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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Instal Siding, Conatruot Deck, Shred, Pool,
RepaiNRepW», Olher.
PLEASE FILL OUR LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCEMM
TO THE INSPECTOR OF BUILDINGS: '
The urtdrJ►si{Fted hereby applin for a permit to build accor&ip,to the,follwa tp
Owner's Name 0"A11
Address & Phone �P Crry'' R(j x 9T� 011) 9 9a
Aftkwes Name �hl( V o CACA-
Address a Phone
Mechanics Name
Address d Phone c t
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DESCRIPTION OF WORK TO BE DONE '
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QUINCY NIA 02165-" - x'`jj ;Admm�strator ,,,
The Commonwealth ofMassaehuseas
Department of Industrial Accidents
office dievestl sum.�I
600 Washington Street, /h Floor
Boston,Mass. 02111
Workers'Co m ensatiou Iasuraace Affidavit: Buildip lumbiu lectrical Contractors
name,
address:
city state: i hone#
work site location(full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel
❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition
❑ 1 am an employer providing workers'compensati✓on for my employees workin on this job
e her 1 Pq"" m*�"•'S3�',iy'E�� s�� „y'fT,� '���-�.,t.+�p'rr ac;' $may '
" '•;r. -;4�, 4 , r^{�rv.5 ", r sy y ,p`T ""**n,+ f 'cc' '�'., ^.. !VltP'i'1'•, „ '�°"0.y,+ e'l
address: 0.t
city: 14,4-1
I Is
insuranee_tro. pniisvA " - °' ��
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
comnanvnamr. Preiserwt+ltr/1 GCL'f1p.n4/'Y J7Ant0l lwp4b I(.):.
address:
in ran r v an
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a `ff
J FF2�� �RtNpitNlr, 't✓Af�P�rJI' ` x a co n „xuv.,
mpany namr F'
address:. IJ7� fJG�Q.IJ� .1. 1
`,A,/�-1 1 h t., ,y h', .t Y.ai ti y l Y'•qq {j �57 1 .Y li'f.q, Yy '' i x.:f�c�tal�la t -•-;. 4 i r4 d n'f"`.� rO/7� '+r�"s'+. � y�e�" 'H�1 Noe�a�'� UCtl�O M k r 4. iv MM p •y7 < r 4 r s Bi
'n
Failure to secure coverage ss required under Section 25A of MCL 152 can lead to the Imposition of criminal pennies of a floe up to S1,500.00 and/or
one yean'Imprisonment m well as civil penalties In the form of a STOP WORK ORDER and a floe of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature Date
Print name Phone#
official use only do not write in this area to be completed by city or town omcial
city or town: permit'license a ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑selectmen's Office
❑Health Department
contact person: phone#; ❑Other
Irn'isM SeP� '-�Mnl
r
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the`law", 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 section 25 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, 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 requirements of this chapter have
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the aMdavit. 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.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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
OIfle0 d Investigation
600 Washington Street,71°Floor
Boston,Ma. 021I t
fax#: (617)727-7749
phone#:•(617) 727-4900 ext. 406
JOB , ujcA <),Si - TUPIS N M SHEETNO. OF
CONSULTING ENGINEERS, INC.
CALCULATED BY— l✓�N DATE
P.O. BOX 6560, SALEM. MA 018]1
PH 978 . 745.6817 FAX 978 . 745.6067 CHECKED BY_ DATE
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EXIST. FLUSH—
JOISTS TO BE RE—SUPPORTED i' K-
W/ FULL DEPTH SIMPSON
FACE—MOUNT HANGERS PSON
V10 SKS-28
�,ist FLOOR
CAP PLATE DIMENSIONS ARE
MINIMUM DIMENSIONS. FIELD
ADJUST AS REQUIRED TO PROVIDE
FULL WIDTH BEARING AND MEET
THE REQUIREMENTS OF SKS-2B EXI . TIMBER
BEAM
6 z$A^ (MIN.) WELDED fie^
CAP PLATE
(1) OF (2) Ys^ DIAGONAL (LAG SCREWS LG.
WELDED STIFFENERS, FIELD
DETERMINE EXACT DIMENSIONS 336^0 NOM. (4^ O.D.) STANDARD
COAT ALL STEEL BELOW Ya STEEL PIPE COL. OR HSS(TS)4x4x
SLAB & I.-0^ ABOVE STEEL COLUMN COATED WITH (2)
SLAB WITH EPDXY, COATS OF RUST—INHIBITIVE PRIMER
SEE SPECIFICATIONS I VERIFY FOOTING & BEARING
CONDITIONS BELOW BRICK
WALL & NOTIFY ENGINEER
I PRIOR TO PROCEEDING
1 W30
TYR
PLATE
BASE PLATE PLAN
SECTION THRU NEW PIPE COLUMN
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� JOB NAME: 18 Ward Street
DRAWN BY: GMN CHECKED BY:
CONSULTING ENGINEERS, INC.
SCALE: AS NOTED
PO BOX 8560160WASHINGTON ST.
SALEM, MA 01971 DATE: 03/17/05
PH 978 . 745 . 6817
FAX 978 . 745 . 6067
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4�
CAP PLATE DIMENSIONS ARE
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ADJUST AS REQUIRED TO PRONDE
FULL WIDTH BEARING AND MEET
THE REQUIREMENTS OF SKS-2B EXI TIMBER
BEAM
6-x8"x3'4- (MIN.) WELDED
CAP PLATE I
(1) OF (2) Y2' DIAGONAL I I (2) %-0 CREWS LG.
