27 TURNER ST - BUILDING INSPECTION f'hr ('„mm,*Ilwralth oI \t uNa.huseltS I I , qt
R� t flojid of (funding Rreulauuns and Standaids i \II Nit II' \1 I I 1
Massachusetts .Sidle BuIIJInc Code. rSlll 'UR. 7''rJitirn' sl
`Y
I Building I'rrnul :\pplicau,m Tri ('tmslruct. Repair, Rrnatatr (h Ik•n„Ilnit a � R,
Ihrc nr- 7nlrl'dmrhlhrlliae
l his SCtIVn Flrr Ottmal l Ise l h,1y'
RuIIJ m�� Pennit N in •r __ -- — Date Api lied:
IF
I BuJJmf Couuw..nnxl n.lu.a,r ut BwWmg, U.tli
� _-- SEC 1'ION I: 51'lli INFY)R\I i'll)N
LI Properly' Address: --- — 1.2 .\ssessors Nlap it Parcel Nuutbers
- - ---
•'' III, \lap \uulhrr 14L:1 ,Vomf:er
� I la is li!Ia ,ur :ecrpteJ slrcr_ ses___ ._--- -,
i.J 7_oninr Information: 11.4 Properly Dimensions:
Prop,n�J Use
\Ica ley 1U Fmrclge I I'I
L5 Building Setbacks Ift)
j From NarJ Side Yards Rear Yard
RalalrrJ e'PruvlJrJ Rcyuued Pn"sided_ _ _ Reyuurd PIl�.r�rJ
1.6 Water u I t.\4 O.L c. 40, §5a, I 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
PP Y=
Zunc: Outside FL.,J Zo :'
Puhhc��Prlrate0 Check if >iunieipul ltl (3n_nr Jisl>t„a1 s%.I-in ❑
41 SECTION 2: PROPERTY OWNERSHIP'
in. I rPe,-
r`iK _ -Cl3RNCL 5T (h.S 1T"2------
4 Address tur Service: _
e _.-,i,_ Telephone
04?—
--- i
I SE'(.'7"ION 3: DESCRIPTION OF PROPOSED WORK'(check all that apple; — -- -
--- _/
�'�rw hotntnution ❑ Existing Building td Owner OrcupleJ Ntpairsl s) ❑ :\Ileraliunl sl ❑i \sIr'I-u_n r" j
_.__
Demohuor� ' Accessory Bldg. ❑ Number ut Units_ Other ❑ S wily
-- O
Bntr Desenpun .rf Proposed Work'_
h-- ---- _-- I
SECTION is ES"fIS1A"fED CONSTRUCTION COSTS
Esumured Costs: Official Use Only �
Item (I.aborand Materials)
I BullJutg Y /Sg�� "'� Building Permit {ee: 5_ InJiiate h,ns Ire a Jc,cnlnncJ
❑ Standard Cilyll"own Apphraonn Fee
I.Iectnral 5 ,
❑ To(al Project Cost Ihrm G) N multiplier x
i. Plumbing 5 '. Other Fees: S_
4 Mechanical 0-IVACI 'S Lrsl: ---- --------- ----
15 klechamcal (fire 1.
Su ,vi s.Inn fir-hrrk ---
�C'hrek `o .\mnunc ('.nh Nnl'iunl
_
b Folal Project Cost S se8fl, ud in Full ._— ❑ Outst.n,Julg B_ILIn.e OIle
r
SECTIONS: CONSI'RCC' HONSFR% WES
5.1 Licensed Construction Supers isur IC'SI.1
I n.m.r Nwuhyr U I-.yin n. n I l.il, 7 �fV-,?Cop
Co( .
\,unr �n l`sL IhdJ,y'I� 1 I nI (,SI. I\Ik• :.cc below
❑
L,Ii i.liJ 1i , INIUI 1•• . I.I
R } Rc,I n. .J I \ I A,Iu 1, I), Ilia
1.11 i:IC
--
I.I:phone \11It_J, II .,I \\ w „ .�u I 1 ii �_• _ _
�9 �+y 111 -\hLI In,�. li•.�
4 6� may/ �.S/ R iJ 11!i.J I> ni L•.i•.0 ___ - _. _
S' RcKish•rc• lon 1nt ucernent untractur011W)
I III' ll�nytun Ni ml I L Re L•! 1 •\JI!IC RC L'!,II JLUI! \Illllhi l'
_ .. -ct•!ys _�-!_� — S Mac
l:�na!w rckpl:mnr —�
SECTION 6: WORKERS' CilliNIPENSATION INSURANCE AFFIDAVIT t:SI.G.L. c. 152. § 2511
Workers Compensation Insurance attidava mull be c,•mpleicJ :old-suhnuned with Ihls apph,an.,n. F,,luie In P!o,lde
this ❑ttidavit will result In the denial of the. Issuance tit the building permit.
