15 1-2 RIVER ST - BUILDING INSPECTION (4) a I'hc Cutnntumvcalth of'btassachusclts
� + [3oarJ ul'l3uilding Regulatiuns and StanJards ��TY
� i � ,n OF SALLM
n ��� (vlassachuset[s Strte Building CoJe, 730 CMR. 7 edition
�i � Krviard Junu�irt�
/ t3uilJing Pertnit Application�1'u CunsWct, Re ' , •novate Or D� olish a /� '�����Y
One-ur Ti�•o-Fumi wellin
This Seaio or OfTicial Onl
[3uilding Prrmit Numbe : Date e
Signalure: �I'Z3 6 L�
13uilJing Cummissiu er/I 1or uf i) 'IJinys Dale
SECTION I: SITE INFORMAT[ON
1.1 Property Address: s� 1.2 Assesson M•rp& Parcel Numbera
/,�} �i �ivC�'
I.la Is lhis an accepted streel'?yes_ no Map Number I'arcel Numlxr
*�» r�_.
1.3 Zoning Informatfon: �.1 Property Dimensions: '"
%oninb Uisiricf Propos.J Use Loi Area(sy�l) Prontage(fl) .
1.5 BulldinR SetbacW(R)
Pront YarJ � SiJe Yunls Re:v Yard
Rcyuired Pruvided Rcyuired Provided Reyuircd ProviJed
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Oulside Flood Zone'7 Munici al O On site dis sal s stem ❑
Public❑ Privule O Check ifyesO P PO y
SECTIOIV 2: PROPERTY OWNERSHIP�
2.1 Owner of Record: �
P��-er Escl�v�yisr %S�z /2iver Sf Ca/.:.,•,
'Nam Print AJJress for Service: �
97g- 59y 1�3g
Signa�urc 'felephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Buiiding❑ Owner-Occupied ❑ Repairs(s) ❑ Alterntion(s) ❑ Additioq.�
Demolition ❑ Accessory Bldg.❑ Number of Units Olher ❑ Specity:
Brief Description of Proposed Work': ^ Jw
R�G!`� ��� �dh �Fn� �:.�/ .ba/Nr/)Onn
SECTION J: ESTIMATED CONSTRUCTION COSTS
��`m Estimated Custs: Otlicial Use Only
�Labor and Materials
I. [3uilding S l ({ p p0,._ I. Uuilding Permit Fee: $ Indicate how f'ce is detertnineJ:
❑StandarJ City/Town Application Pee
2. Electrical S /S`DD, '— ❑Toial Project Cust'(Item 6)s multiplier x �
3. Plumbing .S ,Z 6—D D_ � ?. Oiher Pees: S
�. Mechanical (IIVAC) S List:
5. Mechanicul (Fire S
Su ression Total All Fces: S
Check No. Check Amount: Cash Amoime_
6.Tohrl Projeet CosC S
,Z 0 O D. " O Paid in Full ❑Outstanding Balance Due:
��d-tit,�To : "�a 1 `�'�s`r�r.ir..�- ,�,.� , ,'p� �,..�-vL�� t�`�-al
� �
SF.CTION S: CONtiTNUCTIOIV SEHVICES
5.1 Licensed Consfructlan Supervisor(CSL) � �� � �
Lp/ �rV C v,�� I �S I.icense NwnM:r Iixpi ��iun Umo
Nuns u(CSI.- I luldcj`� �1
/ !71 � •rL{p{ S'�reP� /'yVC ��IStCSLP)'PCI?CCMCIUW) i/
Tr Uescri tion
�k[Jress n� ^— U l;nrestrictcd u l0 35.000 Cu. PtJ
I�oi v� v e rS� � � 1�'T �t Restriaed I&2 Famil Uwellin
- tiignalur� M M�on Unl
. RC Rcsidcnlial Routin�Co��crin
l�rlcphone W$ ftesidemial WinJuw;uiJSidin
6 J � �_ ��—p�� tiF ResiJential SuliJ Fuel Uumin A li�nec Installmiun
-� / U Residential Demolition
5,2 Re isfered omelmprovrmentControcfor(HIC) �S-9, ���0
��— r r� C Regis�ratiun Numbcr
IiIC Compa�nY N:une or FIIC Regi �,^[ mn5
1�� /5.-0,o/r t-,-P e7 �t've t��q /i �
nddre _
�o�v, ✓�•r � �/�"" ���-p99 8r9s ���nDale
Signulure �fcicphonc
SECTIOIV 6: WORK COMPENSATION INSURAIYCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance afiidavit must be completed and submitted with this application. Failure to proviJe
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit A[tached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATIOIY TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT �
�, , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Si� W ure of Owner Date
SECTIOIY 76: OWNER�OR AUTHORIZED AGEIYT DECLARATION
I,� /5 �r�P vi ,� P S ,as Owner or Authorized Agent hereby declare
that the statements and inf'ortnation o the f'oregoing application are true and accurate,[o the best of my knowledge and
behalf.