WELDED SRFFENERS, FIELDLAG
DETERMINE EXACT DIMENSIONS I I 334"0 NOM. (4" O.D.) STANDARD
COAT ALL STEEL BELOW STEEL PIPE COL. OR HSS(TS)4x4x%
STEEL COLUMN COATED WITH (2)
SLAB & 1'-0" ABOVE
SLAB WITH EPDXY, COATS OF RUST-INHIBITIVE PRIMER
SEE SPECIFICATIONS Ki VERIFY FOOTING & BEARING
CONDITIONS BELOW BRICK
WALL & NOTIFY ENGINEER
i PRIOR TO PROCEEDING
y' L P T BASE BASEE PLATE
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BASE PLATE PLAN
SECTION THRU NEW PIPE COLUMN
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3 10 T JOB NAME: 18 Ward Street
DRAWN BY. GMN CHECKED BY:
CONSULTING ENGINEERS, INC.
: AS NOTED SCALE
PO BOX 8560/60WASHINGTON Sr.
SALEM. MA 01971 DATE: 03/17/05
PH 978. 745 . 6817
FAX 978. 745 . 6067
W WW. S T R U C TU RE S - N 0 R T H . C 0 M JOB NO: 04-259 SKS-2A
18 Ward Street
Column Schedule
Column Mark --> C1 C2 C5
Simpson connector at top EPC64 PC66 PC66
Special Notes - Ma be spliced or continuous over C2 -
Roof- 2nd Floor 4x6 5Yex5Yo PSL 4x6
Simpson connector at bottom 2 L30s 2 L50s 2 L50s
Simpson connector at to 2 LS30s Block solid 2 LS30s
2nd Floor- 1st Floor 4x6 5'/<x5'/a PSL 46
Simpson connector at bottom 2 L30s Block solid HGA10
1st Floor- Basement Sill Pipe Column Pi a Column
NOTES:
-Column C2 must bear PSL-PSL at 2nd floor wall
plate, cut out wall plates as req'd to accommodate,
do not over-cut wall plates
-Refer to outline specifications for further requirements
-Columns shall be continuous from floor-to-floor
and floor-to-roof
-Columns of lower levels must align with and
be centered about columns above
-All beams shall recieve full bearing on columns. For
columns noted "Beam splice,"center beam splice
about width of column
-Columns must be centered about existing first floor
main beam
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STPU GU HO Y � SHEET NO SV ZF� OF
CONSULTING ENGINEERS, INC. CALCULATED BY MN DATE �� I
P.O. BOX 8560, SALEM. MA 01971
PH 9,6 . 745.6817 FAX 978 . 745.6067 CHECKED BY DATE
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D PRODUCT 207
18 Ward Street
Column Schedule
Column Mark --> C1 C2 C5
Simpson connector at top EPC64 PC66 PC66
Special Notes - May be spliced or continuous over C2 -
Roof- 2nd Floor 4x6 5'/4x5Y4 PSL 4x6
Simpson connector at bottom 2 L30s 2 L50s 2 L50s
Simpson connector at top 2 LS30s Block solid 2 LS30s
2nd Floor- 1 st Floor 46 5'/4x5'/4 PSL 46
Simpson connector at bottom 2 L30s Block solid HGA10
1st Floor- Basement Sill Pipe Column Pie Column
NOTES:
-Column C2 must bear PSL-PSL at 2nd floor wall
plate, cut out wall plates as req'd to accommodate,
do not over-cut wall plates
-Refer to outline specifications for further requirements
-Columns shall be continuous from floor-to-floor
and floor-to-roof
-Columns of lower levels must align with and
be centered about columns above
-All beams shall recieve full bearing on columns. For
columns noted "Beam splice,"center beam splice
about width of column
-Columns must be centered about existing first floor
main beam
. 0018 WARD STREET 791-05
GIs#: 8644� COMMONWEALTH OF MASSACHUSETTS
MaP x ..x 34 ' e .
-Block: CITY OF SALEM
Lot rr _ nn
Category:. ::". REPAIR/REPLACE
Pernt# 791-05 BUILDING PERMIT
Protect# '- JS-2005-000949-F„v34;;
Est Cost''` $251000 00 s E!{ns
Fee Charged:"," $255.00
Balance Due: " $.00"�,' 3 R PERMISSION IS HEREBY GRANTED TO:
Const. Class:`, Ati'Tt Contractor: License: Expires:
Use Group: �' - a ::,.„ ;PRESERVATION CARPENTRY CONSTRUCTIO SUPERVISOR-084600
Cot Size(sq ft)' 2898.918 r ,,
omn g R3 s�Wwner: CROWLEY EDWARD
Units Gamed: Applicant. PRESERVATION CARPENTRY
Units Lost: " ,� _ _ AT. 0018 WARD STREET
y 1
Dlg Safe#:
ISSUED ON. 29-Mar-2005 AMENDED ON. EXPIRES ON: 29-Sep-2005
TO PERFORM THE FOLLOWING WORK:
791-05 LOFT SPACE TO BE CREATED APARTMENT GUTTED TJS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing? Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Healtb
Insulation:
Meter: Oil:
Final:
House# Smoke:
Water: Alarm:
Assessor Treasury:
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2005-001172 29-Mar-05 330 $255.00
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