The URL can be used to link to this page

10 SUTTON AVE - BUILDING INSPECTION (3) / � - , � Gr�� 3 7� �I��`�LE1VI— �� ' PUBLIC PROPERTY \ �" � 3� DEPARTMENT �� I:I�mERLEYDRI5I;OLL � �(AYOR �?p WASHINGl'nN S'IREEI� � VA1 A��UsS,�c�tLStl'rs 01970 'l�978-745-9595� Fnx:97&7i0-9&I6 APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION. DEMOLITION. OR CFIANGE OF USE OR OCCUPANCY. FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION � � � � Location Name: Building: Propeity Address: �_ �l��C.r�i.c.,, p t Property is lacated in a; Conservatlon Area Y!N�_Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner ot Land Name: � _ � Address: t0 Sc�-r-C'��l /�`�. � G�„1 r'� Telephone: g . ,�.. Z 3.0 COMPLETE THIS SECTION FOR WORK IN F�r�aTiNc= BUILDINGS ONLY Addition Existing Renovation � Number of Stories Renovated Changein Use New Demolition �xisting = Approximate year of Nrea per floor (s� Renovated construction or renovation of ezisting building New Brief Description of Proposed Work: REw,ove. c�e-,li� ;wa-lild--Fl.c�vv� sJv-Fa�7 �� n��c � 5uo�-1 �low-_ EL�u..�i..�z�Cc, a `�a�;.�, a..�e►. G' l,os�if ��- Ykove� s�-�e C:2�� vt.P.t.� D�y^{� ad�l�. ��3e. �vo-� 6�,v5. ��-�v� �.�1 ��k,�.., f �a�y �..,�. �,�.-�/� -�� ul�`' c�� yi`'� , �w�s `�' swT�ct�cl �BlY �'y��•�, v �ba� •�lu-lv�c�( �.w� (�c2-Er-� _ _ _ _ ._ — _ _ - - _ - - — -- _ - _ _ Mail Permit to: S � G � o � 5' p1q�� . , � � _,� What is the current use of the Building? S'�P �a r + �� d�'''GC Material of Building? if dwelling, how many unRs? � Will the Building Conform to Law? Asbestos? ArchitecYs Name Address and Phone � � � Mechanic's Name � Address and Phone�o � F�'�� '� , M� �� ConsUuction Supervisors License# CS �9 I �i 0�3 HIC RegisVation#��j�� Estimated Cost of Project S a �- '"" Pertnit Fee Calculation Permit Fee$�� Estimated Cost X$7/$1000 Residential EsUmated Cost X $11/$1000 Commercial M Addkional $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. Sig�ed under penalty of pery'ury ��%��%«/ � Date �� ✓ �� I� � I � o N I a.�i'\ l .� g� '' � .op � a .. a � c a' a o o � F � ti ab+ i � ;� �3 '+� i a�i a u� � _ � a I - — = a� - .o-�-- v— —��—'�- i�— _ :-- --- --- - -- - _--- i � �\. �� CITY OF SALEM . � � ` ,�. PUBLIC PROPRERTY �� DEPARTMENT KIMBEA[EY DRISCOLL MAYOR IZO WASHINGTON STREET �SALEM,MASSACHL75ETT5 01970 - TEL:978-745-9595 �Fnx: 978-740.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApUlicant Information Please Print Leeiblv . ' 1 / N3rilE (Business/Organization/Individual):�P�e�/�lL4.�, �f,►�,� �lJl.l V2yDftil.S �6V P.ddress: lo�O l fAr�l�-+�l 5`�� City/State/Zip:��_�1c[�!7 Phone #: �/ 7�'- 7�• /�9 i Are you an employer?Check the ap,propriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construc[ion employees(full and/or part-time).* have hired the sub-contractors 2.�I am a sole proprietor or par[ner- listed on the attached sheet. $ �� emodeling ship and have no employees These sub-contractors have 8. � Demolition workin for me in an ca aci workers' comp. insurance. B Y P tY� 9. � Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.Q Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself. [No workers' comp. a 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] "Any applicant tha[checks box#1 must also fill out[he section below showing their workers'compensation policy information. t Homeovrtiers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. �Contractors that check this boz must attached an additional sheet showing the name of the sub-wntractors and their workers'comp.policy infortnation. I am an emp[oyer that is providing workers'compensatian insurance for my employees. Below is the po[icy and jab site informatian. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy dedaration 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 unposition of criminal penalties of a fine up to$1,500.00 and/or one-yeaz imprisonmen[,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 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. !Jo hereby certif under the pains and pena[ties ojperjury that the infarmation provided above is true and correcG Sianature��—C�f�'i[_J�� Date• l� ` `r �(o �_� Phone#• �7� ��( 1z7� Offrcial use only. Do not rvrite in fhis area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Au[hority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: � s --� �y/.'�4 ' /rv'Y' . h Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an eraployee is defined as"...every person in the service of another under any wntract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corpora[ion 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 entiry,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." 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 acceptable evidence of compliance with the insurance coverage required°' Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of i[s political subdivisions shall � enter into any contrac[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 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,aze not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is requued. Be advised that this affidavit may be submitted to the Department of Industrial Acciden[s 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 Departrnent of Industrial Accidents. Should you have any questions regazding the law or if you aze 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 Depariment 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 fill in the permidlicense number which will be used as 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 locatio�s in (city or town)."A copy of the affidavit that has been officially stamped or mazked 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 affidadit 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. a dog license or permit to burn leaves etc.)said person is NOT requued to complete this affidavit. The 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investlgatioas 600 Washington Street Boston,MA 021 ll Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-OS .�K,,mass.gov/dia +h ' y � �. CITY OF SALEM �• � ' PUBLIC PROPERT'Y I�, R�-�""� DEPARTMENT K�nro�ueY ort�scou. �1AYOR ' 130 WASHINGTON$7REE1'� $.1IF.M.V1A15ACH�SETIS 01970 'ITt.:978-7i5-9595 � Fnx:978-740-9&f6 Construction Debris Disposal Affidavit (required for all demolition azid renovation work) In accordance with the sixth edidon of the St�te Building Code, 780 CMR section l 11.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued witkt the condition that the debris resulting&om this work shall be disposed of in a properly licensed ws�ste disposal facility as defined by MGL c 1 l l, S 150A. The debris will be h'ansported bY: /li A <rl / N _�� 4A,1P_ (n�tne ot lululet) The dcbris will be disposed of in : ��c� �.�_��-_ (name of fac�l�t� 2`� fl-�n. . ,_ ,�-�E- 1`7-,o�t�dt�� .. • (rddress of fxdiry) � �—��n!/itJ�i� signaturc of parmit applicant l6•.s o� a�� Jrbiii�fLduC 20'3 'I/8" it) C- t'D C:5 t'7 :.3' Q � � $17 2846 2846 2846 3046 � � � � � �-s � ;g � .-� .-a- �� ry � � � � � � � � �� ,� O p _ � �� m �' pl-j \. � -- ' N ! � � � E � � � � ' _ ..�. - a�.:.-v- W . �• .. 2068 '. ,� r--� � � �/ . � g _ � � i�; vi � � i I �.. —� � �� f I - 2668�-- _.. . . . , �-2668 "�.-,� �` � � � � I �� -� N � .S� (� � n,y �° N S� � N (11 ` A � � 0 f1 W � � II , � U � m A . _% CP = - �_- � � i� � � i ,g �� y6 ,A�2�� - —zssa— 2ssa zssa / � � f � \ �� , � ��,� �� :� � �— s � N �\ �S(� � o R p � m � \\ o � 3`� lU.�i� O � & o _ t`� � � ' 1 �J N �-� N c � � . � j�N � N - ' � (i. ' - F � � � � �-� � , � 2646 2646 2646 2646 i20'-3 l/S° �I i- ��8l4 £-�OZ � 9b9Z 949Z 9>9Z 9b9Z (V � � � ry N � � � \\ p /�, � � o O (� N � � r � N \ �� \ � � �� . � � 899Z ��—�� / 899Z— , I I ��L/L 9-.9_—_ I i , � j i — - -j �n a \ � i I�} �-- _ / I �n � f0 N � V � G � �� I �� \ / 8905 ' \ \� � l � -_ \-�_ . �� -- _,_ _ � � ,/ \\� C�.3 zt� �. � N � � II / . N ((� � � �I � O O .g..a a ��' � � � tl? � CEc � � � � � 'T.: �a.. 940£ 9b9Z 968Z 9bBZ � .� � � � C7 t� C3 � (il �a rn „8/l £-�OZ I I _ __ �_ - _ _ _ _ —__ _