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14-16 PARK ST - BUILDING INSPECTION - AM— — Dme M hourly Low"In to Ntdwb In- , ' 'I am"Al" r P"MIN Lma d In IMCI AWWAI11ANO Y.L.No. gU LDMn Pl AVr APPIdCATM POft Poft ox Deck 1Md, Pool. ('�IOId MAllOhalNr apply) gyp'PapaWR@Pkm /rt o c� i Oyn S P &ka PILL OUT LEttI LV A CMKXMV TO AVOW=AV$IN PMOCIOMI TO THE INSPECTOR OF RM DINtdS' The wldarsipnad hm W apply for a pKnk to bind a000d% to the foMowitp O~sName Ya I)c IN ucltn+1O Address 6 Phone IaOo sgLe,� sr %�/ 117t 77 7a5 Amhbct's Name Addrou& Phone . 1 Meftnics Name Address i Phone No is the pom it twl~ / ,"h oC&tt h�mom a a~ I a one ft for now WAN ' �— wo bAdm ardrm to ba A eoMM@d cool A?o_ Ck UMM 0 � °` dw. • Q Ida. x 2s' Slab Mm yw pw"TY OPPMULMY �0 oP.NCRwrION oP wf�wc TO OF /DRONE J�mock e a 1�d//49rn-4 S tlm uc k lm O A Puck MAIL PERMIT TO� , No. & APPLICATION FOR PERIfT TO AaJ�tee�e "w . /�✓� y �r� .� Sees\ LOCATION 4 Ski 4-1 S J Ad PEF"T QRNffM OF BLUDIMM The Commonwealth ofMassaehusetts Department of Industrial Accidents OJ)iee of Investigations 600 Washington Sheet Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electiidans/Plumbers A licant Information Please Print Le 'bl Name (Busines`sprgat i ati/on/Mvidual)'. 192. q-,2 Address: /�� `(/� C USC Z/ City/State/Zip: Fi✓49t e/' , '14A o L Phonelk 7&1- cY5 S 33 o S Are you an employer?Check the'approprinte box: Type of project(required): 1.❑ 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 I am a sole proprietor or partner- listed on the attached sheet. t ?• 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 ezercis'W their' 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemptiou'per MGL' 11.❑Plumbing repairs or additions myself. [No workers'comp: c. 154§1(4`J;and we have'no . 12,❑ Roof repairs insuranceregnirod.]f. employees. [Noworkers' 13.❑ Other comp.insurance requred]' . *Any applicant that checks box pl must also fill out the section below showing their work na'compensation poHry,mfommtan: t Homeowners who submit&a�affidavit indicating they are doing all wodr and then h$e outside contractma tined subrmt a new affidavit indicating such. ;Contractors that check this boz must attached an additional sheet showing the name ofthr sabmntradots and their workers'amrp:policy information. I am an employer that is providing workers'compensation insuranee for my employee& Below is the poUcy and job site information. / /J Insurance Company Name: Policy#or Self-ins.Lia #: Expiration Date: Job Site Address: `/. —Ao /2,1/C S +" City/State)Zip: 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 cerdit r the pains etumpenaftles of perjury that the information provided above is true and correct Si ` Date: �S_ O O lire: Phone#: 3 30 S O,afcld use only. Do not write In this area,to be completed by clly or town offldaL City or Town: Permlt/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cky/fown Cleric 4.Electrical Inspector S.Plumbing Inspector 6 Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers tn 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 es. H C1.