Print Name
tiignaiurc of Owner ur Au�horizeJ Agent � Uat� 2
tii med under the ains anJ enalties of er'u '
(YOTES:
I. An Owner who obtains a building permit tu do his/her own wurk,ar an owner who hires an unregistercd mniractor
(not registemd in the Flome Improvement Contracwr(f11C)Progmm), will sot have access tu ihe�rbitration
pmgmm or guamnty fund under M.G.L.c. Ia2A. Other important infortnation on the HIC Program and
Construetion Supervisor Licensing(CSL)can be f'ound in 7R0 CMR Regulations i IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the inf'ormation below:
Tatal Iloors area(Sq. Ft.) (inciuding garage, finished basement/anics,decks ur porch)
Gross living area(Sy. Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hait%baths
Type uf he�ting system Number of Jecks/porches
Type uf cooling sysmm finclosed Open -
� 3. "Total Projecl Syuarc Foo�age"may be subs�ituteJ Ihr'Tutal Project Cust"
�,��o o�r� 4
I �. . //� � ��m
I� �
��SS��?e
� ��.r}�'.._,:...'�c.�'i�
c 9e�MM6 W
�'a�em His�o��cal �'o�am��ssion
720 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
' (978)679-5685 FAX(978) 740-0404
, CERTIFICATE OF APPROPRIATENESS
I ft is l�ereby certitled d�at the Salem Historicai Conunission has determi
, ned that the ro osed:
P P
� Construction ❑ Moving
❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage CI Uther work �.
as described below will be appropriate to die preservation of said Historic District, as per the requirements set
Forth in the Historic DistricYs Act (M.G.L. Ch. 40C) and tlie Salem Historic Districts Ordinance.
District: McIntire
Address of PropertL 15 �G R iver 4rrePr
Name of Record Owner: Peter G. Eschauzier
Description of Work Proposed:
Construction qf'one-storey buthroom uddition to the reco• of the house per Helen F. Sides, Architect LLC
cL�rnvrngs scrbniitted Roqf to be 3-tnb �o match color qf main roaf Addition to lauve hoo 27 '/." n•uss i�elur
nacmua!nentif�g skylights•.. Replacenvent qjjence «s needed dw�ing consh•uction to replicate existrng in color,
mnlerial, ilesign, [ocution and outtivm•d appeurcmce..
t
Dated: December 16 2010 SALEM HISTORiCAL COMM[SSION
BY• (//6"" � �
G��� 2�
rhe Itomeowner has the option not to commence the work (utiless it relates to resolving �rh oGtstandmg
violation). All work commenced must be completed within oue year from this date unless o[her��ise in icated.
TI-IIS tS NOT A BUILDING PERMIT. P(ease be sure to obtain tlie appropriate permits fi�om tlie [uspector of
Buildings (or any other necessary permits or approvats) prior to commencing work.