Signed Atfidavit Attached'? Yes .......... ❑ No , _.... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR_CONTRACTOR APPLIES FOR BUILDING PERMIT
4 as Owner of the i prnpel'ty hereby
to acl uu my b"h:dt. it .111 mJlicis
:e':a r.:; u; •.,ork ❑ rrimd by Ihi5 buil:.line permit aply Icaunn.
Swnaturc of Owner Date
C SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
L _ . as Owner or Authm i/.ed \gent heichy declare
that the statements and intitrrnation on the foregolne application are true and accurate, to the best ut my know Icdge and
hehalt. - —
Print N:une
SI¢nauue of Owner ur Authunied ,\gent --- Date
!SltncJ under d1c pains and penalucs ul perjury —1
NOTES:
_y
I. :\n Owner who obtains a but Id ing permit to du his/her own work. or an owner who hies A u III rc gl,Iel eJ r,-IIltarn-
Inot registered in the Home Imprn.ement Contractor (1110 Program). will rru( ha,e acre„ tit the .uhlfratton
program or guaranty Lund under M.G.L. c. 11_1A. Other Important mtutmanun on the HW Program and
(',instruction Supervisor Licensing WSI-) can he frnmd in 730 CMR Regulations I If)RO and 1 10 R5. Ic,f,cro,ei\ !
When .uhs(annal work is planned, pro,IJe the Informirion below _
f,tal tlo(-rs area (Sy. ECI . including garage. finished hasenlenti•url,,s. Jerks ::r f+,)i_h, :
C'rro,s him,, area 1Sq. Et.) Habitable room -mint
Numhcr t't r1leplaces Number of hedroont,
Iswiiher ul h.thio,Ins Nunibcr of LAI: I•,oh, ._.... . .. __ .
Number aJe,k,; I,: I.he,
I ,I,c ,d ;���dnle ,,,lens -._ hit:h ,eJ Ilh,•n
t ..I:.aaI Pit,•IccI Square IS�ntage' mas he ,u h,ul ulrJ for 'f:1 .d Po yert I'::,t"
-Elk CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT -
J
'Its/
\Ls�, pit I_: \\ ,.I ,� 1:!:iII • ";: V, \I1..s� !., .� , . =11
ers
NN orkers' Compensation Insurance -solidacit: Builders/ContractorsiLiect use Print L ebihl
\pplicant Information A A/
\al lli mi, le„ t h_.anva t o 4l Ind s i dua l l: / 1>•��A y -
Wdress:
Oily State,Zip: 1411AD Phone :
Type of project(required):
\re tau tin employer:' Check the appropriate box: -
I.�I y 4� ❑ I ail a general contractor and 1 h ❑ New construction
:tin a enlpluyrr w ith
culpiuyces (full and'or part-oole),• hate hired the ached sheet.
7. ❑ Remodeling
listed on the attached sheet.
,. .in, a sole proprietor or partner- -I here subcontractors hate s.�Demolition
,hip and have no employees workers' comp. insurance. 9" Lj Building addition
working for me in any capacity.
(No workers' comp. insurance 5. ❑ We area corporation and its 10.0 Electrical repairs or additions
Officers have exercised their
reyuia homeowner
l 1. Plumbin re airs or additions
1.❑ I am a homeowner doing all work right of exemption per N1GL ❑ g P�
myself. (No workers' sump. C. 152, a 1(4), and we have no 12.❑ Rouf repairs
insurance required.) t employees. [No workers' 13 5yrOther
comp. insurance required] I
•,\ny.,pplieant that checks.box nl must also till out the section below showing their workers compensation policy infumsalion.
' I lon n.•uwners who suhmd this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$'outracn,rs,het.heck this hox must auac hed on uddninnal sheet+hawing the name of the sub-contractors and(heir workers'comp policy information.
site
/airs an employer that is providing workers'compensation insurance fur my employees. Below is Nre policy and job
information.
Insurance Company Name:
Policy q or Self-ins. Lic. q: sl Sg Ol)A_ -2 07 Expiration Date:
City,State/Zip::
Job Site Address: / "��� �� y' —'
.\ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to.,ccure coverage as required under Section 25A tit hIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.5111too and'or one-vear inlprisonnlent, as well as civil penalties in the form of a STOP WORK ORDER and a tine
nt up Io S'SItuO d day ❑gatllst the \Iolator. Be ad%lsed that a copy of tills statelllellt May be forwarded to the Off-ice of
I ill e,t_anions of the Dl:\ Ibr insur:ulce cxl\crlge \cri icauon.
