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7 SUTTON AVE - BUILDING INSPECTION (2) CITY OF SALEM ' PUBLIC PROPERTY DEPARTMENT KIMBERLEY DRISCOLI. MAYOR 120 WASHINGTON STREET♦SALEM,MA.SSACHLSE'ITS 01970 To-,978-745-9595♦ FAX:978-740-9846 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: Building: Property Address: S� Ut,3 GJL SoAe-mr MG— 01970 Property is located in a; Conservation Area Y 06 Historic District Yd© tA o 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: 2�c-,e- f _ ;rc�r ,,/ u Address: Telephone: 97S ,23 9 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 Rriaf Description of Proposed Work: 1JeNol,s;0o o-F on� (�ccl. w<<� ccoo Gnc� 5G5Ve- ro_k-c— 0A �01A-. Mail Permit to: 12�Z gIL6tz Z e- What is the current use of the Building? VC Material of Building? Wo orb If dwelling, how many units? Will the Building Conform to Law? ✓ Asbestos? Architect's Name Address and Phone ( ) Mechanic's Name T�i Co�S1r�c t;o�J Address and Phone Construction Supervisors License# 06 9 2 7 7 HIC Registration# Estimated Cost of Project$ 600, O o 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 -7 i 0 N O 4., 4n •� Q a � a � F = R _o > V � V � C a d a a d I CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KIMBERLEY DRISCOI.L MAYOR 120 WASHINGTON STREET• SAI.EM.MA.SSACHusErrs 01970 'I-I-:978-745-9595 # FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 4 1 licant Information Please Print LetiblV Name(BusiMWOrganizatiordindividmi): Address: O u'or S City/Slate/Zip. 11i'1a�5l-r—b-e :�Mc.. ofsvSPhone #: 97, ,23 /9/`� Are y/on an employer? Check the appropriate box: Type of project(required): 1.L� 1 am a employer with 4. Q 1 am a general contractor and 1 6 Q New,construction era to ces full and/or arc-tints).• have hired the sub-contractors P y ( P listed on the attached sheet. : 7• ❑ Remodeling 2.❑ 1 am a sole proprietor or partner- These sub-contractors have 8. demolition ship and have no employees working for me in any capacity. workers'comp. insurance. 9. ❑Building addition (No workers' comp. insurance 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions required.] officers have exercised their right of exemption per MGL I I.Q Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work e B 52, 1(4), myself.(No workers' comp. § nd a have no I2.Q Rouf repairs insurance required.]t employees. LNo workers' 13.❑Other comp. insurance required.] Ally applicant that checks box MI must also till out the section meow showing their work=*compensation policy infurrmtiom 'I lomc,,.wn who submit this affidavit indicating they are doing all work and diets hire outside contractors most submit.a new affidavit indicating etch. =Contractors that check this box most attached an additional sheet showing the nmrto of Cho sub-contractors and their workers'comp.policy information. l out an employer that is providing workers'compensation insuranrcefor my employees. Below is the policy and job site information. nn _ Insurance Company Name: Policy#or Self-ins.Lic.#: ___-._____ Expiration Date: Job S lte Address: / •— S-jt� Sc—k-e/ 4,, City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of.'vIGL c. 152 can lead to the imposition of criminal penalties of a tine 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 Invrstigaiiuns ol'the DIA for insurance coverage verification. l do hereby certify under the pains ad penalties of perjury that the information provided above is true and correct SI t tune // Date 7— / — Q G Phon-,7: Official use only. no not write in this area,to be completed by city or town official City or Town: __ — 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#: Information and Instructions Adasachusetts 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." 61GL chapter 152, §25C(6)also states that"every state or local licensing agency shalt 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,IviGL 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 be-en 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 till 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.it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I'itc 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 Deparnnent'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-z6-os www.mass.gov/dia CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASFIINGTON SIAEET ♦ SALEM,MASSACHusETrS 01970 TEL:978-745-9595 ♦ FAX:978-740-9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) r- - In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# __-_ is issued with the condition that the debris resulting from 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 of hauler) The debris will be disposed of in (name of facility) (address of facility) S ature of p it applicant date dr6risafEJnc BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number CSC 06929W -�^ BI ifii St19/1�9�7 . i. 4 Tr.no: 4394.0 Restricted+ THOMAS G RICE - . PO BOX 39 lili MARBLEHEAD;: MA OT Commisaloner