48 PRICE STREET - BUILDING INSPECTION i
��,
\ PUBLIC PROPERTY
57�J'O�
DEPr1RTNIENT
AIMBERI.6Y ORISCOLL
MAYOR C� / 1?0 WASHINGTON STREET#SA Eu ,MAssAcHLsLrM 01970
To--978-745-9595*FAx:978-740-99"
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: 48 Prince Street Building: Three Family
Property Address: 48 Price Street
Salem, MA 01971
Property is located in a; Conservation Area Y/N N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Ownerof Land 48 Prince Street, LLC
LAddress:
% Kenneth DaLLAMORA
11 Fenton Street, Framingham, MA 01701
17
one: 'S08 326 5438
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing Three
Renovation xx Number of Stories Renovated One
Change in Use New 0
Demolition Existing THREE
One
Approximate year of 1920 Area per floor (sf) Renovated
construction or renovation 0
of existing building New
Brief Description of Proposed Work:
Repair third floor ceiling to correct past water damage due
to prior roof leakage,
Mall Pennitt0: Peter Capra, P.O. Box 8515, Salem, MA 01 971
s
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? C S Asbestos?
Architect's Name
Address and Phone
Mechanic's Name « /fit
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee$d"a Estimated Cost X$7/$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 Permit to build to the ab stated
specifications. Signed under penalty of perjury
/Date 06
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Kwam"MWOLL
MAYOR 120 WasHzwoN SmtM a SALEK MAMCtiU58 M 0IWo
nt:979.7459595 a FAx:978.740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricimus/Plumben
Applicant Information Please Print Legibly
Name Organiat BusineW ott/Individual): 48 Prince Street, LLC
( i
Address: 48 Prince Street, P.O. Box 8515, Salem, MA 01971
City/State/Zip: Salem, MA 01971 Phone#. 508 326 5438
Are you an employer?Cheek the appropriate box: Type of project(required):
1.� I am a employer with 4. ❑ 1 am a general contractor and I
employees(full and/or part-time).* have hired the stub-contractors 6. []New construction
2.❑ I am a sole proprietor or partner. listed on the attached sheet.t 7. Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. g, Building addition
(No workers'comp. insurance 3. EkWe ate a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§I(41 and we have no
insurance required.)t employees.[No workers' 12.❑Roof repars
13. ]Other Replace damage
comp.tnsterance requued) 1 i n g
-Any WPilosw tut checb ban#t gnat also w an the netlon below showing tbeir watkem' ngo
y Poke i
t Homaowness wbo submit slob alMevk mdlatng they am doing as wodd end th®has mums connsaw check We box ti Read a"stthmR a mw eAldavk vk md sash.ketlng tCoaftch n ed murt d an eddidaeel shmt showing the acme of the mb.coumm"a and tlu4 wahine'pomp fo intbsta roc
lam an employer that Ls providing workers'compensation Insurancefo►my employees, Below Is the polley and Job ske
informatiow, N/A
Insurance Company Name:
6730707
Policy#or Self-ins.Lic.#: Bldg # 00195, Home Improvemenpba7U".4 10/11 /08
Job Site City/State/Zip:
48 Prince Street Salem, MA 01971
Attach a copy of the workers'compensation policy declaration page(showing the policy number and exp
iration 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 S1,500.00 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 DIA for insurance coverage verification.
Sdo hereby comfy ender t!u and ojperfary that the information provided above Is dad and correct,
ianature• 08 Dam 11 /29/06
508 326 5 38
Phone#:
FAuthority
y. Do not write in this area,to be completed by city or town q(ylclaL
Permit/License#
ity(circle one):
lth 2.Building Department 3.City/Town Clerk 4. Electrical Inspector s.Plumbing Inspector
Contact Person: Phone#:
Information and Instructions
for their employees
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation
Pursuant to this statute.an employee is defined as"...every person in the service of another under any contrail of hire.
express or implied.oral or written."
r is defined as an ndual,partnership,association,Corporation or other legal entity.or any two more
An esrploye " individual. of a deceased employer.or the
of the foregoing engaged in a joint enterprise.and including the legal representativesto employees. However the
of an individual,partnership,association or other 1ega1 entity,emp Ping
receiver er trustee not more than three apartments and who resides therein,or the occupant of the
owner of a dwelling house having construction or repair work on such dwelling have
dwelling house of another to pawns to do maintenance. be deemed to be an employer."
or on the grounds or buildingappurtenant ppurtenant thereto shall not because of such employmentfoyer.
MGL chapter 152,§25C(6)also states that"every state or local ikemsial agency shall withhold the Issuance an
renewal of s neea$e or permit to operate a business or to consu nct buildings In the commonwealth for stay
acceptable evidence of compnaaae with the insurance coverage required."
applicant who has not produced
Additionally,MGL chapter 152,12SC(7)states"Neither the commonwealth nos any of its political subdivisions shall
coerced for the performance of public work until acceptable evidence of compliance with the insurance
enter into any have been presented to the contracting authority."
requirenenm of this chapter
Applicants
affidavit completely,by checking the boxes that apply to your situation and.if
Please fill out the workers'compensation hone number(s)along with their certificate($)of
necessary,supply mbcontrsotor(s)name($),address(cs)and p with no employees other than the
insurance. Limited Liability Companies(L.LC)or Limited Liability Partnerships(LI P)
to carry workers'compensation insurance. If an LLC or LLP does have
members or partners,
re not advised that this afn&vit may be submitted to the Department of Industrialemployees,a policy 4in� Also be sure todn
sign and date the daviL The affidavit should
Accidents for confirmation of msttrance coverage.
tea 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 questicos regarding the law er if you an required a obtain a worked
compensation policy.please call the Department at the number listed below. Self-insured companies should eater their
coin ►ine
self-insurance license tmmber on tha
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 evens the Office of Investigations has to contact you regarding the applicant.
Please be sun m fill in the permiNlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple petmiVh ense 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 has been officially stamped or marked by the city or town may be provided to the
is or licenses. A new aft,dhWE must be filled out each
applicant as a home
that a valid affidavit is t file for future of permit
not related to any business or commercial venture
year.Where ehome owner or citizen is obtainingi license is to complete this affidavit.
(i.e. a dog license er permit to bum leaves etc.)said personcqu>T�
ou in advance for your cooperation and should you have any questions,
The Office of Investigations would like to thank y
Please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of MM11chusetts
Depuftneat of Industltal Accidents
Office of Investigations
600 Washington street
Boston,MA 02111
Tel. #617-m-490o ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26.05 www.mass gov/dia
i�v� ✓�a tOomvrremeuieaCl� a�/O(.aed¢e�ut,Iv,��
+\= Board of Building Regulations and Standards
License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 117484 Board of Building Regulations and Standards
s. Expiration: 10/11/2008 One Ashburton Place Rut 1301
Type: Private Corporation Boston,Ma.02108
DALLbMOR�BROTHERS CON.,INC -
KENNETH DALLAMORA
17 FENTON ST
ca t1.a _✓ice / �
FRAMINGHAM,MA 01701 Deputy Administrator Not valid without signature
�omvnwmroeall�9✓l�.aalar/H/aeQ2
BOARD OF BUILDIN REGULATIONS I�
_icense CONSTRUCTION SUPERVISOR r
i Number CS. 000195
BIrthdate 06/30/1939 /y
Expires i06130/2007 Tr.no: 11556
1, Restricted 00 i.
KENNETH G DALLAMORA� e:"
17 FENTON ST n 9
FRAMINGHAM, MA 01701,
Commissioner
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CTI'Y OF SALEM
' PUBLIC PROPERTY
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DEPARTMENT
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