. , ����;���,�T� a
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9�•�i�CP
Sale�ra Ilisto�ical C'ommission �
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)679-5685 FAX (978) 740-0404
October 5, 2011
Peter& Jan Eschauzier
l5 %z River StreeY
S11em, MA 01970
Dear Mr. and Ms. Eschauzier:
At its meeting of October 5, 2011, the Salem Historical Commission approved your request to
extend the expiration of your Certificate of Appropriateness dated December 16, 2010 to
December 31, 2012.
Sincerely
Ja A. Guy
CI rk
r
��� ��� °r��l� C�TY OF SALEM, MASSAC��USET�I'S
t ,
__�� -
BOARD OF APPEAL
T�
.�
' y� ,-�; 110CG4urnncro�'Siaecr� Sn�e��,M��ss�,o-25errs01970
5;:�;,:�.��:�'"�� Tei_r:978-7-45-9595 � Fax:973-7+G98�6
KIA16GRLE1'DIt1SCOLL .
�L�voic
Notice of Decisions
At a meeting of the City of Salem Zoning Board of Appeals held on Wednesday, November 16, 2011 at 6:30 p.m. at
120 Washington St., Salem, MA, the Zoning Board of Appeals voted on the following items:
Petition of ERIC COUTURE requesting Variances from lot area and lot area per dwelling unit to demolish the
existing structure and construct a two-unit residential building on the property located at 12 RAWLINS 5T (R-2).
Decision: Granted
Filed with the City Clerk on November 30, 2011
Petition of WLODEK MATCZAK requesting a Variance from number of stories, and a Special Permit to extend a
nonconforming structure, to construct a shed dormer on the three-family home at 208 NORTH ST(R2).
Decision: Granted
Filed with the City Clerk on November 30, 2011
,Petition of PETER G. &JAN N: ESCHAUZIER requesting a Special Permit under:5ec. 3.35 of.theSalem Zoning�
�Ordinance to construct a 3.5'x13,' one-story addition on the single-family fiouse on 15'%:'River Street (R=Z)"~�
� Decision: G,ranted _
�Filedwith the CitµClerk.on �lovember30, 2021".
Public hearing: Petition of JAY GOLDBERG, GERREN REALTY TRUST requesting Special Permits under Sec. 3.3.2 of
the Salem Zoning Ordinance to extend a nonconforming structure and to change one nonconforming use to
another nonconforming use, in order to open a Doggy Daycare/Training Business at 9-11 FRANKLIN ST, and to
construct a 32'x24' vinyl fenced area (Bl and R2).
Decision: Granted (Special Permit granted for nine months from issuance of occupancy permit)
Filed with the City Clerk on November 30, 2011
Petition of TAMMIE FAVA requesting a Special Permit under Sec. 3.3.5 of the Salem Zoning Ordinance in order to
construct a third story dormer on the two-family home at 21 BUFFUM ST(R-2 Zoning District).
Decision: Granted
Filed with the City Clerk on November 30, 2011
This notice is being sent in compliance with the Mossachusetfs General Laws, Chapfe�40A, Sections 9& 15 and does
not requi�e action by the recipient. Appeols, if ony, shnll be made pursuant to Chapte�40A, Section 17, and shall be
filed within 20 days from the date which the decision was filed with the City Clerk.
�
' ���,tico�a.,ao� CITY OF SALEM, MASSAGHUSETTS
e
m BOARO OF APPEAL
°' '� 120 WASHINGTON STREET, 3RD FLOOR
ys`� ��Fp SALEM, MASSACHUSETTS O I 97O
�"y����cT� TE�EaHONE: 978-745-9595
��p0� Fnx: 978-740-9846
KIMBERLEY DRISCOLL ,: ; _� '� - - -, _,ry
MAYOR - - -- ,
November 3Q 2011
Decision
City of Salem Zoning Board of Appeals
Petidon of PETER G. &JAN N. ESCHAUZIER requesdng a Special Pennit under
Sec. 3.3.5 of the Salem Zoning Ordinance to construct a 3.5'x13,' one-stoiy addition
on d�e single-family house on IS '/z River Street(R•2 Zoning District).
