40 SPRUANCE WAY - BUILDING INSPECTION EI`1'�IIP-ALE
PUBLIC PROPERTY
DEPARTMENT
samarjuEY ORMCOLL
MAYOR IA WAWNGTON 5TREFr 1 SALEK MASSA01l:5t-M 01970 Q'
TEL"97&74S-959S•FAX 978-740.9846
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
VTE INFORMATIONon Name: Building:
rly Address:perty is located in a; Conservation Area Y/N Historic District Y/N A _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: .�7.
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation 72S
Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation New,
of existing building
Brief Description of Proposed Work:
�?�in owe 4-,OW4-�Pee
)rj�Il4CC
Mail Permit to:
What is the current use of the Building? .46e.,i
Material of Building? ilt l�1,2b If dwelling; how many units?
Will the Building Conform to Law?��i Asbestos?
Architect's Name �� J
Address and Phone l )
Mechanic's Name
Address and PhoneUi�Li
Constriction Supervisors License# /2 --�/�kl HIC Registration#_� 7
Estimated Cost of Project S 79. Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$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 the above stated
specifications. Signed under penalty of perjury
Date
0
N
O
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a
O ,r
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xntaeRcaY nRtscou
MAYOR 120 WnsfmvGTONSTREM a SAtFs4,ldwc4ACHUWM01970
TEL-978.745.9595 a FAX:9M740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information j Please Print Leefty
Name(Business/0rgaovauow1ndividual): �//�/7 / ✓ CD C �c
Address:-L��4i.��L/'4eG
City/State/Zip: Phone#:
Are you an employer?Cheek the appropriate box*
1�,p I am a employer with { 4. ❑ I am s general contractorType of project(required):
and I
employees(fitll and/or part- e).• have hired the subcontractors 6. ❑New construction
tim
2.❑ 1 am a sole proprietor or parow- listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity. workers'comp. insurance. 9. Q Building addition
[No workers'comp. insurance 5. ❑ we am a corporation and its
required.) off cem have exercised their 10.❑Electrical repairs or addition
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or addition
myself.[No workers'comp. c. 152,$1(4),and we have no 12.❑Roof repairs
insurance required)t comp y workire 13.❑OtherZlBD ��?2
insurance required.]
'Any W VBeaex chat chocks boa al muR Ww Nt cox the section below Amiog orb works'compensation Policy intbunstlon.t Homeowms who submit this affid"indkating they an doing aV work and the him ouuWs caffiftw n mast submit a osw afRdsvit i sack.
rCooftwsm thst deck this bet now anaehed an additional sheet dtswmg the name of the enb cootraGon Red thob wartms'comp,policy infetmatloa
ram an employer that is providing workers'compensadon lnsarancefor my employees. Below b the policy and fob sloe
lnformadan
Insurance Company Name:
Policy#or Self--ins.Lic.ll:_ Expiration Date:
_- fob site address: c;eyistawz;per'%;, /��
Attach■copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requited under Section 25A of MOIL c. 152 can lead to the imposition of criminal
fine up to S 1,500.00 and/or one-year imprisonment P� panel
of a
y prisonmrnr as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 3250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D/A for insurance coverage verification.
on
l do hereby certify er the pains p aides of perjary that the information provided above b tare and correct
Si
[Jlk ::::7. t write i a this area,m be completed by city or town oJJlelaL
Permit/License iole one):uilding Department 3.City/Pown Clerk 4.Electrical Inspector S.Plumbing Inspector
Phone p•
Information and Instructions
General Laws chapter 152 requires all employers to provide workers' compensation for their a 1
Massachusettss is deemed as"...every person in the service of another under any contract
Pursuant to this statute.an employs
express or implied,oral or written
"an individual,partnership,assoeiatiM corporation or other legal entity,or any two or more
An eaaploygo n defunct as and including the legal representatives of a deceased employer,or the
of the foregoing engaged in a joint enterprise. a to ee& However the
of an individual.partnership,��on m other legal entity. P Yna mP y of the
receiver trustee house not more thaw three apartment and who resides therein,or the occupant
owner of a ellingellmgf another to do maintenance.construction or repair work on such dwelling ham
dwelling who employs ys persons
thereto shall not because of such employment be deemed to be an employer.
or on the grounds or building appurtenant
MGL chapter 152,425C(6)also states that"every state or local ikendull agency shall withhold the Issuance or
renewal or a license or permit to ope nts a business or to ceostraet buildings in the eommoswealth for say
applicant who has not produced uxeptable evidence of cemPllaaee with the insurance coverage required
Additionally,MGL chapter 152,$25C(•1)states"Neither the commonwealth not any of it political subdiviaioas shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requireatent of this chapter have bien presented to the contracting authority."
