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29 OCEAN AVE - BUILDING INSPECTION PUBLIC PROPERTY DEPART VIENT KISNERLEY DRISCOLL MAYOR I?0 WASHINGTON MEET♦$AiliN,.ASSACi1l;56115 01970 TtL-978-745-9595* FAx:97&740-9&% APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION - Location Name: Building: Property Address: Gl ©CPew lhlmwe- U�BIYI ,' O/ 7 Property is located in a; Conservation Area Y/N Al Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: U 7 B✓ s dBI� :.e✓� . Address: /5 11le✓ Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING. BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated p�S construction or renovation of existing building New Brief Description of Pr-opposed Work: J ,^ Mail Permit to: � /yB✓ a /rl, . 0/9 70 What is the current use of the Building? Material of Building? (A) If dwelling, how many units? �S Will the Building Conform to Law? ..T.-- Asbestos? V es Architect's Name Address and Phone j Mechanic's Name r Go WL6 V I-A Address and Phone S77 CJ' w R 19 �� �`� � /* — Construction Supervisors License# O"Z87- HIC Registration# 144 97L eLA Permit Fee Calculation Estimated Cost of Project$ ' Permit Fee $� Estimated Cost X$71$1000 Residential Estimated Cost X$11/$1000 Commercial 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 eermit t it o the above stated specifications. Signed under penalty of perjury X Date 10 L OG 0 w a H O � 9 a � ` C t ✓lee -Po�vma�ualt/ o�✓Ifamarluoetu1', BOARD OFBUILDING REGULATIONS License:. CONSTRUCTION SUPERVISOR, �� - Number .CS� 040282 t Birthdate 04/47/1955- E*ress:04 17l2008 Tr. no 23888 ' -_ Restylct ed, PHILIP GOUZOULE� �rf 50 EVANS RD MARBLEHEAD, .� Commissioner rt� �iEe �°?ivrrzanncnlOE o�,-/ uae!!d I �.\ Board of Building Regulations and Standards I. HOME IMi?RFFOVEMENT CONTRACTOR - Re istratlen\144872 � y�ExpiraUone: -&2 6 PHIL GOUZOULE� ' . --PHILLIP GOUZOU � ti -50 EVANS RDA MARBLEHEAD, CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KAfaER1EY DRLSCO[1 MAYOR 120 WAsHwaroN STREET*SALEM,MASSACHUWM 01970 TEt_9M745.9595 a FAx:9M740.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers Applicant Information ��11,, Please Print Lebets bly Name(Business/Organimtion/Individuaq: Pttl L Ga✓cow[ CyNsP2 JG7T otV Address: SO f'*V3 )e-A ci /state✓Zi : fl � 4,4 h O 1* ty p '�LC'f t � l Phone#: Cl L SLI— Are you an employer?Check the appropriate 1.❑ I am a employer with 4. I am a general contractor and I Type of project(requlred): employees(full and/or part-time).* have hired the sub-contractors 6. [1 New construction 2.0 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. 0 Demolition working for me in any capacity. workers'comp. insurance, [No workers' comp, insurance S. We are a corporation and its 9. 0 Btuldmg addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12. Roof insurance required.]t employees. 0 nP [No workers' comp. ;nm,.a�ce required.] 13.0 Other '�Y aPPHc&W t Cheeks bat el mug alw fill out the section below showing their workers'Compensation policy iafomunoo. t Homeownmr who submit thin a@Ideva indicating they am doing all wort and rhea Inn outride contractors must submit■new anklavit lodingn tContractom that check this box mtut attached anadditional sheet showing the name of the sub-contoetote and their �•u'odtm'onmP•policy infetroatlao. I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy andJob site Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensatlon 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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D e for insurance coverage verification. /do hereby c u der the pains and penalties ofperjury that the information provided above it true and correct Si atu t • 10 l l 06 Phone#: _ 60- 31-�P SFr OJJlelal use only. Do not write in this area,to be completed by city or town oJJlcial, City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. 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, contract Pursuant to this statute.an employee is defined as"...every person in the service of another under any 1 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 to 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 r 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 sban withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for,any applicant a ly, has not produced acceptable ates oither f thcompliance commonwealth noonwealth nor any of political�subdirequired. s shall. Additionally,MGL chapter 152, Forman enter into any contract for the performance of public work until acceptable evidence of compliance with the insura°c° requirements of this chapt er 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 contsactor(s)name(s)•address(cs)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 rs' compensation Sa�.,a^ce• If an LLC or LLP does have members or partners,are not required to carry worke employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.for pit or be sure o sign and date the license is being requested,not the Department of shoulddavit. The affidavit be returned to the city or town that the application questions re: din the law or if you are required to obtain a workers' Industrial Accidents. Should you have any quain g . Self-insured companies should enter their compensation policy,please call the Department at the number listed below self-insurance license number on the a riato line. City or Town Officials it is complete and printed legibly. The Department has provided a space at the bottom Please be sure that the affidav of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applic In addition,an aicant nt. Please be sure to fill in the permit/license number tiona m as which will been ear,need only submit used as a reference ne affidavit indicating current that must submit multiple permit/license applications Y Si a licant should write"all locations in (city or Site Address pp if necessary)and under 'Job be provided w the polictic information cop ( i or town ins p y ° Y affidavit that has been officially stamped or marked by the city Y " of the filled out each c _. must be town). A copy - permits or licenses Anew a6"iduvtt applicant as proof that a valid affidavit is on file for future pe 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 Offlee of Investlgatlons 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SAL.EM PUBLIC PROPERTY DEPARTMENT N.wa 13BWAUenctorS?%w#SujmLNAwAcHL arDatl7e Consimcdon Debris Dispwal Affidavit (required fog ill demolition and renovadois work) In aeeordsmee with the sbtdt edition of the State Building Coda,780 CMiit section 111.5 oebr*and dw provisions of MGL a 406 9 3* Building iae . 0 is issued with the era Um that eha debris resulting fivm this work shill be disposed of in a properly Ueeased waste disposal tleiUty an defined by MGL a I 11.S 130A. The debris will be transported by: (name dbsumd The debris will be disposed of in: (Hams of ftwity) (ad&w of Ixilky) s' of psmiit applicant Io� dus 21loG