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RILEY PLAZA PARTEING - BUILDING INSPECTION -FCA fAe&V42-1 -CL4 qj 44sl Crly ()I-" S m,f-?"vf 1 PUBLIC I ROPIAl- 'Y';z 31�rl- , ngw V� DEPARTN/lENT 120W\:;11M.1...SIR' I I I )7S-7 t5-951115 F APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS [IMPORTANT, %pplicarus must complete all items on this page SITE INFORMATION Location r-lk - 0 12," ��0, NeLOS,�"L�n- Building Property Address- KUv1e-!4 P-i�lZr, Map# -2 Located in: Conservation Area Y/N—Historic district YiN Use Groups (check one) Residential(3 or more Um its) R21 Type of improvement Residential (hotel/motel RI (check one) Assembly(churches) Al New Building Assembly (nightclubs etc) A2_ Addition-- Assembly(restaurants,recreation) A3 Alteration V;P, Business B Ae LOS Repair/Replacement Educational E Demolition Factory(moderate hazard) FI Mov&Rclocate Factory(low hazard) F2 Foundation Only High Hazard If Accessory Building—_ Institutional (residential care) It Other(describe) Institutional(incapacitated) 12 Institutional(restrained) 13 Mercantile M Storage(moderate hazard) Sl — Storage(low hazard) S2— OWNERS111P INFORMA-1[ON(Please type or Print Clearly) OWNER Name Address Telephone DESCRIPTION OF 'D -a- L I r-va t, x; SE,0 Ce-1, ye 3 t."( 11 Ik i-,00 ESTIMATED CONSTRUCTION COST IV os14,4 0? 1755) So�Se CONTRACTOR INFORMATION Name IM0.t }L QC �\ V�- $ Address 41 7 D V e-H pto k t— ft�arbLei.ec2 01 " Telephone -44 71 q Construction Supervisor's Lic # r 5 ` 07 9e/:5j Home Improvement Contractor# ARCHITECT/ENGINEER INFORMATION Name Address Telephone Mass. Registration # i dr PERMIT FEE CALCULATION y Residential est. cost.x_`67/$1,000_+ $5.00= Commercial est. cost x $1,1L$1,000 + $5.00= 4 , COMMENTS ��,s , s a. c o v-x w. iwv,4+y Qta�e��-- ol�n�eer The undersigned does hereby attest that all information stated above is true to the best of my knowledge under the penalties of perjury Sigtte Dat o '"mac _144L CITY OF SALEM PUBLIC ['ROPKERTY DEPARTMENT Norkers' Compensation I1'sullance .�1'tidacit: Buildens/Contractorsi Electricians/Plumbers Please Print Legibly t )liiant Information N.III1C .Itu.r.m.. 1 h;_an Valn.n ln.Lt,.Iu.JC / -t CL�/� Will-ess Ca) State Zip: vlA l of Cl e&.0 kt1 ©199-f Phone 1. tire you an employer:' Check the appropriate box: Type of project(required): I I ant a entploy'er w ith g 4. ❑ 1 on) a eneral contractor and I b. New construction ❑ ❑ cnlpluyces (full and'ur part-time).' list a honed the ached t,hee WfS listed on the attached sheet. 7. [�RemuJeling ' I on a sole proprietoror partner- hp and have nonu employees loyees I hose cob-contracwrs ha+e 8. ❑ Demolition o+orking for me in any capacity. workers' Bump. insurance. y. ❑ Building addition [No workers' cutup. insurance 5. ❑ We are if corporation and its 10 ❑ Electrical repairs or additions required.) olficers have exercised their n ht of exem Lion per MOL I I.❑ Plumbing repairs or additions 3.❑ I ❑m a homeowner cluing all work g p myself. [No workers' comp. C. 152, y 1(4),and we have no 12,❑ Roof repairs insurance required.) t employees. [No workers' 13.0 OtherT Sic+--s6✓� comp. insurance required.) It •:\ray apphcant that checks box NI 11111A also fill out the sectmn below..hawing their workers'cumpensaiun policy inturmalion. ' I Ion la-Uwncrs who Submit Ihl9 affidavit it Indicating they are doing an work and then hire outside contractors mLLlt)Obmlt anew aftldaV II Indicating such. ('•�nvacmrs rbar.'heck this box nlu..t attached an add ...nal t heed showing the name of the sub-contractors and their workers'comp,policy information. I ant an employer that is providing workers'rompen.sation insurance jar)ray employees. Below is the policy and job site information. Insurance Company Name: Policy q or Self-ins. Lic. $I: Expiration Date: Lob Site Address: City State/Zip: .%ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). failure it) secure coverage as required under Section _'SA of NIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S l jo0.mt)and'or one-year Imprisonment. as well os ci+tl penalties In the dorm of a STOP WORK ORDER and a fine nl till Ito l_'Jl)00.1 d.ly d_l'allbt the +tolatnr. lie ads Ised that a copy of tllls statement Inlay be for\+'arded to the Othee of . In`c+n•_.um rats of the DIA Gor insur.ince cotcrlge ,cnlic:mon. 1 Jo hereby :ertili' under the pain+ 11tai petraltiev of pc•pary that the ur/orrrwnou prurlded ohud a rs true and a orreet U//iriul a)e snip. no not it rite in this area, to he a'antpleted by riry or town oJjiciaL ( il+ or town: -. - ._ I'ermit/Liccme q - . _ _ _ _ ... _._ 1++uin4 \uihority' Icircle one): I. Board nl Health 2. Building; Department 3. ( ityr rnwn Clerk 4. Electrical In+pechlr 5. Plumbing In+pretor b. other -- -- - ---- - - - ('Intact Person: __-- Phone d:_.