7 SUTTON AVE - BUILDING INSPECTION (4) --
„� PUBLIC PROPERTY
i DEPARTMENT
KIMHFA.EY DRISCOLL
MAYOR I-V WASHING oN SIXEFFr•SAL V l y1ASCACHLSLI-IS 01970
TV1--978-74S-9595 0 FAX 978-740.99"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Locaticn Name: Building:
Property Address:
Property is located in a; Conservation Area Y/N PJO Historic District Y/N V CQ
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: �1 4M c
Address: 1�
Telephone: 73 239- Y9/
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 Desceyri—ptiion of Proposed
Work:
' V Jtida'ti vti V v�''U
Mail Permit to:
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name 4 At D
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ d0o o PermitFee 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 X
Date
m o
CIA
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CITY OF SALEM
�• PUBLIC PROPERTY
DEPARTMENT
.MAW* 120 WASMNGUW S'17 =•c_•,^NLASSACHUSEM Ot970
Tn.-97s-74s-gs"*FAx.976740.964
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
accordance
with the sixth edition of the Stan Building Code,780 CMR section 111.5
Ia ,
Debris,and tha provisions of MQ,c 40.3 54.
Building Permit A' is issued with the condition that the debris resulting flrom
this work shall be disposed of in a properly licensed waste this fmaility as da8ned by MGL a
1 l 1,S 150A.
The debris will be transported bY:
(a&=09 naular)
The dcbris will be disposed of in :
(naaoe of fsoility)
(addrw of facility)
s+�
yi AWc of pe t applicant
/o - y- 06
due
CITY OF SALEM
• PUBLIC PROPRERTY
DEPARTMENT
KIMeERLEY DRISCOLL
MAYOR 120 WAsHNGTON STREET•SALEM,MASSACHUSE775 01970
TEL 978.745.9595 ♦FAX:979-740.9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: -7 SO M
City/State/Zip: S0.\-en., Phone #: 975' 7VS"- y,-3g
Are ou an employer?Check the appropriate box: Type of project(required):
1. am a employer with 4. I am a general contractor and I
em loyees(full and/or part-time).* have hired the sub-contractors 6• New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• Remodeling
shipand have n
o employees These sub-contractors have 8. �Demolition
working for me in any capacity, workers' comp. insurance, g Building addition[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have a 10.❑ Electrical airs o exercised their rep r 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 12,0 Roof repairs
insurance required.] r employees. (No workers'
comp. insurance required.] 13.❑Other.
*Any applicant thin checks bone#1 must also fill out the section below showing their workem'cam 'oo policy Homeownum who submit this affidavit indicating they are doing as work and than hire outside corm rs musty�ormatloa,
submit s new eHidavit indicating curb,
tContractom that check this box must attached an additional sheet showing the name of the sub-contractors and their workers,comp.policy infohnetioa
I am an employer that iv providing workers compensation insurance for my employees. Belo
information w is the policy and Job site
Insurance Company Name:
Policy#or Self-ins. Lic.#: J[- Expiration Date:
Job Site Address: 7 S� In 0.yP City/State/Zip: Ma 01 qY5
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 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 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 under the pains a nalttes ofperjury that the information provided above is true and correct
Signature- Date-
Phone#7 3�0—
=anly.only. Do not write in this area,to be completed by city or town official
n: Permit/Licensehority(circle one):Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
son Phone#:
Information and Instructions
employers to provide workers' compensation for Massachusetts General Laws chapteree i152 defined requires all
"...every person in the service of another under any conetragm hire
s
pursuant to this statute,an employ
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
oeaue construction ntb lling t
se
or on the gromds or buildingPpurteanth eto shall nnt bcaus of sucmploymetbe deemed to work on 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 25C acceptablestatesv Nether the commonwealth nor an of its political ce of compliance with the insurance subdivisions shall
Additionally,MGL chaplet e p § ( )
, y
• 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 your situation and if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of than the
insurance. Limited Liability Companies(LLC��r Limited coomLpr Liability Partnerships(If an)with no LLC or Lemployees
P ldoes have�
members or partners,are not required to carry
rkers
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
regardingepermit
the law license
i you are required to btbeing requested,not hen w orrtme t of
Industrial Accidents. Should you have any qua
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 Otflcisb
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 applicr. In addition,an ant.
Please be sure it fill in the permit/license number which in
g�used ear,need only submit one affidavit indicating current
icant
that must submit multiple sari)and under
applications
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 on file for future permits or licenses. A new af:,davitmust be filled out each
i i
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.
you in advance for our cooperation and should you have any questions,
The Office of Investigations would like to thank y Y Pe
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 Investiptions
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.man.gov/dia
10/03/2006 21:06 9787449188 NORTH SHORE SURVEY PAGE 01
MAP 45 LOT 52
PHYUSS AROUTH
IRON KIABERLY AROUTH
ROD 5.4' S.0' S84'30'44"W LOT CORNER
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SUTTON AVENUE
PLOT PLAN OF LAND
ow �"^ 7 SUTTON AVENUE
SALEM
4 PROPERTY OF
THOMAS RICE & TRACY FLAHERTY
SCALE 1" — 20' OCTOBER 4, 2006
NORTH SHORE SURVEY CORP.
14 BROWN STREET, SALEM, MA #2764
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