16 PROCTOR ST - BUILDING INSPECTION +, 4-f. r= hC131 .IC PROPI �.R'f1'
- 1211AA XylU;.lu,%Jlltl l I ♦ ?V: '.I,AI'.»A III >I YI-n10 II
111 9-8 -li ')i'li ♦ 1'\\ 9-14--411 0846
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: :Ik lic:mt.s must complete all items on this page
SITE INF0JCNI,%T ON
Location Name ^Y --I'?/0, 1, Building ay-1
Property Address
Located in: Conservation Area Y/N J Historic district
APPLICATION DATE
Use Groups
(check one)
Group Humes R3 Ra_
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) R1 _
(check one) - Assembly (Theaters) Al _
New Building_ Assembly (restaurants & clubs) A2r_A2nc_
Addition Assembly (churches) Al _
Alteration Business B
Repair/ Replacement_ Educational E_
Demolition_ Factory(moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) If _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile M _
Sturaee SI _Moderate Hazard
SturaEe S2 Low I Lizard
(I\%NERSIIIP INFORNIA I'ION(Please type or Print Clearly)
OWNER Name &&I-i/f EMbDSs/ vG- Cao2P•
Address %- VARAta Y S7' Stv1-,e rl
r
Telephone 7 — 5/ G O 6
Signature
DESCR22ION OF R'OHR TO BE PF.RFOPoNIF-D .
!/�NvG SfdrNr,
1•S I V%L%1'I?D CONSTRUCTION COST e2-
/4 0
CU\'I'ILA CT Olt [NI.OR>IA'l'Rri
Name J
Address Y /tliiG
Telephone 97Y-62/- `132-7 / / 9y�,
Construction Supervisor's Lic # (',
Home Improvement Contractor # /2/2 d2-
ARcurr -UPENCINE'ERINFORMATION /� 6"��'l
Name
Address 57 /t1/!t Ate xaw L Ni9$1
Telephone
Mass. Registration #
PRunuT t•ET CALCut.A•rtoN
Estimated Cost x $11/$1,000 + $5.00=
CorotnuENTs
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the pens 'es of perjury
Signed (owner) (agent)
APPROVED BY : Cfa^'✓J
DA I E. APPROVED: //
CITY OF SALEM
�;.. PUBLIC PROPRERTY
DEPARTMENT
SIALLI aSAtr vt,kfv.%%% In ,t II,JIhTe
I f.l. 'irl 7li-•t 01 tx 97x 74, +a46
Workers' Compensation Insurunce liffidu.ii: Ifuildcrs/Contractors/Electricians/Plumbers
11iLJnt Inforinrlim (/ Plcase Print Leeihlv
NIIITIdlllualwst)r�]cn/vAnnlVlnJlv,luull: DOsy////�/vr�FI
C I 1 y.S to tc.%i p I'hunr
Are)ou an employer?Check the appropriate box: I')pa of project(required):
1.❑ Ian ampluycr with 4. ❑ 1 :un a general contractor and 1 6. Q New rucuun
q,lop ces(full and'ur part-tune).• hate hired the suh-contracturs 7. ernudeline
2. I sun u sole pmpricux or partner- listed on the anached sheet.
ship:llttl leave pr ctor or pcs These sub-contractors have S. ❑ Dentolitioll
working file me in any capacity• workers' comp. Insurance. 9, Q Building addition
Inn workers' comp. insurance 5. ❑ We are a eniporation and its
I rcg it h J
ofticcrx have exercised their 10.0 Electrical repairs or additions
ri ht of cxcm Lion r hIGL 11.❑ Plumbing regain or additions
3.❑ I ;till si ho o %vorkr s' col all work c 5152, §14),Pnd we have no
myxlf. [No workers' cuntp, h ( 12.❑ Ruuf repairs
insurance required.] t cmpluyecs. IKo worker' I J.❑ Other
cmnp. in,urancc ruquircd.J
•cn. .,gthcud dial checks box 01 must:Jsu till WI the yawn Iwhlw diowuty Ilwa wurkaos curs,pun aWiwr,whcy mliamatit
' I IummrW rwn Who udlmil this afflJavit indiuuna IN)am Joint'all WQrt ared then him Wlalde CNtrraxiom moat submit a new llridavil indi tnlx 4rch.
-r.wewtra,Thal check this box mtuo altxhad..n aedaionaf.shoal,huwina the nmw of the oab-contrxtorn and'heir wurkon'comp puhey mrurtnannn
/ono us, employer that It pruviding ovorkers'rampenvation hosurance for ray enoplaiwes. Below is the pu/iey and jub.ire
injurmatiaa
Insurance Company Name: _-- - -- -
1'olicv a or Sclf-ink. Lic. rt: _".. . . -_ Expirallun D,ue:
Job Site -\ddrass: Ctty:StaluZtp.
Attach at copy of the workers'cuonpcntatian polio) declaration pane (showing the policy number and expiration date).
Fadurc to ,ccury coverage as required under Section 25A of>WL c. 152 can lead to the imposition of criminal penalties of a
tine up he il.500.00 and/or une-pear ineprisnnmcnt, as well as civil pcnultics in the futin of a STOP WORK ORDER and a fine
Of up to i25o n0 o Jay .leainst the violator. lie advised that A copy of Ihu slaicmcat may be forwarded to the 011icc of
I nt:aigalnnb ui ',hc OIA :or ul,a'JIICe ancar�c eel ilia aCun.
/do hereby t:rtiw 'der doe p.rinv and penaltiev of perjury that the uofunnoo/fan provided above is true and correct.
DAtc_-- Y
t)//iriul rue unly. /)a tat smite in this area, ru he tunoplered by toly ur town u//itial.
(-ilv or (own: __. _—. Pct init/Licc rise 0
1„uing %uihurity (circle onc):
I. 11oard -if IIcalth ?. Ihuldiu;} Ileparuncut 1. Cih."lotto C'Icrk J. Lla•Ancal lu.pcctur :, pluwbint; lavpccwr
b. Il0wr _
('tonal l'crwil: .. Phone It:
Information and Instructions
�Liss.i.hu..cm Ui ncral Laws chapter I i2 icquires all :ml)lo>crs to pro%lde %vorkers' compensation for their enip loycCs. )
Punu.ml to Ells .nature, all rmphuoee is dclined is " every poison in the service of anutiier under any contract of hire,
t%ptees or nnpbcd. oral or written r
An :mpluJ•rr is defined as "in individual, partnership, association, corporation or other legal entity, or any two or more
.a the loregoo;g engaged �n a pint cnicrpnse, and including the !cgil representanvcs of a deceased empluycr, or the
rccener or trustee or .oi utdivndual, painlcrahrp, association or other legal ennty, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the
daclhng house of another who employs persons to dia maintenance,construction or repair work on >uch dwelling house
or on the-,rounds or budding appurtenant thereto shall not because of such employment be deemed to be in cmplo)er."
>tGL chapter 152. §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal alto 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."
\ddiaunally. NIGL du ipter 152, 425C(7)crates "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of puhlic work until acceptable cv idcnee of cunnpliance with the insurance
requirements of this chapter 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 itib-contractor(s) nante(s),address(es)and phone number(s)along with their certificate(s)of
mswance. 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 duce(he affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Uepartment of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain is workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
sclr-insurance license number on the appropriate line.
('sty or Town Officials
PICasc be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of file affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'l;asc be sure to fill in the pennitilicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit liccitse 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 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
(,e. a dug license or permit to burn leaves etc.)said person is NOT required to complete thii affidavit.
I h: i)mice of Inyesfi-,anions would ll; c to thank you in advance fur your cooperation and should you hays aary questioui,
please do not hcstrare to give us a call.
ncc Dcp.uancni's address, telephone and fax number-
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. q 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
e:•.:>;d .ui www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I t i s v'N -4;.');�r; • I X: ':7N 'a}'AS44.
Construction Debris Disposal Allidavit
(reeluired lbr all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Dcbris, and the provisions of NIGL c 40, S 54;
Building Permit 1f is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
14 6 L& C id c Q4xT1 N c--
(name of hauler)
I he debris will be disposed of in
(name of facility)
(address of fanlitv)
signawre of permit applicant
— date --