Loading...
67 PALMER ST - BUILDING INSPECTION W �4.ftfQS�7b'ST�f fIL.EB-�.APPROVED BY T+IE ,spwianl ,PIwR TPA PERMIT BEING GRANTED CITY OF SALEM No. 3 L i�`\\ Date ©6 �q�YHMB d°a Is Property Located in Location of the Historic District? Yes_No_ building rp� �I Lf Is Properly Located in the Conservation Area? Yes_ No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, epair/Re lace, er: PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name � � ��� Address & Phone IV Architect's Name — Address & Phone n I n Mechanics Name ix Address & Phone What Is the purpose of building`? Y � Material of building? Y \L `4 If a dwelling, for how many families? Will building conform to law? Asbestos? Estimated cost 41 City License # N A State License # L G IO6 E Home ,^rovve�mel nett X r Si ature of ppli�ca SrGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE �p Z �� Id rw �,1� o s � , Ca�� � ti MAIL PERMIT TO:��B ICe �� No.. v� APPLICATION FOR PERMIT TO LOCATIONk PERMIT,GRANTED me APPROVED e . INSPECTO OF BUILDINGS .. } P nq The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigadons 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electridans/Plumbers Applicant Information Please Print Leeibly Name (Bu ws&i0`,tion/Indiviaaal): Y> Address: City/State/Zip: -MA- a(gf r Phone#: 711 a?�,l 4S-(( Are an employer?Check tbrippropriate bo=:' Type of project(required): 1.LEI I am a employer with 2(2 �' 4• ❑ I am a general contractor and I 6: ❑New construction (fan 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., workgg'comp. insurance. 9, Q Building addition [No workenl' oomp,insurance 5. ❑ We ate a corporation a➢d its' required J officers have execssod their 10.� Electricat tepaus or additions 3.❑ I am a homeowner.doing all work right ofexemption per MGL- 11.0 Plumbing repairs or additions myself. [No workeW.comp. c. 152,§1(4y,and*shave no , 12.❑ Roof repairs insurance required l t. employees (No workers' mp.insuranc13.❑ Other co Murray- Any . ' applicant that chedis box al tntta also fill out the action below showing ilick wmkon'compeasggoa policy infirteatitin: t Homeownets who submit this affidavit indicating theX ate doing all wait and then hiee�aidside wtgieatotsmiat subimt a new affidavit indicating suck tContrxbta that clock We box`nmet attached®edditioad.hart showing the name oft subcontintors and then wottete'wmp.policy itifomtation. I am ae'emphryerthar Lt providing workers'eontpomadon insurance for my empAocm Below ir the policy and job ske inforinatioe. /� Insurance Company Name: Ai )AQn WA 4) Le/YJ Policy#or Self-W.n�^^Lic. M 317 w C ) Expiration Date: toy Job Site Address: 'S 1 eM IM City/Statc0p: Attach a copy of the workers' compensation policy deciaration page(showing the policy number and expiration date). Failure to scare 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 imprisonmen;as well as civil penalties in tux 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. 1 do hen rrdfy uncle► pales and penakla ofpsr/ury'that the informadon provdde h true and correct Si tune: Do- Phone #: �L LK-� 08kial use only. Do not write In Aft area,to be compkted by city or mm ofykdaL City or Town: PermWUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cky/I'own 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 works' compensation for their employees"-• y Pursuant to this statute, an employee is defined as"...everyperson in the service 9 another under any contract of hire, express or implied,oral or written." An employer is defined as"an individ»ai,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 em e PIO)W,or th receiver or trustee of an individual,partnership,association or other legal entity,empbying employ However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant elthe'" 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 sban not because of such employment be deemed to be an employes." 