12 POPE ST - BUILDING INSPECTION (4) No•,,57 City of Salem 3 e Jfer �
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APkJCATION
PERMIT TO BUILD ADDITION, YAUMMONS OR NEW CONSTRUCTIO
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Se mom OWA* NTATION FOR THE ABOVE MUST BE ATTAO*D.:
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CONSTRUCTION T ETERQ1f inO.BECOMPL _ fof)wMnoa Mom
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I hereby cat*MM me proaotie WO*b a e odredby ft owrts d ieaad and dat I hM Dean etUtor¢ed by nr owner to maNt this appYrseon
as his aift w am%aho we to Can u p ON moicam laws at tft urad{Cbm
e at appGcera Aftm` ,/ 5 5/9✓ ✓1 y ¢ ar9O6 / e
ne Commonwealth ofMassamuseas
Department of IndustHdAccidents
Offim of InvenVadons
600 Washington Sheet
Boston,MA 02111
wwidmas&SOVAN
Workers' Compensadou Insurance Atlidavit: Builders/Contractors/Electrician&4%mbera
Please Print Legibly
ApoInInA Intormatio p
Name CHS&A 6• 45r�vcTi �NG
Address:
City/SAP Phone#:
err Check the approprhste box: of project(r M��)'
r(3
n�� 4. I am a general contract�r and I
a employe with 6. ❑New oonstrucd0n
loyees(�and/or put time).• have hired e a s edhed sbe ft s T. Remodd6ng
listed on the attached sheet=
a sole proprietor or Partner' .These sub-contracton have S. ❑ Demolition
and bave]b emploYca workcsiV comp.insurance. 9. ❑ Wiling a&Vdon
wonting for me in any caPWiLY- 5. ❑ we area corporation acid its
Mregn�en' �,insurance 10.�Eicctricai repairs or additions
officers have exercised their or addition
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs
.. c: 152,1 1(4),and we have n0 12.0 Roof repairs
b eea. (No worketa13.
insurance oregaiied.]tamp employees-
m cp iosurance required] Li Other
wok
v�Y.p and plicati that eheala box 01 nut abo fill out the nodoo lx>�vrak mdffien ima oo�sde,' ooutnetms mint abmit a my affidavit bdi�g such
t glomeowuett who abort thin affidavit htdiedhoa They dome
:Contraclon thtd.check thi,box nut etteched toaddib=W,heck gwwba the ran of the wb-w tradora Hair en' Poli
cy es'mfornubm
law a estPloy
a that isP roWdhrg workers'eonrpsnsafon b urdnee for sty emp/oyeea Below it the polq x"Job site
bnforar.riea. f�sou D�,�rvt7 J��S 00.
Insurance Company Name:
Policy#or Self-ins.Lie �2�� I5' Expiration Date: o� U
p�1� S 1 Sxleo A-46 City/StatefLip:
Job Site Addrds: ��- i7
declaration page(showing the policy number and expiration date}
Apach a copy of the workers compesntios policy ea of a
Failure to scare coverage as*W°II0d trade Section 23A of MGL a 152 can Iced to the
the form of aositi011 Of criminal STOP WORK ORDER and a fine
fine up to$1,500.00 and/or one-year imprisonment,as well a•civil penalties
of up to$250.00 a day against the violal01. Be advised that a copy of this statement may be forwarded ib the Office of
Investigations of the DIA for insurance coverage verification.
I As herby ce►tlJj'under the pins dudPend&m ofXrJwy dW the hrfore ddpx ProvUtJ b true and correct
1�-
M 79 J.33 - Vry9 -
OAMI rue dni,K Dd dot wrbe hr tj*"4 to be c*#WkId 0 e*or town oakW
City or Totes: ��� PermkR leeme M
Insular Authorky Jairek one):
I.Board of H 2. ttflding Department 3.Ckyll'owa Clerk 4.Electrical inspector S.plumbing Inspector
6.Other
Contact Person: Phone N:
.L1aa Va aalea6aVaa feral star >.anAba aa%,6aVa1A
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees,
Pursuant to this statute, an eaVloyee is defined as"...every person in the service of anotber under any contract of hire,
express or implied,oral or written."
An employes a defined as"an individual,parmasbtp,assoaado%cotporation 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 anployer,or the
receiver or trustee of an individual,partnership,association or other W entity,empkrying employees. However at
owner of a dwelling louse having not more this three apartments and wbo resides therein,or the ocapaot of the
dwelling house of another who employs persons to do maintenance,consnucdon or repair wort on such dwening house
or on the grounds or building appurtenant theme shall not because of such employment be deemed to be an empbycr."
MGL chapter 15Z 125C(6)also states that"every state or local beemteg agency shalt wftbbdd the Issuance or
renewal of a Mcense or permit to operate a business or to eose tsmet buildings In the commonwealth for any
applicant who ban eat produced acceptable evidence of compliance with the hu oranee coverage required.-
Additionally,MGL chapter 1S$125CM 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 issuuaoce
requremmts of this chapter bave bem presented to the contracting aathoritji."
Applieants
Please fill out the workers'compensation affidavit completely,by checlmg the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(sl addrcsa(ea)and phone number(s)along with then,eatiflcate(s)of
imurzom Limited Liability Companies(LLQ or Limited Liability Partnerships(I.I.P)with no employees other than the
members or pumas,are not minired 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 Deputmi at of Indosttial
Accidents for confirmation of insurance coverage. Also be aerie to sign and date the affldav& 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 ifyou are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured compania should enter their
selPfimuance license mrmber on the apptopiiate tine.
