhe ckbds will be disposed of in (maw of 4ultay)