5 SCHOOL ST - BULDG PERMIT APP 07-305 ROOF PUBLIC PROPERTY
�1
DEPARTNIETTtT a
MAYM 1 WAswtucrcw S17EET
S.'�WAA LSLI-M01970
11•3-978.745.959E•FAx-97&740-98"
APPLICATION FOR THE REPA_UL RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTLItZ OR BUILDING
1.0 SITE INFORMATION
k Location Name: 411
C swtl m Building:
i Property Address:
S SCLOA Spree �'
Property is located in a;Conservation Area YIN Historic District Y/N
4
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land '
Name:
Address: r'-
5 Sc�.ao �free�'
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition
Approximate year of Area per floor (sf)IN;ewq
construction or renovation
of existing building
Brief Description f Proposed Work:
Mail Permit to:
What is the current use of the Building? It dwelling,how many units? 7_
Material of Building? _ .__--
Win the Building Conform to Law?
Asbestos?
Archited's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors LIcens"# ��s HIC Registration#
Estimated CoV Project S � Permit Fes Ca1=cuO bn
�3 7 Estimated Cost X$741000 Residential
permit Fee i Estimated Cost X S11131000 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 above stated qn
specifications. Signed under penalty of perjury
Date to b ob
0
N
s
6.
461
r O\ an
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
lCA1aER1EY DRLSCO[l
MAYOR
120 WAsrmvcTONSTREET•SAI M.NfASsAcHtjsETrs01970
Workers, Compensation Insurance Affidavit: Builders/Contractors/Elect icon/Plumbers
Applicant Informatio
Please nt Le
Name(Business/Organizaeon/fndividual): a7
Address: qZ -fir v e.Go, �1 dew,
City/State/Zip: Lin r� �A— o, oL Phone#: 991 S/j -9306
Fam
mployer?C!141 :
appropriate box:
employer wit4. I am a general contractor and IE[]Remodeling
roject(required):
ees(full and/ time).• have hired the sub-contractorsw construction
ole proprietotner- listed on the attached sheet. t have no em m°deliag
These sub contractors have for me in ancity. worlcera'co molitionkers'co rpo Lion and i
comp. ice 5. �] We are a corporation and its . 9 addetioa
required.] officers leave exercised their ctrical3.❑ I am a homeowner do work right of ex lionrepairs or additionsmyself. amp Per MGL bing repairs or additions[No workers c. 152.§10),and we have noinsurance required]temployees. (No workers' f repairscomp. insurance required.] er
Any apDautn that ehecb box el m tIR om the seetion below showing their workan'
Homeoweas who submit this aNidwit indiwina they an do' all compensation policy iniormadmi.
rConaacton that mf wade and thins outside emrtaetors must submit a new affidavit indicating
cheek fhb box must at4ched oo additional sisal ehowina the name of the sub-eonhaetoes and their workma•eomD•poi mfotmap osi
i fo as employer that it providing workers'compensation insurance for my employees. Below it the policy and Job site
information. , I'
Insurance Company Name: �qsS atTc1'or� c fc, o
Policy#or Self-ins. Lic.#:_WC 1�4`1
nel <t° Expiration Data: O2
Job Site Address: �! c
City/State/Zip: . r,LAt-�� O(S�I)
Attach a copy of the workers'compensgtion 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 S 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 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,
do hereby certify ander the p and penalties of per/ury that eke information provided above it brie and correct
Si a r • fey
D to/ OG
P I - 3co
LL6.0ther
al use only. Do not write in this area,to be completed by city or town oJJidaL
r Town
Permit/License#
g Authority(circle one):
I. rd of Health 2.Building Department 3.Cfty/Towo Clerk 4. Elect Inspector S.Plumbing Inspector
t Person
Phone#•
Information and Instructions n for then employees
ter 152 requires all employers to provide workers compensaao contras ot<hirer ;r
Massachusetts General Laws employee is defined as"...every person in the service of another under any
Pursuant to this statute.an mapp Y
express or implied.oral or written."
visual,Partnership.association,corporation or other legal entity-or any two or more
including the legal representatives of a deceased employer,or the
An employer n defined as"an indi to ee& However the
of the foregoing engaged in a joint eoartneisc.hi and employing emp Y
of an individua4 Partnership,association or other legal entity. of the
receiver or trustee having not more than three apartments and who resides therein,ah n occupant dwelling house
owner of a dwelling house who employs persons to do maintenance.oonstrUction or repair to er '
dwelling house of another �ttto shall not because of such employment be deemed to be an emp Y
or on the grounds or building aPPOBIIt
eve state or local
tteenaiug age°�'shall withhold the issuance or
2 25C(6)also states that-every ct buildtn&a in the commonwealib for any
is ,4 ter construct chapter r m
GL P business oaired.
