56 VALLEY ST - BUILDING INSPECTION the ('otnnuvme:dth of ,\lassarhusens
I
a 13tianl of litulJing Regulations and S(andaid,
'a ,, L \l:u>drhux•(Is Stale Buddine ('„de. 780 , R, 7i' iJutm
\II \Il II' 11 I I 1
�I
Iuilding Permit Application TO ConNlwc:(. Repair. Reno)a(e Or I)etiloliAl a K, 111. ./
I !)nr- r)rTuro-l�turrilr /hiellin\' I l .c
-- -- I hu-Serntr rr Olfirtal I"I Unly � ----- _.
Buildin_ Perin Nt iher �
Date Applied:
Si n.uwc 1 ate7u
BwIJmF (',numi,.:u iv ln.ltiitur Pl It iIJ U.ue -
SECTION I: SIT►( INF(IR\I:\ IIO:V
I 1.1 Properii Wdress: I 1.2 lssrssurs \lay L Parcel Numbers —
56-��aL.yty - — - -- _
I Id is lhb .In JCCCpICJ >ileCr� \e� Nr___ Map Vwuher --- ._- P.u..cl ..\uuihi
1.3 %onin ---
g Information:
1.4 Property Dimensions:
'', I 7nnv Urctncrr•nit I I.v, i —_ ._ __ _ __ _—______._ _ .
Front Yard Side Yards
V-------T Near N u,d I
Neyuoed I Pro"ded Ne uneJ
<_- � ___ 4 PnniJcJ Ni yuued !'ii ) JiJ
_
1.6 Wale u I t.N.G.L r .i). < -J------------,
p Y §..1) L7 Flood Zone Information: I.S Sewage spusal Sysrenr
Puhlic Private❑ Zone: _ Ou(side Fhx)d Zone!
Check it yes❑ \huucipal On site dielxrSil y',tem
SECTION 2: PROPERTY OWNERSHIP(
2.1 Ownert )f Record: — —�
I�Name i nti Address for Service: ------ I
`- Telephony
SEC ON 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction Existing Building ❑ Owner-Occupied ❑ Repawy.$) ❑ .AI(eratiom,,) ❑ :\J_b n:m ❑
�i
Denu)!ition ❑ I .Accessory Bldg. O Number of Units Other ❑ Specily —
Brie, f DC�:rtpl i Pruned Work':_�J__
—dQTd'1! _
----
i
SECTION 4: ESTIA►ATED CONSTRUCTION COSTS
Item I Estimated Costs. ----�
II ahor:nd \t:uerrJsi Official Use Only
I 7Lhamcal
I. Building Permit Fee: $ rahiss tee i. JeieinuniJ$ ❑ Standard City/I'o%nApphcatton Fee
❑Total Project Cost' I Item G) a multiplier ___$ _'. Other Fees: $ i yJi\ :\Cr $ � Lnc
Fie --- --
Su I )rc s,ioo) total :\II Fees: 5
b total Prvr'ea'f Cost
) ( heck Nn ('heck .\noun(: __.___( '.i,h
❑ Paid in Full ❑ Oulsi.inJim-,
I
SECTION 5: ('oNSTR( C HON SERN ICES
5.1
LLtlll. Isla 1111c ol "cc
L f2S>
R,,Il ovd I"s, I mull) ,u1, la it'll,
sl-'llattic
\�s
110
Registered 110 irripro%viluent Con
Iru Actir i Ill(U) (�<3
(L Ivr
ji. Re "dille 12 06/0
--:011-2—A
F�rlrju"Il Mae
I-elepholle
slellitute
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT t%I.G.L. c. 152. 2506))
Workers Compensation insurance attiduvit must be completed Ard liahromed w ith thi, appllcatl-In
this aftidaV,[ will result in the dental of the issuanceo[ the building permit.
Signed Affidavit Attached' Yes ...I.... 10 ,,r, .� �.SECTION 7a: OWNER C3
AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner -
it the 11.11711"L I property hereby
to Cif
hch.dt. Ill
w %%ork authorized by this building permit ,Ippication.