__ .--_---- 1 Information and Instruction's \I.t—I,4u,cn, tJcncral l .iw,chaptcr I �_ rvquu c, all cinplotcrs to pros ide workers' cotopco,ation for nhet`nuplovces. n'o.uLi to ill ill eurploiree i, Jclined .is cl cn pet ,)it in die ,vtv ice of A;it icr uuiler it cowract•ol 11i iie. or mp!icd. oral or wtitien rnploi er i, fell tied .i, � to fid] dual. I'.n u:crn1111r. .1„00.11t011. :orporanon or other !c__at cunt%. or .sty two or more ,•I the to a iolin cutcipn.e. dnJ in:luJnie the le, al Of dccc.t,ed ctnplo�er. or the cner of uu,tcc ot.ut 111J1\iJual. p.utncrnhip. i,„octanon or otter Icgal ciint s. 'undo-\nlg cnlplocce., I IOw ev er the ,,•.s ncr or .1 Jwclllog hJLiSe h.ry ing not :more than nhrc•e .iflartincnts and tsho trade, tlicrein. or the occupant of the Jwc ling h,m,c Of i nnher who cmplo" person, to dO nt,u acnance, con r-taoion or rcpair Durk on ,Lich dwelling house ..r „n the grounds Or hudduig ipputten.uu thetcur .11.111 not hecau,e Or o%:h cini lov nicnt be deemed to he an eniplo}er. \1(.I. chapter I�', C'�Uo) also .ate, that 'c%cry state ur local licensing agency .hall ssithhuld the issuance or rencss of of a license or permit to operate a business or to construct buildings in the contmonstealth for any applicant who has not produced acceptable evidence of compliance with the insurance cu%erage required." \Jdmonally, .%I(iL chapter IS 2, 42 ( I-r ,rates "Xeidicr the cotnniunwealth nor any of Lis political suhJnutuns shall cuter into any contract for the performance of public work until acceptable es idcnce of wniphance with the insurance rcqurenicnts of this chapter hate been presented to the contraoing authority." Applicants n Please till our the workers' compensation affidavit completely, by checking the bores that apply to your situation and, if nee CSsary, ,upply Sub-culls rac torts) nainets), 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 dues 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 Industrial 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 nurnber list:;d below. Self-insured companies should enter their ,elf-insurance license number on the appropriate line. - City or Town Official Please he sure that the affidavit is completeand printed legibly. The Department has provided a space at the bottom Of the affidavit for you to till out in the event the Office at Investigations has to contact you regarding the applicant. Please he sure to fill in the permit,license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license 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 (ci(y or town).- A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the .Iltplicant is proof that a valid atfidavil is on the for future permits or licenses. A new atfidavit must be filled out each >car. Where a home owner or citizen is obtaining a license or permit not related to any business or conuncrcial venture i i e. a Jog licen,c or permit to burn leases cue.),aid person is NOT required to complete this affidavit. Ilie t niice of Investigations would like to thank \ou in advance fir vour cooperation and should you have any questions, plane Jo nol hc,ualc to give its a all I he Dcp.0 nncnt', address, rcicphonc and tax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021 1 1 Tel. 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Sk CITY OF SALEM PUBLIC PROPRERTY ` DEPARTMENT • �7'AK i!�� •I` 12, A'N'I II\i SIR I:,'T ♦ }.\1I \I. \t.\,i i .i I 171: v.'8 -.t;-'Fv5 • I-\Y: 978 'a.:9.44+, Construction Debris Disposal Affidavit (required lur all demolition and renovation work) In accordance ith the sixth edition of the State Building Code, 7S0 CNlR section 1 1 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit It is issucd with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c t 11, S 150A. The debris will be transported by: c l name of hauler) 1'lie debris will be disposed of in (mmlir of facility) laddress of facility) signature of permit applicant - __—T—T date J'a