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 constmet boiidings in the common lthwea for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required- applicant Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions of public work until acceptable evidence of compliance with the insura�e enter into any contract for the performance ter have been presented to the contracting autlority." requirements of this chap . . Applicants Please Moot the workers'compensatin affidavit completely,by checking the boxes that apply to your situation and,if sub-contractors)names),addresses)and phone number(s)along with their certificate(s)of necessary,supply insurance Limited Liability CompasiC8(LL.C)or Limited Liability Partnerships(LI.P)with no employees other than the members or partners,are not required to carry workers' compensation insurance: If as LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of affidavit Accidents for confirmation of insurance coverage. Also be'sure to sign and date the affidavit. The affidavit should be retumed to the city of town that the application nyue��the the lat or w oore is being mittested,not the if you are equir` ed to obtaina workers' of lndustrial'AccideWs Should you have any goes bebw. Self insured companies should enter their compensation policy;please call the Department at the number 4s ted self-insurance license-number on the te liner City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Doartment 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 m any given y�a reference need only submit one affidavit indicating current that must submit multiple permit"icenser. in addition,an applicant e applications 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 licensee omit r bur leaves etc.)said person is NOT required to complete this affidavit i.e. a do p ( g 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 Departmeofa 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 Revised 5-26r05 www,mass.gov/dia i CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASNINGTON STREET, 3RD FLOOR SALEM. MASSACHUSETTS 01970 STA14LEY J. USOY1CZ, JR. TELEPHONE: 978-745-9593 EXT. 380 MAYOR FAX: 978-740-9846 Salem BuildingDeDertmeIIt Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. The debris will be disposed of in: C �S��` (Location of Facility) © (` 'SEA Si ' tore of A plicant Date EXCLUSIVE USE c EXCLUSIVE USE UNITS 9-12 EXCLUSIVE USE UNITS S-S UNITS 1-4 S I BEDROOM BEDROOM TBEDWROOMO ROOM BEDROOM BEDROOM 'BEDROOM I BEDROOM UP I w d BATHROOM BATHROOM UP CL - I 'n G.. CL^ 34.0' I CL CL MNN PANTRY MAIN KITCHEN 1 KITCHEN. ENTRANCE PANIRV ENTRANCE n MAN I 4O.S 40.3' EDITRANCE I UNIT 9 UNIT I LIVING UNIT 5 LIVING AREA AREA uVMc ROOM AREA BATH ROOM 1089 t S.F. BEDRaOM BEDROOM 1089*t S.F. ROOM 69S * S.F. ROOM DINING DINING DINING I ROOM ROOMEXCLU ROOM EXCLUSIVE USE EXCLUSI WE USE UNITS 1-4 USE UNITS B-S UNITS 9-12 UNITS 1- FIRST FLOOR ELEVATION = 101.0' s f n W` N r I CERTIFY THAT THIS PLAN SHOWS UNIT 1 BEING FLOOR PLANS CONVEYED AND THE IMMEDIATE ADJOINING UNITS FOR I` AND THAT IT FULLY AND ACCURATELY DEPICTS ITILPALMER STREET CONDOMINIUM e THE LAYOUT, LOCATION, DIMENSIONS, APPROXIMATE AREA. MAIN ENTRANCE AND THE IMMEDIATE COMMON aeow SALEM AREA TO WHICH IT HAS ACCESS, AS BUILT. MAY 20. 2005 � � NORTH SHORE SURVEY CORPORATION 2 OS 14 BROYM STREET - SMEM, MA JQ4r 0AEG. PROFESSIONAL LAND SURVEYOR 0 EXCLUSIVE USE s I P-oaM BEORDOM 6ED � 19 BATHROOM CL MAIN EN Elec 11 9y /� r I� hl.s V+ 10(4 01, UNITARE �L� Ff S�sTr j� 1089 i S.F. SEDWOM need �noXX f 1m �d.uv� n a4 ��'`yy//�yyy 99'1��yy'`g�p USE uthorit>h r,.p(CLUSI VE USE CITY of"'.1.1 FL A.' 'WECTION. Or.c;vi .. ...n WITH THE ME W04