M per to operate a burin
renewal of a license has
or pe table evidence of compliance with the insurance coverage bs visions shall
applicant who has not produced acceptable of its politic
o
152, forma)states"Neither the commonwealth
lle evidence of compliance with the insurance
Additionally.M nL�chapter �.o�Q of public work until acceptable
enter into any
of this chapter have been presented to the contracting authority."
requirements
pppllcanb the boxes that apply to Your situation and,if
Please fill out the workers' compensadon affidavit completely,by checking
address(ea)and phone numbers)along with their certificates)of
supply sub-conttactor(s)namc(s), Partnerships(LLP)with no employees other than the
necessary. im Y Ce antes(LLC)or Limited Liability
insivaace. Limited Liability •d to carry workers' compensation insurance. If an LLC or LLP does have
members or parmers,are not, be submitted to the Department of Industrial
employees,a Policy is required' Be advised that this affidavit may - The affidavit
Accidents for confirmation of insurance coverage. Also be sure to sign and date t the nesBud�of the Department �
be resumed to the city or town that the application for the permit or license is being 9
Industrial Accidents. Should you.have any questions regarding the law or if you are required to obtain a workers'
Department at the number listed below. Self-insured companies should enter their
compensation policy.Please call the Dep run
line.
self-insnrawA license number on the r
a
City or Town Officials provided a space at the bottom
rimed legibly. The Department has p the applicant'
Please be sure that the affidavit is complete and p B Y' has
of the affidavit for you to fill out in the event hich Investigations
be�a�reference numberl In addition,an applicant
Pease be sure to fill in the permit/license given year.need only submit one affidavit indicating current
that must submit multiple pocmit/Ucense applications in any 6i
and under"Job Site Address"the applicant should write all locations in (city or
policy information(if necessary)
tamped or marked by the city or town may be provided to the
town) A copy of the affidavit that has been officially stamp es.isP.see _A new afusine r must be filled out each
applicant as proof that a valid affidavit is on file for future Pf• t not related to any business or commercial venture
year.Where a home owner or citizen is obtaining a license or Perini
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required m complete this affidavit
and should you have any questions,
The Office of Investigations would like to thank you in advance for your cooperation
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
Offlee of Investigations
600 Washington street
Boston,MA 02111
Tel. #617-727-4900"t 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www niMS.gov/dia
CTTY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
ran 130 WA"Ub a M VnMT•SAtFat.M&UA a-WM OIVO
Mm.97 US-9S"*F.ne W&74&"U
Consimcdon Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,780 CMB section 111.5
Debris.and the provisions of MCJL a 40.S Sot
Building Permit 0 is issued with the condition that the debris resulting fiam
this work shall be disposed of in a properly lieeosed waste disposal d]teility as defined by MGL a
Il1.31SO&
The debris will be transported by:
c Z-
(Hams o[hsatsd
The debris will be disposed of in:
(n•or facility)
_. VV.
(address of facalg)
AM Az-
S.jr
sipaaue ffp tit applicant
1016106
due
trlti.�IZJ�O
71m 1°oo....ilea� o�✓�.aaaa���raeQ3
Board of Building.Regulations and Standards
HOME IMPROVEMENT CONTRACTOR 4
`Repiatration: 125815:
Expiration 3/9/2008,
Corporation., i -I
MAX SONTZ ROOFING SF�RVICES INCH ,,'
�- BRADLEY, SONT�
82 SANDERSON
LYNN,MA 01902, Adminirtntor
'i a ��e �Oof» �Yino�a ea�(i o�✓uaaoaaG�ael�
BOARD OF BUILDING REGULATIONS
License:CONSTRUCTION SUPERVISOR`,�
Numtte� S 075255
} B ,
61 �. Tr.na 6442.0"
i BRADLEY�d= SO �_s=
T€ 7 McKINLEY RD
MARBLEHEAD,�t�
{ commissioner