A piiblic hearing on the above Petition was opened on November 16, 2011, pursu�int to
Mass Genera] Law Ch. 40A, $ 11. The hearing was closed on November 11, 2011 �vith �he
follo�ving Zoning Board of Appeals members presenr. Rebecca Cuman, Richard Dionne,
Annie Harris,Jamie Metsch, and Jimmy Tsitsinos (altema�e).
Petitioner seeks a Special Pemut pursuant to Section 3.3.5.
Statements of fact:
' 1. Peter and Jan Eschauzier presented their petition at the hearing. .
2. In a petition date-stamped October 6, ?011, peeitioner requested a Vanance from
rear and side yzrd setb:�cks, btit it was determined by the Building Comrnissioner that
a Special Permit to ex�tend a nonconfomung single-family home �vas needed, rither
than a Variance.
3. At the hearing, a member of the public expressed concem about the hisconc integnty
of the house.
, 4. At the hearing, Board members scated tha� the addicion ccould no� be visible from
the public �vay, and �hat building in this rnanner was in keeping with die
neighborhood, �vhich alreadyhas hoiises built veryclose co�,e�her.
The Board of Appeal, after careful consideration of the evidence presented at the public
hesring, and after thorough review�of the plans and petition submitted, makes �he following
findings:
1. Desirable relief may be granted, since the proposed ntodification �c1ll tto[ be
substantially more detriinental than che esisting nonconfornung suzicnire to
the neighborhood.
?. In pernuttinb such ch.iiige, the Board oF Appeals requires certain appropria[e
conditio�s und sufeguards as noted below.
. �
On the basis of the above findings of faict and all evidence presented at the public hearing
including, but not limited tq the Plans, Documents and testimony, the Zoning Board of
Appeals concludes:
1. A Special Permit under Sec. 3.3a of the Salem Zoning Ordinance to espand a
nonconformuig single-family house is granted in order to conscnut the proposed
addition.
In consideration of the above, the Salem Board of Appeals voted, five (5) in favor(Cuman,
Harris, Dionne, Tsitsinos and Metsch� and none (0� opposed, to grant petitioner's request
for a Special Pemut and Variance subject to the folloRnng tem�s, conditions, and
safeguards:
1. Petitioner shall comply cvith all city and state statutes, ordinances, codes and
regulations.
2. All construction shall be done as per the plans and dimensions submitted to
and approved by the Building Commissioner.
3. All requirements of the Salem Fire Department relative to smoke and fire
safetyshall be strictlyadhered to.
4. Petitioner shall obtain a building permit prior to beginning any construction.
S. E�cterior finishes of the new constnution shall be in harmony with the
e�cisting stnicture.
6. A Cettificate of Inspection is to be obtained.
7. A Certificate of Ocaipancyis to be obtained.
8. Petitioner is to obtain approval from any City Board or Comrnission having
jurisdiction including, but not limited to, the Planning Board.
9. Unless this Decision expresslyprovides otherwise, any zoning relief granted
does not empower or authorize the Petitioner to demolish or reconstruct �he
stnica�re(s) located on the subject property to an e.Ytent of more than fifty
percenC (50%) of i�s tloor area or more than fiftypercent (50%) of its
replacement cost at the time of destniction. If the stnicture is demolished by
anymeans to an estent of more than fifrypercent (>0%) of its replacement
cost or more than fiftypercent (SO%) of its lloor area at the tune of
destnution, it shall not be reconsmicted escept in confornuty nith �he
provisions of the Ordinance.
� . . 3
K_(_I�.• �R (/.r n - JB-z— L
Re ecca Curran, air
Salem Board of Appeals
A COPY OF THIS DE QSION Ht1S BEEN FILED WITH TI-� PLANNING BOARD
AND Tf-IE QTY CLERK
Appeal from chis decision, if any, shall be made pursuant to Section 17 of the Massachusetts
General Laws Chapter 40A, and shall be filed within 20 days of filing of this decision in the
office of the Ciry Clerk. Pursuant to the Massachusetts General Laws Chapter 40A, Section
11, the Variance or Special Pernut granted herein shall not take effect imtil a copy of the
decision bearing the cenificate of the CiryClerk has been filed with the Essex South Registry
of Deeds.
