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51 VALIANT WAY - BUILDING INSPECTION EIT�-0��' d PUBLIC PROPERTY DEPARTM��tEnrENT KIMBERIEY DRI5COLL MAYOR 120 WASHINGTON 57AFET• SALKK MA1SACHLShTIS 01970 -ML-978-745-959S # PAX 978-740-98I6 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: j i /A ' / n l , Property is located in a; conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: nit (:E7 S rc,,_f-5 �C � Address: S Telephone: Jac Cz F"-- G 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 (so Renovated Q, construction or renovation of existing building New/ Brief Description of Proposed Work: %3A-1 New �^' k II> l=%c, c, e. /4 t c l-=/A �c �� l-f�.,� r v Mail Permit to: What is the current use of the Building? Material of Building? ktgk Piz If dwelling, how many units? Will the Building Conform to law? y r S Asbestos? Architect's Name A' Address and Phone A,) � ( j Mechanic's Name Address and Phone Construction Supervisors License HIC Registration# j f `7 Estimated Cost of Project$ S00 � Permit Fee Cal ulation Permit Fee$ 3y, �� © Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional$5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated .7 specifications. Signed under penalty of perjury i %�' �,� • /� Date z �' vl0 0 N a+ o° `�i Q a o CITY OF SALEM r: PUBLIC PROPERTY DEPARTMENT KIMBERLEY Ot15ODLL SE'TS 01970 WYOa 120 WASH Xar(Y+S17tErT*SALFl� VhbSACHL TEL-97a-745-9595• FA3:976-740-934 Construction Debris Disposal Affidavit (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code,780 CMR section i 11.5 Debris,and the provisions of MGL a 40.5 54; Building Permit M is issued with the condition that the debris resulting fiom this work shall be disposed of in a properly licensed waste disposal facility as donned by MGL c 111,S 150A. The debris will be transported by: (eama of ltwlar) The debris will be disposed of'in : /G c��77�S I Q r✓� t�of facility) (addrm of hcility) sipatwe o/Permit Applicmt 2� e- .trl�;.Jtdue 09/24/2006 22: 17 6174845155 SICWMALSH PAGE 01 r DAit(MRypgYYY'n ' ACQM CERTIFICATE OF LIABILITY INSURANCE o!/a31200E wwyoeER !L7 �4_ 4 F T)4 4_ S THIS CERTIFICATE H%SUED AS A MATTER OF INFORMATION Inc ONLY AND CONFERf NO RIGHTS UPON THE CERTIFICATE Sico fI Mal sA InsYrance AgencY, MOLDER.TNU3 CERTIFICATE DOES MOT AMEND,EXTEND OR lOf COMMd AW AL R TN E !AFFO BY T !PO EB LOW 0 3B OWRWE NAICf .0 BeSE 1 INDURERf pFPOR01N0 C Belson%, RA 02478 A COO Iasuraaca Co. 002 INSURtD An astor• INsuacA OnaBw if Saavisn Ave. wsuRERa Gran to Instant• Y C Marbl•M•ad, MA Ol949 W WRW C. I NaWPRD IN6L'RGR O T1R POIICBi80F IN$UMNCE LI57ED BELOW NAVE BEEN ISSUED TO THE INSURED MANED ASOVE FOR THE POLICY PERIOD—IN D.NOTWITHSTANDING DING GOVE ANY RE�yEREMENT,TlRM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT NATM RESPECT TO W HICH THIS CERTIFICATE MAY BE IIONS OF R MAY PERTAIN.THE INSURANCE AFFORDED SY THE POLICIES OWQAIDED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS No CONDITIONS OF SUCH POLICES.AOORIOATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS. POLICY NUA•iR T fRIC Y LIMIT$ eR TYPSOFSAVRANCc EACH OCCURRENCE $ 1 000 00 6"m LIABILITY De 1 =47to s 300. coMMtAMLOVARALUAIW:Iry FBIUSS337 03/05/2006 03/05/2007 CLAAA6 MADE Q OCCVR MCD 6xP(LA& VV VOLIFT7 f $ A PERS:WAAAWINJLRY S 1 DD0 gut CERERAL AOOREOATE f 2 000 PRODUCTS-OOMPOP A00 S 2 000 OERL 600ROGATE LIMB AWLIGS PER' POLICY � � LOC j ►UTOROMLE LUaIITY cOMSWGO 9NOLE LIMT a(tA ALCM ANY AUTO ALLOWNEOAUTOS i�M PAS V Y f SCHEDULCO 0009 .RRCO AUTOS (vIReeidRngRY S NON.OWNGDAUTOS - PROPERTY CAMAOC a (P.wegRnh AUTO ONLY•CA ACCIDENT S tMAO@LMaYTY GA ACC 1 ANYAUTO OTHER KY'. AO3 6 RACHOCCURRENCII f SACSSWMSReU.A LM59LITY — — OCCUR F-1 CLAIMSNMOC A00RCOATe S S If RETENTION 1 X WC IITA ' WORRMS COMPENSATION AND ad EMPLRORYpEpRRSa'TUtAtLLRT NC$734436 02/24/2006 02/24/200? E.L.EACH ActENT S 100 0 B CFOiMMSASN,BB=,CW CCvTIvc c.LasGAac.ueMPLOYf s 100 MrV40mm C, E.L,OISeASG.POLOYLW f 5" o. 0960RIPTON UP OPSRATON I LOGTION$I VEHICLES I E%C LU SION%AODED BY ENOORSEMENT I SPECIAL PKWAS&ONS SHOULD ANY OF THE ANNE DEtcRM[O POLICIES BE CANCELLED SSPORRE THIS EXPIRATION DATE THEIReOP,THE lsswNOINSURER WA.L GNDEAVOR TO MAIL IU DAYS ITTGN NOTR:E TO TIe OCSIIPICATE NOI.OSR NAMED TO THE LEFT, SLIT FAILU O MAIL SUCH NOTICE SMALL IMPOSE NO OOLIYATION OR UAERITY o CITY OF SALEM WW0VPCIN TNt INSURER,ITSAOeNTS OR REPRC75NTAT S. SALEM, MA AUT ATrve jw ACORD2f(200VW) FAX: (781)f31-0476 ® OORATION Tfif CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERI.EY DRISCOLL MAYOR 120 WASHNGTON STREET• SALEM,MASSACHUSEM 01970 TEL.978-745-9595 0 FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaalicant Information /J / � ) Please Print Leeibly Name (Business/Organization/Individuai): /fi/t��' v ter/ ;E E/�s CCE Address:, T City/State/Zip J✓�/2/S j Ch`CR 1� yPhone #: Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I 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 10. Electrical repairs or additions required.] officers have exercised their 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.❑ 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 than hive outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 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.#: C_ 3 1& t,l _ Expiration Date: Z ]ob Site Address: I{{r Jkj (Ioft City/State/Zip: ;A`I — /9 7 Attach a copy of the workers' compensation policy declaratt n 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 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 Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties o rju that the information provided ab ve is true nd correer- Z�Si nature: Date: ®�� Phone#: Official use only. Do not write in this area,to be completed by city or town ofjiciaL 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 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 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 its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirement 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any$iven 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 stampe&or marked by the city or town may provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new aflidavic 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 bum 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-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia