10 VALIANT WAY - BUILDING INSPECTION C-rrY-O-F SALEl
�U PUBLIC PROPERTY
DEPARTMENT ,
KIMBHUXY DRISCOLL / Q�
MAYOR 120 WASHINGTON STREEr•SAL L ry MASSAcy{CShI'[S 07970 `1
TtL,978-745-9595 • FAx:978-740-9846 1
G
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: q 4 OaA.Oul Building:
Property Address: r
16 J i le,a,t
Property is located in a; Cons rvation Area Y/N MO Historic District Y/N O
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: L/a' DG NN -S J' d
Address: l
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FY,cTIPJG BUILDINGS ONLY
Addition Existing .3
Renovation Number of Stories Renovated 3
Change in Use New
Demolition Existing
Approximate year of Area per floor (so Renovated a ao
construction or renovation /?F7
of existing building New
Brief Description of Propo a Work: / S
p„f t• 6iu16 f (aoN �?. /A/f}./ Htw 'A
X, *414 ,./ VoN► /)p o.,of" 7We4
t �QiN� / ✓NOu ?, IN/S&
oNt� ��r-.f�t✓ J�'r'�/ -��ew '�w �/../�S'{�C� S7�sr'f{ �J•J7+'r
CVrY' rer►s}i►„� P .�►.+e /i:y /n.t '+^oC► + �' �/N. 6oS'rr�.rni� . .
— - - -
Mail Permit to:
What is the current use of the Building?
Material of Building? t✓QO� If dwelling, how many units?
Will the Building Conform to Law? _ _ Asbestos? -0
Architect's Name /y A
Address and Phone ''11
Mechanic's Name ���V6 M�/ 9 •77/' (0 73�
ne a?S-3 S-L
Address and Pho �^'��'Af
Construction supervisors Li ense# On 113 2- HIC Registration#
Estimated Cost of Project3S Permit Fee Calculation
Permit Fee$ •.Estimated Cost X$71$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 buil tp the above stated
specifications. Signed under penalty of perjury
-Date D
e
9
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-- - -.ate— — --- - — - -- - -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET ♦SALEM,MASSACHUSETTS 01970
TEL:978-745-9595 ♦FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Orgmizatior✓Individuaq: �• ' "l �L 4001V4 /
Address:
City/State/Zip: Ls'eTe 0 L-Oq �,"'y
4 Phone #: 97? 7 7/ G 7.3 F-
A,rr-e an employer?Check the appropriate box: Type of project(required):
1.L I am a em to er with 4. ❑ I am a general contractor and I
p 6. ❑New construction
employees and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7 Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp.insurance required.]
•Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: A>9 / 4) 4�G Ny a 73y Expiration Date: O A
Job Site Address: 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 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$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.
I do hereby cert' nder paid pen ies erjury that the information provided above is true and correct
Signature r ^� Date: R/y�
9
k.
Phone#• / -Ia / 7� 6 734E
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
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
r
Massachusetts 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."
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 cbmmonwealth 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 coinmonwealth 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 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 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 fill 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. a dog license or permit to burn 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,
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 Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
� . J� 8ommonuea�c n�./�,daac�e«de/�d:.
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: .111834
Explratlon:i.--2/4/2007
Type:.,,DBA
KEITH MACDONALD CARPEN_ TER/WOODWORK
KEITH MacDONALD
253 CENTRAL ST
GEORGETOWN,MA 01833 Administrator
BOARD OF BUILDING REGULATIONS
.. License: CONSTRUCTION SUPERVISOR
Number: CS 056432
�. Birthdate: 08131/1,962
Expires: 08131.12008 Tr.no: 28710
Restrict
KEITH A MACDONAt,D:_,,,'...
253 CENTRAL ST
GEORGETOWN, MA=01'833' '
—' Commissioner
• 34 (Policy Provisions: WC 00 00 00 A)
67
1 NY INFORMATION PAGE
l WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY
POLICY
INSURER: TWIN CITY FIRE INSURANCE COMPANY
HARTFORD PLAZA, HARTFORD, CONNECTICUT 06115
NCCI Company Number: 14974 THE
Company Code: 7 HARTFORD
0
o Suffix
.-+ LARS RENEWAL
POLICY NUMBER: 08 WEC NY6734 00
Previous Policy Number: NEW
HOUSING CODE: SB
m 1. Named Insured and Mailing Address: KEITH MACDONALD
o (No., Street, Town, State, Zip Code)
N
0
0
`n 253 CENTRAL STREET
+ FEIN Number: 043522249 GEORGETOWN, MA 01833
State Identification Number(s):
The Named Insured is: INDIVIDUAL
Business of Named insured: CARPENTRY
Other workplaces not shown above: 253 CENTRAL STREET -
GEORGETOWN MA 01833
2. Policy Period: From 06/10/06 To 06/10/07
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: TARPEY INSURANCE GROUP, INC -
PO BOX 567
WAKEFIELD, MA 01880
Producer's Code: 083924
Issuing Office: THE HARTFORD
4401 MIDDLE SETTLEMENT RD.
NEW HARTFORD NY 13413
s (BOO) 962-6170
Total Estimated Annual Premium: $3,595
Deposit Premium:
Policy Minimum Premium: $500 MA
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
Countersigned by ILIA x-)P It.4 I Cr AA C r, G0 'p
Authobzedloppresentatwe Date
Forth WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 0 5/0 3/0 6 Policy Expiration Date: 06/10/07
ORIGINAL
CITY OF SALEM
�• PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY ORISCOII
MAYOR 120 WASHINGTON SIREEr•SALEMI MASSACHL;SEM 01970
-may 978-745-9595 • FAX:978-740-98"
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
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
1L1,S150A.
The debris will be transported by:
(name or hauler)
The debris will be disposed ofin :
e.e de) 7—Tn# f4
/A• (name of facility) M
VV (address of facluty)
sivature of permit applicant
/ e)
date
,Icbrisal7�ut
18" W
4DB
soffit above sink
with halogen
lightin
roll ut
tras bins
Granite top breakfast bar
® 30" Range w/microwave
O O
oven and recirc vent above
Cabinets set at 84" with crown CTD
mould and open soffit
counter
depth
tall pantq ref
or broom
window seat at sill hei