Applicant
affidavit completely,by checking the boxes that apply to Your situation and,if
Please fill out the workers' compensationes and phone number(s)along with their certificate(s)of
necessary.supply sub.contractor(s)name(s),address( ) Partnerships with no employers other than the
insurance. Limited Liability Companies(LLC)or Limited Liability ninsuanf if an)LLC or UP does have
members or psrners,rue not required to carry worker compensation be insurance.
employees,a policy is required• Be advised that this affidavit may be submitted to the Department of Industrial
Accident for confirmation of insurance coverage. Abe be sure to sign and date the affidavit The affidavit nt of
be returned to the city or town that the application for the permit or license is being requested,not the Department
Should you have any questions regarding the law or if you are required to obtainshq>uld rkers enter their
Industrial Accidents a<the number listed below. Seif-insured companies
compensation policy,please call the Dep
artm self-insurance lieeoes number on the a
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
censse umbber event the 0which will be used as ae of investigations reference number.to contact YOUI addition,an applicant
egarding the applicanL
Please be sure it fill in the ermtr locations in any given year,need only submit one affidavit indicating current
that must submit multiple ssaZY) nd under
applications
policy information(if neeessery)and under"Job Site Address"the applicant should writ"all locations is (city or
marked by the city or town may be provided to the
town)."A copy of the affidavit that has been officially stamped or or licenses Anew aE ,dsvie must be fined out each
applicant as proof that a valid affidavit is on file for future permits net related to any business or commercial venture
year.Where a home owner or citizen is obtaining a license or permit
(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,
pies se do not hesitate to give us a call.
The Department's address,telcphgme and fax number.
The Commonwealth of Massachusetts
Department of bndustrial Accidents
Offla 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•mesa.gov/dia
CrrY OF SALEM
' PUBLIC PROPERTY
DEPARTMENT
Kass"OVACOLL
m vas 139w.8mlcnwsnsa•S. SlkMASW0L=M4lW6
Construetiom Debris Disposal Affidavit
(required lbt all dmolidoa sod reeovadeo work)
Ia tcm&mos with tbs dz&edidos ddw Sbte Building Codes 780 CUR seedos 1113
pebdk asd dw provision o(SAM o 406 0 Sit
Smuftremoko is lased with dw oondidon dtss the debris remblus 8mt
tide wart shall be disposed oils a propsly lleeosed arasts diopo d dtoilitlt as dodo"by Mdt.e
1 li.s tso�►.
The debris will be t:anspoeted by:
rotes
'�� (sws dbuJsd
The debris will be disposed of in:
_�(cams of fSeiliyrl
(�of heiliry)
sisaaruos o +it�ppliraor
due
�chnw7.ys
NOV-10-2006 15'05
RON SHAH
5 Stuart Rd.Peabody,MA 01960
Tel. (97g) 815-0789 Fax(978) 977-7889
MA Lic#035-041 H.I.C.# 132777
CONTRACT
x BC-42 fireplace with glass doors,variable speed blower and
Supply and install LennoWay
associated piping and chase cover at 4Daid for assoc anon Includes removal and
termination cap and storm collar to be p Y permit
wping,installation of fire
og neces ary o hook p blowder land instal ation of the ba kerstopsboard in lieu of tncal
sheetrock.
NOTICE: THIS CONTRACT MAY BE CANCELLED BY THE
CONTRACTOR By MAIL OR TELEGRACUSTOMER By PGGH WITHIN THREE FYING THE DAYS OF CERTIFIED
SIGNING.
Terms of payment: Deposit of 1000.00 at time of contract acceptance,balance to be paid
upon completion of work,
Price: 2879.00
Accepted by owner By con 1
Date 4o4a 6