, � CITY OF SALEM
';�,,. .;�� PUBLIC 1'ROPRERTY
?F`-r'� DEPARTNIENT
�;.��
.iulG M:1'Y:)NKC��11.
. U.�r��x I1C\Vn�r�i.�a:io�S�ixe�7 � Snu:��.M.�i�.u:in .r.�ru0l'i7�
� ��1'�:�.:978•;�tiHi')5 r I'.�r:77N-NC�7x�6
�Vurken' Cumpensation Insurance :�(fidavit: l3uiidcrs/Contracturs/Electrici•rns/Plumber�
�pnlicant Infunn•rtion Plc•rve Print LeeihlY
V81TC(BII(IIICSS/Of�]11V]bONIp1IIVuIUJIY. / /// / ru'eN �( S � a GQ�'vto+.�T'v'N `� dLfGn ✓t�7(T � 5'
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:��Idi'��s: ��I /� rzt�1 �'r-P � f �✓P
City;S�acc;%ip:,��crv,✓ers �/�_ I'hunci.:: /� / � � C�% .S�
:\re qou nn.mployer'!Ch.ck the appropriute but: 'Pype of praject(rcyuireJ):
I I.❑ I am a cmpluycr wi�h - 4. ❑ I ;�m u gcncrai cowracwr and 1 !>. � n�w conuruction
n lo �res lull�nJ/ur erbtime).• hav¢ hircd thc;ub-cunuacturs
�,�+ P Y ( �' 7. ❑ RemoJelinQ
2�1 I :un�sule prnpric[or or partner- lisred un rFe anachcd.hcet. �
- ,hip and h�vc no empluyces Thex subcontrrcmrs have tl. ❑ Demoli�ion
working fi�r me in any capacity. ��'urkers' comp. insurance. 9.�wlding�ddi�iun
Ko workers'cump. iiuurance �• ❑ We are a rniporation �nd its
I 10.0 Electrical rapairs or addi[ions
rcquircJ.] offiecrx havc cscrcisaJ thcir .
ri�ht ofexcm lion �r hIGL I I.Q Plumbing rcpairs or adJitinns
3.O I ;nn a homcowncr doing all work S P P'
myself. �Ko��,orkerr' cump. c. 152. j ll3).anJ we have na 12.0 Riwf npairs
in.urance rcyuirtd.J t .•mployecz. �Ko workars' IS.Q Olher
comp. inwrancc rcquircd.j
•,t�ry:�,pLcun�tlw�chccka boa BI OlUll.IISY IIII W111I1C sl'Qiall IKIOW fllUWlllu Ih�lf NWfI[L•UI cump¢nauion puliry inlirtrtutiun
`i I.�m.uwncn whu uNminhi�a%IJavi�indiu�ing Ihcy arc doiny ull�wrt a�d il�cn his uutsiAe cwur.xma muA.uhmi�a new al'f:Aavi1 indiW iag.uch.
�Cortmniun Ihm ch¢ck�hii box m�rl:nixh�d un adJilimul.�h.,rol ehuwiny Ih.'name of thu sub:antrxWn anJ iheir�ruhen'cump.(ndicy inPormariun.
/mn m�rn�pluyer f!m!l�pruriJinX�vorkrrs'cmnpen.en�inn insu�nnee jur uiy emp/opee.r. Brlory is/hr pu/iay unJ Jab silr
iujeruru�iva
In.urancc Cumpauy Vame: __. �.. . .... . .......____..-------
Pnlicy A or SclGins. Lic. K: ----.... . . ... ..._ Expirm�un Date: .
lob Site Address: Ciiy;SlalN"Lip:
.\et�ch��cupy of Ihe workers'cmnpens•rtiun pulicp decl•rralion pu�;e(showln�;the policy number�nd ecpiratiun d•rte).