DateSlgnalurC ------------
It 011 rier, SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
Wt-) as Owner Authorizedor agent heichy dl the best or my knowic4t: Jild
that the statements and intormitionon the foregoing application .tie true and accurate, to
behal S-TQ0
Print Nain
Date
SILtattle tit Owner Or Aut o ized .Agent
.Stgrted under the ,M',,I'd Penalties Ill pegurv)
in LIFIll 'i-1111.1clot-1,
I. An Owner who o tains a building permit to o his/her own work or an,)wner who hires
I not registered in the Ill Improvement Contractor (HIC) Program). will not ha%e access to thermb d faill-11
program or guaranty fund under 'vI G 1, l 142A ()ther important Inhumation on the Ill(' Pr,,gt ,t
Cons(mcf-in Sup er%isor Licensing ICSIJ can hetoUnd in 7SO('%IR Regulations 1 11) RO :rod 1 10 R5,
k is planned. pio�de the mWornatwn below
When urllariflai work (including garage. finiNhed hj,ejjIeIj[/jLjI1S, decks or portly
tloors area(,Sq. H I
Habitable room count
l,,s I jctng it ej I Sq. Ft 1Number l,i hcdrt,,,m,
ssumberct Iurpluees N'Llinh,:rol 11,11t
N'llilbel of h.1111loom, Numhe, ot ic,k,, poi,hc,
I .pe ,t heating
I sJ,e of co,,Ihlle 'N'tcrin
s he I�jt I i u I edt for IF c,I
"I anal j1r(,Je,j 'it]IJ,Lre l,, age
CITY OF SALEM
a y
PUBLIC PROPRERTY
DEP �RTMENT
Construction Debris Disposal Affidavit
(tvyuired lirr all demolition and renovation work)
In accordance \%ith the sixth edition ofthe Slate Building Code, 780 CNIR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
/1/,,a27'4l S/nE i 'il iw5
(name of hauler)
The debris will be disposed of in
SAZ,C-_AAA
(name of 17lity)
laddress of Iacili(v) -
vgnamrc of p� min app cant
date —
CITY OF SALEM
• � PUBLIC PROPRERTY
j1�
it
a`' o� DEPARTMENT
'Mr:el H:I Y DILM w n l
%IX%k-it 12L WMHIN itw^ST:<tan' • SAL E.M.M.tss.tOII it.-frs0197,^,
Tht.: 978-745.95`t5 • 1'.ts. 97x-741^�lsxt
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Leeibly
\ y tltiant Information /�� T}' ((�,/— , 1
V 81nt: lnu<ntcsvt)rganiratinNlndly utuall: �sTE2 v �eo1 r 'gN �p �
City,Slaw,Zip: �7V G(t^ Mone0:� 7�
:%rc v an employer:' Check the appropriate box: "type a roject(rcyuired):
i - 4. ❑ 1 ;un a general contractor and 1 G. New construction
I. Ian,a employer with_?� have hired the sub-contractors
e 1ployccs(full and/or put-time).' 7. ❑ Remodeling
2.❑ 1 :ull a sole proprietor or partner-
listed on the attached sheet.
ship;Ind have no employees These subcontractors have S. ❑ Demoliriat
workers' comp. insurance. 9. [:] Building addition
working for me in any capacity. 5. ❑ We are a corporation and its
INo workers' comp. insurance 10.0 Electrical repairs or additions
right ight off have exorcised their
i�ht exemption per i.❑ Pm
.MGL 1 Plumbing repairs or additions
3.❑ 1 all, ;,holmowner doing all work c y152, §1(4),and we have no 12.❑ Roof repairs
myself. (No workers' ctnnp. anployces. (No workers'
insurance required.] t m 13.❑ Other
cop. insurance required.]
•nay;,jtpl,caut shut checks box lit most also till out the section tuJuw slowing their workers'compen ation policy Intiuire"i' .
' l Iomer,wnen who submil this affldavir indicating they are doing all work and then hire outside corometon musl vuhmit a new at'f:Javit indicating.ueh.
1hul 'heck this box must attached an additional she•t+hewing the name of the sub-contractors and their wuhcrs'cornm policy mfir manun.
/um un employer that ix providing workers'c•ompensntioa insurance for my employees. Below is the policy urrd job site
hifornrution
----
Insurance Company Vane: L/af�' 1 / q U ..
Policy 4 or Self-ins. Lie. h:
�/S J�`'6 /6 ( _04 X Expiration Date: 0
City,Slate/Zip:
Job Sim :\d<Iress:
Attach a copy of the workers' compensatiu ulicy declaration pate (showing the policy mmnber and expiration date).
hailwc to secure coverage as required under Section 25A of>IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 anLvur une-year imprisonment, as well as civil penalties in the Conn of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violator lic advised that a copy of this stulcarcnt may be lurwarded to the Office of
Invc,ugwton;ol'Ibe MA for insolence cawveragu terilication.
/Jo hereby ccrtifv r er die pu'rs 1u nultir of perjury that the iufortnution provided above is true and correct.
�i�:laulrc' - -
official use only. Do not write in this area, to be cuusplcted by city ur folvrt O ficiuL
City or Town: --- .. Permit/License x_ ..
Issuing.\ulltorily (circle one):
I. Beard of lle:dth 2. ISuildiu , Mpartutcut J. CiINlronn Clerk 4. Electrical Inspector 5. Plumbing; Inspector
6. Other
Contact Person: _ _. Phone it:
Information and Instructions
\lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enipl'oyces.
Pursuant to this statute, an empluree 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 hxegomg engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of .ul 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, cunstruction 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."
%IGL 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, :NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subtfivisions 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 tine 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 Laurance. 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 he 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.
t he 0Mice ill Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please du 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
iC.'Vi,ed 5-30-05 Fax # 617-727-7749
www.mass.gov/dia