/Ju hereby TerriJi' I e I to airs Id penalties i J'perjury that the infiortnation prtrided above is true Turd correct
Date: - O
pr.„ire :
—(I/Jiri'll ale will'. Do oar n rite in this area, a be a ampleted by city or When official
its or town: _- . .. . --._... —.
_ Pennit/l.icense Is
Fstuing .\uthorily (circle tine):
I. Board nt lleallh 2. lli ilding Department ). ('ih/I'olsn Clerk J. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: ___-- _ Phone --
Information and Instructions
%I,i—.i,I!it,cI IS ( ener.!I I it%s c!!:gnrr I reyunc. .III cmplutrrS I t I Pro\Ide workers compensation for I fie ir entplo\ces.
I'w,u.lnt 11, tills ,t.uute. all r1111pi'mee I, Jelincd .is " eter\ pcnon 'it the ,cn!ee of.ino(her under suss contfjet of hire.
r\pie,. or implied, oral or ttnncii
\;: employer I, defined as ".ut inJlt dual. palfrersh!p. .is.onanon, corporation or other kcal cnuty, or sun two or more
,,I Ilic cn„aged in a Toms enterprise, and u)cludu!g the legal rcprc.rntantc. of a deceased or the
eccner nr nu.,tee of in utJludual. partner,hip. .t.uocjaIion or other Icgal enwy, cntployutg cmplotec.. Ilot\e\er the
ner of a duelling house hat Ink! no( :pore than three apartments and t\ho reside, therein. or t!te occupant of the
tilts ci!ing house of.uwther wkho enq)lots persons to do maunrnance. construction or repair stork on such dwelling house
a .,n the ,rounds or building .Ippurten.uu therew ,hail no[ be:ausc of such emplutntcnt be Jeemcd it, be an en!ploycr.•'
\I(it. cImpter I S?, %2iCto) also states (hat "es cry 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 common"ealth for any
applicant who has not produced acceptable es idence of compliance with the insurance coverage required."
\Jdnionally, \IGL chapter 152, ss?q'(-I stares 'Neither the annmonwcalth nor any of its political suhdiv isiuns .hall
cn(cr into any contract for the performance of public work until acceptable ct iJence of contpl lance 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, are not required to carry workers' compensation insurance. If an LLC or.LLP dues have
employees,a policy is required. Be advised that this af-fidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The atfidavit 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 omciab
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of(he affidavit fix you to till out in (he event the Office of Imestigations has to contact you regarding the applicant.
Please be.cure to fill in the permit,license number which will be used as a reference number. In addition, an applicant
that must submit multiple permitilicense 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
(oft It)," 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 tilled out each
}ear. Where a homc owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.c. I Jog license or permit to burn leaves etc.) said person is NOT required to complete this dff(davit.
I he ([Alice of fit%estigations would like to (hank )ou in advance for your cooperation and should you ha\e any questions,
111CAIC dU I101 lelltate it) 4it'e IIS a call. -
I he Dtrattnirnt , address, Telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021 1 1
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
ya- CITY OF SALEM
A . . PUBLIC PROPRERTY
DEPART'.10ENT
Construction Debris Disposal Affidavit
(rcquired li)r all demolition and renovation work)
In accordance \%ith the sixth edition of the State Building Code, 780 Cv1 R section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris tesulling from
this work shall he disposed of in a property licensed waste disposal facility as defined by MGL c
I I I. S 150A.
The debris will be transported by:
✓
(name of hauler)
The debris will be disposed of in
(IjaAc of facility)-,a //
. 44 -
�addre+, ul I�cllilvl
Y IL llalur �l' It t111l alit '�!��_
Aug 19 08 08:02p Benny Popek 603-279-3103 p.2
j
LI TLr� � 27 Tumer St .
Nrrl�wr Skeet� Unit 02
Condarr*dum Trust i Satmrr hra,01970
I
August 11,2008
To Whom it May Concem:
i t authorize Mejia Construction to work on the porches at 27 Turner Street n Salem Mk as described
below
i
j Shore-up eldsting roof overhang, demo existing 8'x18' 3-porches and exterior lighfirg rebuild new
8'xQ0' pressured treated lumber porches and w8h new exterior righting. Construction debris to be
removed from site daily.
AD work to be done compliant with any applicable building oodes.
i
Sincerely,
Lisa J. Popek
Trustee,27 Turner Street Condominium Trust
i
I
1