14 SETTLERS WAY - BUILDING INSPECTION r►-�-
What is the current use of the Building? ,
Material of Building? I,✓vaG� if dwelling,haw many units?
Win the Building Conform to Law? �S Asbestos? �C7
Architect's Name
N• A- '
Address and Phone
Mechanic's Name N
Address and Phone
Consbu:k n Supervisors License S G-S $6S`2 HIC Registration 0
Estimated Cost of Project S t3"O Permit Fee CalaAatbn
Permit Fee ll 61' o o Estimated Cost X$7/$1000 Residential
Estimated Cost X$1141000 Commarclal 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
specifications. Signed under penalty of perjury X
Date
el
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CITY-OF s -
PUBLIC PROPERTY
DEPARTMENT
KMOW-U CV DRLWAA .
Surx MASSACJ/USt'il3 01970 -
TM 9711-74S-9S"*PAM 978-740.9M
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: Iq Se YT/erS WA Building:
Property Address
og L E W"
Property is located in a;Conservation Area Y/N—,6_( _Historic Dlsbiat YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: Scc Tf— U-1 • CRigE
Address: !cf $B /�r5 1 ✓ y
/ewe
Telephone: C '7 —7 Ll-4 _ 27c,4 p CC 4 7v�423— 997/
3.0 COMPLETE THIS SECTION FOR WORK IN ILOINGS ONLY
Addition Existing
Renovation � Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Scief Description of Proposed Work:
le6f-►`O,t5 KI'r46N eoi(o;n���S
Mail Permit to: 7f--6 e n t e r w
CONNOLLY
Planning•Design•Construction
Scott W. MacRae
PROJECT MANAGER
Connolly Brothers, Inc., 152 Conant Street, Bevetly, MA 01915
P:978-927.0053 F:978-927.7928 C 978-423-9971 E:smacme®connollybrorhers.com
CrrY of SALEm
AM PUBLIC PROPRERTY
-W1, DEPARTNOM
>L�uw l'1't.�eN::�7m1i 1rR�i�t:mr.m{t+vtta»r a�'1s:.4
r-
Coanstrucdom Debris Dispaat Affidavit
(mipi and he an&mention and tmeovaden work)
to aaonta»es w itb the dxtti edidon oldw stun 8uildl"Cod%7W C%1R section 111.3
l7ebc*wA dw pmvisiwu o/rtGL a 44 9 Sk
guild sli Pon t _ is lammed with the aond dioe that the debris resuldng t3emts
this wait shalt be disposed of in a property licensed wam disposal fbeility as defined by MOL e
ll1.! U"
The debris will be transported bye
CkAj-iieS GEot26,E 77Zo4cX
_. tnowe of haW+A
rho&--bris will be disposed of in :
GG.ea-r le 6Eo�6 TI-y L!�r r�
toy Ni95h �R Kd •
030 � j
,,.L:r,r�a•,rra�:t.ry �
PH.. $S iS1 Sbp ^72 7y
,W -
3 �
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
stvinr airs utset:uu
Mvraa 12C'Iassaw`reta Srstatr a SitutK W.miicy a v.-r ix Mn
Tht:97 F743.9S93 a F.xx:9M740.9946
Workers' Compensation Insurance At'lldavit: Builders/Contractors/Eleetridans/Plumbers
Annlleant Information Please Print Legibly
Name jouvac >Mrwni:atiowIndiv-dlnll: __ Se oTT- elf• Mjj r—21fG
Address: ert/erB CA-)
city/stareizip: leer lR m/ >rJ Iahone N: 9 7v al7 144-- 7-7`4-0
Are you an empbyw*Cheep the appropriate boa:
'ryt»o1 project(►rt'rtrad):
1.❑ 1 am a employer wits 4. ❑ 1 am a ycmtral conw3ctor and 1 6. ❑ New construction
employees(cull and/or part-time).• have hind the sub-contractors
2.❑ 1 am a sole proprietor or partner- lined on the attacked sheet. t 7. ❑ Remodeling
ship end have no employees Then sub-eommetors have & Q Demolition
working for me in any capacity. workers' comp insurance. 9 Q Budd ing addition
(No workers,Cottµ insurance 3. Q We are a corporation and its
squired) officers haw exercised their 10.0 Electria!repairs or additions
3. t" I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or addition@
myselL(No workers'comp. C. 152,if 1(4),and we have no 12.0 Roof repairs
insurance required.) t employees(No workers' 13.❑Oskar
comp. iM1wrarue required.)
•xiq;i 0960 W/Clucks sea rt mac oho Nt out tin r 1iiia trsraw thaw'ias their wwt@W QMApNW{Yn pulwy ioamo atim
I1�wrois who sulunW this aaldwu indlsalaa try era dung di wok and than hie aaaWa casnrawn raw submit a nw antasvh i"caiina ua-h.