P❑ilure to+ccurn cover�gt yt rcquired under Sedion 25A uC�IGL c. 152 can lead to the imposition of crimin�l penalties of a
tina up �o SI.i00.QQ unJ/ur une-year imprisunmcnt, av wcll�,civil �xnul4cs in ihe 1'orm ol'a STOP�YORK URDE2 and a fine
. ol up to�'_iQ.00;�Jay aguinst ihe�iula�or. Ile alvi.icd thut a copy uf thu,iutcmunt may be �urwarJeJ io ihc Upice�C
� Im�cnugammy �ftlic UTA ior in,ur:ux� �ovcrayc�critic.uiun. . �
� /Ju/�ueAy acrrijY�����l�r r/�r nriiu��end prnu/tics u/'perjury thul d�e i��Junnullon pruviJed uGove it�nrt i�d coirerl.
tii�t:r,unre' -- . Uat.. Z
I'h�n:•;i;
O[/iciul i�se mdy. Oo nn!ivri�e Gi diix ureu.!u hr rmup/cled by rily ui lorvn��/JicruL - . i
Cirvor'fnwn: __ . Pcrmit/I.ic.nseq.-,-._ _ . I
� I�suing.\ulhorily (circic uuc): �
I. I{i�arJ nf IIc:4th ?. iiuildin� Ucpartwcnl ). Cilri fo��n C'Icrk a. Llectrical luspcctur i. Plumbin�; Incpcctor �
G. O�hcr .__. -
C��utu.l Pcnou: _ . ._ I'honc 7: �
Information and Instructions _ ,
\I:153dlIlU%CliS GCRI'fJI L�\Vi iI1JNfC( I�Z Il'yU1fCS:lII CIII�lIO)'Gf5 IO P(OYIIIC WUfI(Cf4� WItIPCI11dIlUf1 �Jf II1CIf l'111PIJYCC.1.
Pursu:uu w�iiis,�aw�e, an rmplu�•rr i.Jctiiud ax"...every per.on in �he xrvice uf anwher under any�untnct of hirc.
c�press or implird. or�l�x writmn..•
�n�,nploycr u dctined as"an indiviJunl, purtnenhip,associatiou,coryora�ion ur o�her Icgal cnnry, or any�wo or more
,�i tFc t�xe�oing tngaged in a julM en�erprix,and including the legal ropmsrutativas uf a deceased empluycr,or ihe
lCCtlVtf Uf ICIIJICC UI :ll1 tll(IIVI�IUJI, pmmenhip.:L150C1�I1JR Of O[IIC( ICb'�I entiry,empluying employees. Howevcr the .
�wnet ol a�welling houx huving not more thun�hree aparbnenb and who resides therein,or�he occupant ut the
�Iwrlling Iwusa of anothar who omployv persons w Jo mrintennncr,cumtruction or repair wurk on such Jwelling howe
�ir on rhe eroundc or builJing appurten:utt thercto sh•rll not because of such tmploymcnt be Jeemed tu be an rmpluyer."
.tiIGL chapecr 152, �+35C(6) also sta[as chac "every shrte or local licensing •r�ency shall N•ithAold the Issuancr or
rrnewul uf u Bcense ur permit tu uperate a busiarss or[o canstruct buildingf in the communweal�h for auy
:ipplicant who has not producrd •rcceptable evidence uf cumpll•rnce with the Insurance covera�e requlred."
.a�Jitionally, hIGL chapter 1 i'_, §25C(7)srahs"Neithar the conunonweal[h nur any of its political subdivisions shall
encer into:uiy cuntrac[ f'or ehe perfummnce uFpublic work until amept:�ble evidence oCcumpli;uice wich the insurance
rcquiram¢nu oY ihis ch�ptar h�va betn presantoJ tu thcconcreaing au�ho[iry."
