25 ROSLYN ST - BUILDING INSPECTION -CITY-OF`SAL --
��Q� PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 1?0 WASHINGTON STREET♦SALLK\WSACHLSEI-IS 01970
TFL 978-745-9595 • FAX:97&740-98"
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: 41'e1W J/ Building:
Property Address,
Property is located in a: Cons ation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation ✓ Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of e Building? t�u�
Material of Building? If dwelling. how many units?
Will the Building Conform to Law? 5
Asbestos? Zf,1fAb
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# d? .31 HIC Registration# � 3
Estimated Cost f Project Permit Fee Calculation
Permit Fee k ` Estimated Cost X$7/$1000 Residential
Estimated Cost X$111$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 th ab t stated
specifications. Signed under penalty of perjury
/6,
Date
N �
ems+ 4
9
1
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OF —4— a— -- - -
CITY OF SALEM
PUBLIC PROPRERTY
l DEPARTMENT
KMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET *SALEM MASSACHUSETTS 01970
TEL:978-745-9595 •FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organiaation/Ind' id 1):
Address: l � /�
City/State/Zip: 41 ? Phone #:��— /7 dl' 4&2
Are n employer? Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t �• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ 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, §1(4),and we have no 12.❑ Roof airs
insurance required.] t employees. [No workers' 13.0 Other Q—C-1<5
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providin workers'compensation insurance for my employees. Below is the policy and jab site
information. / ,L
Insurance Company Name:
�� S (�TJ
P Y ��
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: t,�,Q,5— cS CitY P/State/Zi 5 y�/e�
Attach a copy of the workers' compensat' n policy declaration page(showing the policy number and expiration 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 $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 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.
I do hereby certif a the in d al ' of er'ury that the information provided above is true and correct.
Si nature: Date:
Ph ne#: v
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
G
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association, corporation 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 employer,or the
receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a 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."
Additionally,MGL chapter 152, §25C(7) 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 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 sub-contractor(s)name(s),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 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 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 number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be 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 (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
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF SALEM
' PUBLIC PROPERTY
T� DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON S7RF=•SAIFM,MASSACHLSMS 01970
TEL-978-745-9595 • FAX:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
ris and the provisions of MGL c 40, S 54;
Building Permit# resultin from
Deb is issued with the condition that the debris 8
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name 0f hauler)
The debris will be disposed of in :
name of fscilit
(address of facility)
snan a of permit p cant
date
drbiisalLJuc
8'-0"
(V
10 %
i
i
EXISTING PARKING LOT o
M
PRIVACY FENCE
W/ PASSIVE DOOR
1 N
EXISTING RETAINING WALL 10
1 o /
LrLo
j
' 3'-0"14'4"
' STAIRWAY
OPENING i
o W/RAILING
151-0" DN /
' SOLID PARTITION WALL /
184 sq ft
//EXISTING BUILDING
DECK LAYOUT PLAN
DECK REPLACEMENT AND ASSOC. WORK
JANNETT CONDOMINIUMS - SALEM, MA A• 1
SCALE: N.T.S.
IDATE: JAN 2006 R M X NORTHEAST INC.
C D ;
1 - /
NOTES: ,
-COLUMNS ON GROUND LEVEL —
1. SHALL BE 6" DIA. TUBULAR
STEEL COLUMN 2
2. SHALL BE CONNECTED TO -
STEEL PLATE CAST INTO NEW
12" DIAM. CONC. FOOTINGS °O
co
-COLUMNS ABOVE FIRST FLOOR �
1. SHALL BE 6"X 6" PRESSURE —
TREATED LUMBER 3
-FOOTINGS
1. SHALL BE 12" DIAM. CONC.
2. SHALL BE 4'-0" DEEP MINIMUM /
4
ao
00
SEE
1 NOTES _ j
bo /
A B r;
1 7 - -
1 r�
/
8
i
1
1 COLUMN LAYOUT PLAN
DECK REPLACEMENT AND ASSOC. WORK
1 JANNETT CONDOMINIUMS - SALEM, MA A— 2
SCALE: N.T.S.
DATE: JAN 2006 R M X NORTNEA$'I' 1NC.
a
2"x6" HANDRAIL
1"xb" DECKING
PT 2"x"8" LAGGED @ 2' O.C.
2"x2" BALLUSTER
HANGER
2"x8" JOIST 916" O.C.
(TYP.)
2"x4"
HANGE ANGLE IRON
(fYP.
I� DOUBLED 2"x8" GIRDER
ANGLE IRON 6"x8" BEAM
b"xb" POST
TYPICAL FRAMING DETAIL
DECK REPLACEMENT AND ASSOC. WORK
JANNETT CONDOMINIUMS - SALEM, MA A 3
SCALE: N.T.S.
D ➢,f V ________.__ ____
{ CENTER RAILING
JOINTS ON POST
LOCATIONS
6"x6"
POST ---..
b"xb" POST
2"x6" HANDRAIL
----- -- 2"x6" HANDRAIL
2"x4"
2"x2" BALUSTERS
2"x4"
11
U v 4
2"x2" BALUSTER r'
1"x6" DECKING
,I DOUBLED 2"x8" GIRDER
6"xb"
-4-
POST _ _ _ WHERE JOINTS ARE REQUIRED
ALONG GIRDER THEY SHALL BE
CENTERED ON POST LOCATIONS
ELEVATION/CUTAWAY
RAILING PLAN & ELEVATION
DECK REPLACEMENT AND ASSOC. WORK
JANNETT CONDOMINIUMS - SALEM, MA A- 4
SCALE: N.T.S.
PLAN VIEW/SECTION DATE: JAN 2006 1 R M X NORTHEAST INC.
�-2" X 6" HANDRAIL
I2 X 4" 4"
MAX
I ,
2" X 2 BALUSTER
I � (TYPICAL)
1" X 6" DECK
BOARDS
(SEE NOTE)
I2" X 12" STRINGER
1" X 8" DECK
BOARDS 24"-----
(SEE NOTE) CONCRETE
CONCRETE /LANDING
FOOTING
12" DIAMETER
GRADE
48" MIN."
BELOW
GRADE
NOTE: CUT DECK BOARDS TO STAIR ELEVATION PLAN
APPROPRIATE RISER AND DECK REPLACEMENT AND ASSOC. WORK
TREAD DIMENSIONS. JANNETT CONDOMINIUMS - SALEM, MA A- 5
SCALE: N.T.S.
DATE: JAN 2006 R M X HORTHggr INC.