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15 OCEAN AVE - BUILDING INSPECTION J __ Flic CommonttrJ(h tit Mdssachusells - - - 1 ---- --. . t I3lrard of 13ulldin9 Regu m lations and St. Jurds t l ,� \lassachusctls Slue I3uIIJing ('ode. -,Sit ( 'MR. 7"' eJink n \11 `I( II' \1 I I 1 a. I �I g BUildi I" Permit Application TopC onsmict. Repair. Krm,td(r Ur I)rmt li.h aI l I,, ,l ) If ,,l, 0m, it lh Sectnn or Othclal l'se Only IiullJln_ Payout Nulnhrr - Date \ppltccl: SI_nalure- ��• l ' oZ-- - -- -- Bw Wulf ( ,numn�u,I is 1/ Im1 ' nlr,rt Bw ldings Ua ... . .S .C7'iUN 1: 511'li IVEI)H\I:\'IION ------------- -- 1.1 Pr perh \d ass: 1.2 Assessors Slap & Parcel Numbers AC/- _ l 1.1 Is [his In Ja,epled sheet' lei I111 hel 1.3 P.itnirg Informat?oa: I It1 Property o imensi'ms: Zoning District PmposrJ Use --- I I'm +r"a n,q n( fn/ II Ice :III 1.5 Building Setbacks (ft) - ` -- -- .front YarJ 2.Jr Yard' R r,tu:,rJ Provided Re wcJ _��r4 14,��IJ,J -i _ 4t Pruv�Jrd K uued I :..`. \\atcr Supply: (.N.G L e. 10. §51) 1.7 Flood 7_nnr Is!formation: 1.8 Sewage Disposal System: PI,;.lic ❑ Pncete❑ Zone: Outvtle Flood Zone:' II Chem iI yes❑ 1lumnpal ❑ On .ne J,slH,.al s,,wm Q SECTION 2: PROPERTY OWNERSN111t --------- —J y 2.1 Ownerl of Record: -.--- -----i VLiI r !Pn nl I Address for Service- r---- - .--.—_—� _ SECTION 3: TION O} PRCPOSED 1VORK=(check all !hat apply) r— I Nev. Clntslrucnorr ❑ Existing Btoldmg ❑ G%' ;2r. - ----_.—_---�_/ r U caa�ed ❑ Repalrslsl AIterat „nls) ❑ un t ❑ )enuslitit%n ❑ I arcesm>ry Bldg. ElNu;^h .rui hits Other O Sp'clly —_ Brief Dexripuon of Proposed W„rk': r°.fh.01r�..._� iJ0 lie 1Lz S C HON J: ES"!II\IATED CONSTRUCTION COSTS (tern fanmated Cos�- -----i (I.ahur and Materials) Official Use Only 1 RuIIJIng S I- -BwlJing Penn, f te: 5 __ InJ;cute hu s% tee I, Ja1rI nunrJ t �— ? lilrc.. .tri S �-- ❑ Standard City/1'tran :\pphaaunn Fee f— ❑ Total Project Cus1` l Item GI x multiplier 4 Plumbing S s --- ' - ----_ —_ � _. Other Pees: i 1 a Mechl antral Ili\':\CI S I List_ blech.Imcal (For —� _-- ----- - --- ! Suppre.swill y f,rt.11 :\II Fees: o pulal Project Cost S ss © Q freak . n (�)trcl .\m,�unt ( ;,.h 0 ✓�/D Paid in Full ❑ t)ubt.InJln_ ii.l(.Tory Due Z/0. � � --- ' -------�--1 l Ic5.2 2506)) INSURANCE AFFIDAVIT ANI.G L. C. 152 SEC _,,-rthis affidjW will result in the denial of (he issuance ot t he building permit. IS AGENT OR COP as O%Nnerot Thcsuhl,--o propel(y hereb-Y that me true and to the best it rn� kn,)%kI � d under the Pallis old nahicsot peril; NOTES: An O%kner winsa building permit it, ce,s I,, the ml-I'Mil"ill � � � � � � � � - `/ `« ��x`w � kuybon�Jyw``�� m� mw/'n: , /� J �k v |v./�h/ � vv��o .vp'u"u/ ."' � //n�|uJ'opguu��� 6m`h�Jh��uou� `«/`^� »` ` ` � | T.,u| dw.p �n^'�q� K/ x^h/uNev ion, omn/ --_-_�--�-- �--- --- N"*her '.t h/Jr'"n` - �-- - - -� -- - � �u.o �/ u h `* " p\Azu--------��� ---- �mn�� |/'� /h � r..| |u � \,n`hc/ ..| I,um`^`m` ----' Nwmbel � |``^`hc` � |��|« ``�h** .~,�� `�`««« �--------� '--' | | J � /|w, - �-_---_-- | | � .| |`� ` `v `|. m" ! . `um | FqaS1 J:ollt.Lgew /! »e `«"««"'e« "" ''`'l llr '' '------ - \ � � � CITY OF SALEM ,. PUBLIC PROPRERTY =- DEPAR"I'MENT l construction Debris Disposal Affidavit . (reyuircd lirr all denwlilion and lCllO 'aUUll work) In accurdance ith the sixth edition of the State Building Code, 7S0 C'NIR section 1 1 1.5 Debris, and the provisions of b1GL c 40, S 54; Building Permit tt 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 1 11, S 150A. The debris will be transported by: � M C�r �) C� TColr�� � � s �JI I name Of hauler) �/ The debris will be disposed of in (namr of factlily) laddres< ul racilitvl 11cna utc of penult .tpplicant Mate <� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 160284 Expiration: 7/9/2010 Tr# 270454 Type: Partnership Maximum Construction Inc. Fernando Felisberto 37 Lawkenie St. Watertown,MA 02972 Administrator Board of Building Regulations and Standards Construction supervisor License I License:. CS 85231 Birthdate .312211959 Expiration: 3/22/2009 Tr# 11434 Restr"on 00, FERNANDOC FELISBERTO�/,,.�'�' �� } 37 LAWRENCE ST WATERTOWN,MA 02472 Commissioner CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT .IVn;Nt IN JN M 1 n1 vl tit lk 12C W,sstu:\ci l c t..NSlsettr • SA lei st, M.1».u_lII it I rs0197-� -1],1:978-715.9595 • 1'.s R. 978-74L 7846 Workers' Compensation Laurance Affidavit: Builders/Contractors/Electricians/Plumbers \ f flicant Information Please Print Le ihly Irk x �I81Tlt: lausuwsv 1�rganv:uioNlndry ulual l: © I \dtlras?1J L Al r / City,State,Zip: D0 Phone "'I Arc you an employer? Check the appropriate box: T)pit of project (required): I.