,
Applicanb �
Plcase lill out the workcrs' compeusation aftidavit complerely,by checking [he boxes ehat apply to yuur si�uaiion and,if
necessary, supply iub-contrac�or(s)n:une(s),address(es)and phona nwnber(s)along with their certificate(s)uf
insw�ance. limited Liabiliry Companies(LLC)or Limited Liabiliry Partnerships(LLP)with no employces Wher than the
members ur paRners, �re not required to carry workers' compensa[ion insurance. If an LLC or[,LP does have
employaes,u policy is rcquired. Be adviseJ that�his alfidavit may be submit[ed to the Dep•rrtrnent of Industrinl
:�ccidtnts For confimiatiun uf insurancc rnvarage. Also bo sure tu xien unJ Jule the•rllidaviL The af'tidavit should
he returncd tu tlie ciry or town that the applicauon for the pennit or licanse is being mquasted, nof the UcpaRment of
InJustrial AcciJents. Should you have any yuastions rogarding[he law ur iFyuu ara reyuirtd tu obtain a workers'
compensation policy,pltase call the Dep;utrnent at Qie nwnber listed below. Self-insurod comp�nies should anter their
sclf-insurance license number un the appropri•rtc linc.
City or'fown Ofticiyls
Plcase hc surc that the affidavit is complett :md prinmd Icgibly. 'The Deparhnent hax pruvided u spacc�at the bulWm
oF�he aF�idavit for you tu fill ou[ in the uvent the OI'tica ut Investigations has ro contact yuu regarding the applicanc.
Plcase ba.aure to till in ihe prnniblicense number which will ba usad as s retbrcncc numbcr. In addieion,an rpplicant
ii�at must submit mul�iple p�nnio'lice�uc applications in any biven ye:v,nead oniy submit one aftidavit indicating wrtent
rolicy inf'ormu[ion 1 if neceasary) :uid undzr'7ob Site Address"the upplicant should�vrite"all lucatiuns in (city ur
aiwn)."A cupy nf the uftiduvit ihat h�s bteit o(ficiully stampcJ or marked by [lia city or town may be provided tu thc
applicant;u proof that a vulid a(fidavit is on fila f'or future pe�mitx ur licanszs. A new attidavit must be filled out each
I ya.�r. Where a hume uwncr ur citizen is obtaining a licenx or permit not related to any business ur commtrcinl venmre
�i.�. a dug licanse or permit w burn leavts ete.)saiJ perwn is VO'C required w complc[e this uffidavit.
I�hc 1)I IKl'UI I11Vt1tI�JUO(75 µ'UUIII IIRC IJ �I78IlIC}'OIl 111 JIIV:UII'C f0[yJUC iOUPtlf�Il011 JIl(I tiIIUUIII YUU I70VV:lfly I,LLC�IIOIli.
pleaat du nut htsi�atc to givc us u ca1L �
Thc D.:parunen�'s address, eelcphone �nd fax numbar.
The Commonwealth of Massachusetts
Department of Industtial Accidents
O[1lceot[uvesU allon�
s
600 Washington Street
Baston, MA 021 I i
'Pel. M 617-727-d900 ext�06 or 1-877-MASSAFE
Fax N 617-727-7749
itcvi�cJ ;.�G-US -
www.mass.gov/dia
,� CITY OF S.1L.E.�I, 1�L-1SSACHL'SETTS
• BI:II.DING DEP\R'I?IEVT
� 1?O WA.iHLYGTON$TREfiT, 31O F200R
� T�L (97� 7i5-9595
F�x(978j 7�f0.9&46
Kl.1BERLBY DRISCOLL
�fAYOR 'Ilio.+us ST.P[Eaxs
DIRECT00.OF Pl'BLIC PROPEAIY�HCIIDLYG CO\L�IISSIONER
Construction Debris Disposal Affidavit
(required foe all demolidon and renovarion work)
in accordance with the sixth edition.of the Scate Building Code, 780 CMR section l l 1.5
Debris, and the provisions of MGL c 4Q S 54;
Building Permit # is issued with the condition that the debris resulting from
Ihis wark shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c
I11, S i50A.
The debris will be transported by:
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(nam of haulnr)
The debris will be disposed of in :
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(name of facility)
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. (addrcss of faciliry)
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