City or TOM Ofseiale
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 full out in the went the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the pamittlieense number which will be used as a reference mmtw. In,addition,an applicant
that must submit multiple permiUticense applications m any given yew,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in i (city or
town}"A copy of the affidavit that has been officially stamped or,narked by the city a town nosy be provided to the
applicant as proof that a valid affidavit is on file for there permits or licenser A new affidavit mint be frilled out each
year.Where a home owner or citizm is obtaining a license or permit not related to any business or commercial verare
(i c. a dog linen or permit to burn leaves etc.)said pasou is NOT required to complete this affidavit
The Office of Investigations would Bite to thank you in advance for your coopastiou and should you have any questions,
Please do not hesitate to'give us a call.
The Department's address,telephone and fan number;
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investlgatlom
600 Washington Street
Boston,MA 02111
TeL #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2ti-os www.mm.gov/dia
wr
f DEC-119-2005 07:50PM FROM-Structures North 19787456067 T-760 P.001/003 F-894
, f
STIUCT NS
,
NUT4
60 WASHINGTON STREET, SALEM, MA OV70 CONSULTING
PHONES 1478.7"17 FAX IJM745-W ENGINEERS
4
To: Building Department,City of Salem
Attn: Mr,Thomas Saint Pierre Building Fax#: (978)740-9846
j Commissioner
From: Edward Moll,P.E.
Re: Salem Heights Apartments
CC: Mr.Bradford McIntire,Corcoran Jennison,
(978)744-5616
V Data: 9 December 2004 Pages: 3,including transmittal
Ii nn
�.... Hagen, ❑FarRedew ❑AeRegttested ❑Pleesecomment
I
Dear Mr. Saint Pierre,
The attached letter will hopefully address your concerns for the damage caused by Salem Heights
Apartments being struck by a pickup truck last Saturday.
Upon arrival we determined that the condition that the building was in due to damage by the vehicle was
an imminent life-safety hazard.
The contractor,building management,and Structures North acted expeditiously to address the hazard, and
f the attached letter details this effort.
Please contact me immediately should you have any Farther concerns.
Regards,
,
Edward Moll,PZ
i
Pagel of 1
I
............
07:50Pld PROt9-Structures North 19767456067 T-760 P.009/003
STAU F-894
GUAIS
N OAN
CONSULTING
ENGINEERS,
9 December 2005 INC.
Building Department
City of Salem
120 Washington Street
j Salem,MA 01970
Fax: 978-740-9846
Attention: Mr, Thomas Saint Pierre
Building Commissioner
1 Reference: Salem Heights Apartment, Salem,MA
Emergency Stabilization of Damaged Brick Veneer Wall
Dear Mr. Saint Pierre,
� We received a phone call (torn Phil Casella of Casella Construction of Saugus on Wednesday
i morning the 7th of December. Phil indicated that a ear had struck the base of the 10 story brick
veneer exterior of Salem Heights Apartments off of Pope Street in Salem. Phil requested that I
observe the damage and make recommendations for stabilization and repair. Following is a
detail of site visit and follow-up:
Salem Heights Apartments was reportedly struck by a small pickup truck some time on Saturday
the 3rd of December. The damage was to the east end of the south wall of Building B which is a
10 story brick veneer apartment building. The truck took out a center Y-2"wide brick pier
between 6'-0"wide punched stacking window openings. Upon initial examination it appeared
that the brick veneer extended the full 10 stories above us unrelieved. This was confirmed by
examining drawings provided by Brad McIntire, the building maintenance superintendent. The
drawings by Smith Sellew &Doherty Architects and Engineers,dated January 17, 1976, clearly
indicated that the brick veneer was unrelieved for the full height of the building.
We determined immediately that the masonry could not be safely stabilized by the timbers that
the contractor had on hand, and discussed various shoring options. We decided that a shoring
contractor should be brought in as quickly as possible to stabilize the building fagade. Casella
Construction then cordoned off the full width of the affected exterior bay of masonry out to and
beyond the parking area. I contacted Isaac Blair Shoring and Rigging Contractors of South
j Boston, a-mailed them the photographs of the damage,provided them with the shoring loads, and
i helped them to work up a materials list for the shoring implementation.
60 Washington Street, Suite 401 • Salem,Massachusetts 01970
Voice 978.745.6817 • Fax 978.745.6067
www.structures-north.com
DEC-09-2005 07:51PM FROM-Structures North 19787456067 T-760 P.003/003 F-894
Salem Heights Apartments 9 December 2005
Salem,Massaehnsetts Structures North Consulting Engineers
Isaac Blair Shoring Contractors arrived on site at 9:15 AM Thursday December Sth and began
the shoring installation. The shoring consisted of(4) 2'-0"x 3'-0" shoring towers with S8 x 18.4
needling beams. The needling beams picked up the steel angle lintels on either side of the pier
that was taken out by the pickup truck.
I returned at 1:30 PM on December 8th(that afternoon) to confirm that the shoring was in place
and complete and that the brick veneer exterior was stabilized.
We are now working with Phil Casella to develop and implement the permanent repairs to the
brick veneer pier that supports 10 stories and 15 tons of masonry. This letter is intended to
confirm that the building is secure and that the shoring that is now in place has addressed the
public safety concerns.
It was an excellent call on the part of the City of Salem to request that a professional building
design consultant be brought in immediately. The hazard due to vehicle damage to the brick pier
that supported 10 stories of masonry above was very significant and imminent.
Please call immediately if you should have any questions regarding the information contained in
this letter.
Very Truly Yours,
j Structures North Consulting Engineers, Inc.
P
{ Edward H. Moll II, E.
Principal
I
I
2
I
I
CITY OF SALEM9 MASSACHUSETTS
* PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978.745-9595 EXT. 380
MAYOR 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.
n/The debris will be disposed of in:
Am Pg fLZ LEA.) S'' f5 (Location of Facility) / R1
Signa a of Applicant
_j 46't-� -
Date
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