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 ter have been resented to the contracting authority." requirements of this chap P 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 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 Industriai'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 fisted below. Self-insured companies should enter then' self-insurance license number on the appropriate lino City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided as space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you re the applicant Please be sure to fill in the pemvt/hcense number which will be used as a reference number. In addition,an applicant that most submit multiple permittlicense 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 most be filled out each e or permit not related,to any business or commercial venture year.Where a home owner or citizen is obtaining a licens (i.e. a dog license or permit to brim 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 Deparanent's address,telephone and fax number. The Comtnonwealth of Massachusetts Depatment 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 5-26-05 www,mass.gov/dia CITY OF SALEM, MASSACHUSETTS • PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVIC2, JR. TELEPHONE: 979.743-9593 EXT. 380 MAVOR FAX: 978-740-9846 Salem Building Department 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: w (Location of Facility) x_ - v S Signature of Applicant Date ✓die tnamuiorr��',..✓� BOARD OF BUILDING EGULATIONS iI license: CONSTRUCTION SUPERVISOR i mber Nu C3y 062497 BirthQate 09I05F1958 a1g �Explres�09/0512 Tr.no: 11153 r - Restriaacte 00 ROBERT.) AANIEt �^ 2 8AUURNST0180 Commissioner i MOCIN I y W y to Site) I x4re ?#)' y mAkim .,ao g I C� • IJLC�.L o� i. r. 4 �d N Z I XLI .6X4x*4A • SIXII s AT a. NiTMtt�! G'a514'R4111�' •N tRSi119'4VR}t' :'»' �J'fYHnv^'.Y58ifapge:� i x.t ..':� x, AviWdt�TlU114Xi10�1r?NY� inns: >� Tfb'E'RmediiSl�WR I� 11 ' i 1 t ly a u.' R ' r MUM Iwo AL ',�A4�e87Ao5SSA67s' w-'��x— •.�' ..e .. o Hum i71f6wiPE6xJ �., ; • r• r 7.r t ►� u i ► , '1 A / r + Alk • • ► r 1 � r � J • NEI I rA , Am"WX7 �mr Man L P al L Id b ki `AA I XVi[ J. I Vr L CK, FLOORPLAN ALENTI 40 File No.: 30675G dfess:1416 PARK STREET Case No.: State: MA Zip: o1970 TEWAY FUNDING sl.a 1 BEDROOM BEDROOM BEDROOM BEDROOM BATN BATH NITCHEN MTCHEN b b ,e LEVEL 1 LEVEL 1 a DINING UNIT UNIT 2 DINING BEDROOM U ING ROOM LIVING ROOM BEIXi00M / 8IP BEDROOM BEDROOM BEDROOM O ® BEDROOM HADI eAni 14TCHEN MTCHEN 6 -y LEVEL? LEVEL T? DINING UNITY UNIT DINING BEDROOM LMNO ROOM IMNO ROOM BEDROOM B+.v NNUdows^' 1 ' AREA CALCULATIONS SUMMARY LIVING AREA BREAKDOWN Deacdptlon Size Net Totals 9reakdown SubtotaM first Floor 2091.00 2091.00 First Floor Beoond rioor 209i.00 2091.00 41.0 z 51.0 2091.00 1 8600nd Floot d1.0 : 5i.0 2091.00 1 =S�M{pIG � IlofUrKIR� �`I � �rd + IUuk� ck.{ CaH! /� / LtlVl� dLe I ANb] NrY S iix13 • E6R SS-'2 Di00 R r xiz U Itl�j ' y b22Z fit" ll � ii. AN 0 IT o a mil �: y t QI LI 4. lQD °a4 6� c� ® T �� 8xt �os s T T T I NDnW � r• r �• 'W41 ► cmKrpxmm k :u W IF ►`[� AV ► / . � \A r ' • • 10 Ll • iciw' FLOORPLAN /ALENTINO File No.: 30675G Idress:u-10 PARK STREET Case No.: U State: MA ZIP: 01970 TEWAY FUNDING 31.0' 1 BEDROOM BEDROOM BEDROOM BEDROOM BATH BATH KITCHEN KITCHEN b w LEVEL 1 LEVEL 1 b, a DINING UNIT 1 VNIT 2 DINING Y D � BEDROOM UVINO ROOM LIVING ROOM BEDROOM BEDROOM BEIMROOM BEDROOM © ® � BEDROOM 81 BATH BATH KITCHEN KTCHEN h -y LEVEL 2 LEVEL 2 4 OWING UNIT UNIT! DINING e BEDROOM LMNO ROOM WINO ROOM ®S� DS{D� BEDROOM 510 Rey��2n 1 AREA CALCULATIONS SUMMARY LIVING AREA BREAKDOWN Daacdpdon _ Size Net Totals breakdown Subtotals rirst rloor 2091.00 2091;00 rirst Fluor 840ond door 2091.00 2091.00 41.0 i 51.0 2001.06 Second Floor 1 41.0 z 51.0 2091.00