❑ I ;ern a employer with 4. ❑ 1 :ern a general coulractor and 1 6. ❑ new construction enl lloyces full aneL'ur art-time).• have hired the sub-contractors ( ( p 7. ❑ Remodeling. 2.❑ t kill a sole proprietor or partner- listed on the attached sheet. : ship and have no employees These subcontractors have 8. ❑ Denlolitipn working for me in any capacity. workers' comp- Insurance. 9. ❑ Building addition INo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions i required.] officers have exercised their right of exemption per MGL I L❑ Plumbing repairs or additions 3.❑ I ant a homcowncr doing all work c y152, s 1(4),and w have no Myself [No workers' comp. � 12.taRuuf npain insurance required.) t employees. lno workers' 13.❑ Other comp. insurance rcquircd.] •1m.grphcaul that chucks box 01 must also Jill out the wtCllan I,cluw showing Ihcir workers'eumpen W ion policy inlirtnutiun ' I lomeuwcen who submit this anWaviI indicating they are doing all work and Ihcn hire outside caurxton Muir suhmil a new as11.davit indicating arch. -f\mmtcmrs that check this box mirth atgchcd.cat additional slti<e1 showing the nail of the subcontractors and their wurken'ctsnsp.policy inform:niun. l tun its employer that i.r pro viditilf rvurkers'c onipetreatiost insurance•jar lily eurployeer. Below is the pulicy and fob.site infurtiution. Insurance Company Vmne: I'olicv is or Sclf-ins. Lic. ?I: . _.___ Expiration Date: Job Sitc Address: ___. City,Slate/zip: Attach of copy of the workers' compensation policy declaration page (showing; the policy number and expiration date). Failure ht secure coverage as required under Secliun 25A of.\IGL c. 152 can lead to the imposition of criminal penalties of a tiny up to 11.500.00 and/ur one-year imprisonment, as well as civil penalties in the fossil of a STOP WORK ORDER and a fine of up to S250.00 it day againsl the violator. Ile advised that a copy of this statement may be forwarded to the 011ice of Investl,aunlis ul illc OIA for iocur trcc cos cragu wtification. /do hereby c ertijv strider die pttinr and penuhics ujperjury that the mtfurttration provided above is true attd correct. DAtg____ --- N Official mse only. Do tint write ill this area, to be rumpleted by city or town official- Cily or fawn• _-- -- Pcrmit/License p_ _. Issuing; Aulitm-ily (circle one): 1. IA,ard of lleallh 2. IAlildin- llcpartuleut .i. Cit),"form Clerk 4. Electrical Inspector 5. Plumbing; Inspector 6. Other _ Contact Person: __ _ Phone it: Information and Instructions i >lass.ichusetts General Laws chapter 152 requires all employers to provide workers' compensation fix their employees. Punm;mt to this statute, an empluree is defined as"._every person in the service of another under any contract of hire, espress or implied, oral or written." _ An employer is defined as"an individual, partnership,associatiou, corporation or tither legal entity, or any two or more ,rr the tLregoing engaged in alum(enterpnse. and including the legal representatives of deceased empluycr,or the receiver or trustee ut an individual, partnership, association or other legal entity, employing emplo)ees. 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." .%IGL 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, NIGL Chapter 152, g25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfornwnce of public work until acceptable evidence ut'cumpliance with the insurance requirements of(his 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-contructor(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 contimtation of insurance coverage. Also be sure to sign and date the affidavit. The alf idavit should Lie rcnuned to(he city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any 4uU (dens regarding the law or if you are required to obtain it 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 Investigations has to contact you regarding the applicant. Phase be sure to till in the pcnnit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitAicense 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(hat a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled 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. it dug license or permit to burn leaves etc:)said person is NOT required to complete this affidavit. I he I)Itice of hrvestiga(4tins would line to thank )'ou in advance for your cooperation and sliciuld you hale :my questions, please LIU nut 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 Fax # 617-727-7749 www.mass.gov/di'a