{C maven that Awk that Itat own adaelrd as addakx d,hot.owing the nasty area and thae wuAen'owns.pdiry M&nnadta
i ens an employer that it providing workers'comperawdoe insurance jar my employees Below is the puNay andlab sire
iujurarat/w�
Imurancc Company Nome: --- ._
Policy a or Scir-ins. Lie. 0: _ .- Expiration Date:
Juo Site Address: Cityrstatetzip:
attack a copy of the workers'compensation policy declaration Palle(showing the polity number and expiration date).
Failure w secure coverage as required under Section 25A uf.MGL C. 152 can lead to the imposition of criminal petulties oft
fine up tit SI.S00.00 and/or one-year imprisonment.as well as civil penalties in the forts ors STOP WORK ORDER and a fine
of uP to S250.00 a day at(ainst the violator. Ik advised that a copy urthis statement may be forwarded to the Office of
IIIY.�thalltllls UI the DIA for imurarcc:ovcra,;c verification.
1110 hereby certify ender th pains art penuities ofper/try that/IN inforwalNon provided above is true and correct
15.
4 4 - 7-7 4to G 9>o z3 -
F11ffkhadvjraa1pL DOway write in rho acre.to brrrraspfettedbydryortown offld-A Lsown:Authority (circle one):ofItralth 2. Building Department 3. Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
Person: _ Phone 4•
Information and Instructions
Massachusetts General Laws chapter 132 inquires all amPloyent Oviss e�woe ther04 �uoatti any con foran of
of Airs.
u defined as-...evay person Putsuaru to thin Manua.an seyfgea.
e•pness or implied,oral a written-
O f he yore o n defined m
as md1VWtsa4 pumeabtp,aseoctano�corporation or other a sad err say two f t meta
Of the foregoing engaged in a jtriat enterprise.and ixhtdirtg the legal reprssmtativa of a deee:rsed employer,or the
uweianoo or other dial entity,eetpbyiug arttpbyees However the
receiver or«ttstet of an iudiridual.Pormers6tp. and who ban Of therein.err the oeettptutt of the
owner of a dwelling berme having not more than three apartneab
dwelling house of another who employs Persons to do maiammwa,cuostructon i or repair work on such dwelling house
or on the grounder or building appurtenant tbtttem shill not became of snob employmtmt be deamad to be an employer.
�lGL chapter 15Z 42SC16)also tosms that'�a'ay state or Weal Ikenshg agency sW withheld the Isetaaee or
a o raft a baslnas or a construes buildings In tM cemmoawaaMY far any
retmwd s •ieeaw or permits M ebb svidanet of compose"with the Insurance coverage required"
aPplfeaN ty ttaa star produced accept" nor Any of ib Political subdivisions shell
Adak mlly.MGL chaff 5� �')lic w r the conunonweaUhvtde�of compliance with the insurance
enter into any contract public wok until acceptable
requiromenb of this chapter have been presented to the contracting audoriry.-
Applicant
Please fill out the workers' compensation affdavit completely,by checking the boxes that apply to your situation sad if
upply eAWAMaactor(s)aame(s),addMes(es)and phooa number(s)along with their cortificate(s)of
in Limited Liability Companies(LLC)at Limited Liability Parntenhips(LLP)with no employees other than the
members or purtncn,are not required to carry workers' compensation insurance• if an LLC or LLP does have
employees.a policy is required Be advised dot this affidavit may be submitted to the wMdav t ant of Indusaial
Accidents for confirmation of insurance coverage' Ababa sort to sip and date the at0dd, n The apart it should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
ltulusmial Aceidcrim Should you have any question regarding the law or if you an required to obtain a worken'
compensation policy,plessa call the Department at the number listed below. Sclbinsumd companies should enter their
.elf-insurance license number on the anotOmiallit lam•
City or Town Olf efsb
please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottons.
of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant
I'Icasc be sure to till in the permivlicense number which will be used an a reference number. In addition,an applicant
that must submit multiple permiulicense 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 for anion 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 n on file for future permits or licenses. A now affidavit moat be filled out eseh
year. whore a home owner citizen is obtaining a license or permit not related to any business or commercial venture
,i.e. a dog license or permit to burn leaves eteJ said person is NOT required to complete this affidavit
fhu Oftis of investigations would like to thank you in advance for your cooperation and should you have any questions,
1case do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of MassaciluSC s
Department of lndlisodal Accidents
Omer of[givadsaft"
600 wasltin6ton Street
Boston, MA 02111
Tel. M 617-7274900 ext 406 or 1-977-NIASSAFE
Fax 0 617-727-7749
2aviscd 3.26-03 www.nim.gov/die
Board of Building Regulations and Standards
�. Construction Supervisor License
LICg�nse�CS 66647 -
Birth e 4124/1966
�ERn a io h�T/22412009 Tr# 8934 - . . ...
i SCOTT W MAC 'J -
( . 41 NICHOLS ST 4�'��'"
SALEM, MA 01970 'o Commissioner ;
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