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51 WARREN ST - BUILDING INSPECTION (2) ��NBidtlBrilEf O AMMOVED By TW PGOR MD A P.EB4!AGING GRANTED CITY OF_SALEM DW bti PIOWIV Ward In Ioost"m of ""Cato Dillow YN�No_ aaU"us 51 1a14 `I`�r9 ST Y Rawly Woalad in :� �CawlNllgn Awa? Yam Wo_ � BWLDW PERMIT APPLICATION POW Permit to: (Cirole whiotwwr apply) R�f,_Rar� W U�tall Sfdkp, Conatnrot osolc. SMd. Pool. AiRRaplaos. Other. PLEASE RLL OUT LEGIBLY i COMPLETELY TO AVOID OELAYS IN PROCEWA TO THE INSPECTOR OF BIND NG& The undersiprted hereby &XWu for a permit to build a0000ft to the toOWMV Owners Name 0 2 A,�\ AddressliPhone f729 9Vi -8'�h ArduteWs Nan" Address& Phone j 1 Mechanics Name 7'�)R .,; c l i eA Ad ou A Phorm a .9frr (70H 63 y- 0 6 77 V"Ia"p mpoaa or bWldtip? Q e+s ; )� e.a c 1bbIW or bYYdYlp? M a diwalYp,1w how rmny MmAn?�T vm Wi ft mdom to law? Aabaara? EsWnatad coat 4 cs� city Lwn s am umm• © 7 7/ 9'� X SoWum of Applicant 8WW UNDER THE PENALTY OF PBRrURY DESCRIPTION OF WOVA TO BE DONE laLRce_ / T— %JSr�e r1 14 rip e-ia, n �4: l noJ AL; �Z2 TrA.� MAIL PERMIT NO. APPLICATION FOR PEFVW TO LOCATION ✓`/ l PERMIT GRANTED APPYKYVFD OF BUILDINGS The Corotnonwealth ofManschusena iiepanment of IndusMd Accidents / Offlee of Investigations D� !� 600 Washington Slot Boston,MA 02111 www olmsgo e/dle Workers'Compensation Insurance Affidavit: Builders/Contradors/Elecbidans/Plumbers Please Prid Leeibly ADDI Inform o Name � 1 ' ! La � •,-�e_ � Mix iiJS le � _ "_R U/ 4 5YJ_ Addrees.s: /`a- C>if Ys phone# ��►- C�3 A- 0 6 77, City/J1 W71p: /1�11`�Vnie uj.c�3.� the Type of project(required): r2. you as emplayerL Chest 4. [] 1 am a Swazi coutracartor and 1 6• ❑New comtructioa I am a employer with —• have hired the eats coot<acbnemployees(thB and/or put.time)• listed on the attached sheet= 7. �Remodeling I am a soh;proprietor of pa:taa- .I.�sub-eoutracon have 8. ❑ De�litim ship and have no anpbyea w wkew comp. insurance. 9. ❑ Building addthon worldog forme in any capacity. 5. ❑ we area corporation acid its • 10.0 Electrical repairs or additions (No worker(' comp•insurance offtm have aracised their ra juv d) right of exemption per MGL 11.❑ Phtmbiag repairs or additions3.❑ I am a homeowner doing all work a 152,1 1(4),and we have no 12.❑ Roofmyself [Noworkeis' repairer insurance required.]t 0009 employees. [No wod a' 13.❑ Other comp.insurance rep find•)• bill Policy inibamfifign: 0AEY app>i�r dal checb box 01 rout deo 9ttouttbe aedim below all allow gkw west and then at III outgde' 000ttk+tma ww wtmR!now davit iod�a suck f Homeowvees wbo aabout Me dfi&Vit bmWsties w% domes rContruotaa liar drat dug box must atteehd m ed&twnd dicer dlowma the nam of the wtsoonhadm sad 1hde wmtma'cov4.policy mfaamnhon I aw sx ewplay.that i,provfdixd tankers'contpemsatlon lmsurexee for my employees Below!s the poUcy exdJob alts lnforma" Inauance Company Name: Policy#or Self-ms•Lie.#: Expiation Date: ob lob Site Address: MylStatelLip: S(�i�. Attach a copy of the worker' compensation policy declaration page(showing the policy atunber and e*mllloa date} Failure o secure coverage as rcqu¢od under Section 25A of MGL c. 15PI2 can lead to the imposition of criminal P of a to$1,500.00 asdlor ono-ycu�as well as civil penalties in the foim of a STOP WORK ORDER and a fine fine up of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded o the Office of Ins atigations of the DIA for isssra11"c0vaage verification' I d.hariy cs dYs pltlms.xd pc"a&jes sfnerpxy tier the Inform agox provided abow b eras and Correct Odlclsl we adp Do and twits in th6 arcs,m be ensrplsrd by e1V orm m offleld City or Town: Fwmwueeau M Issuing Authority(&dc one): 1.Board of Health 2.Building Depw tnest 3.CkyiTowa Clerk 4.Elecried inspector S.Plumbing Inspector 6.Other Contact Paws: Phone#: iia1V1 111N611V11 Kll\a i11A161 16a\.a.1Vn1L7 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an errphyee is defined as"...every person in the service of another undo any contract of hire, express or implied,oral or written." An sesployer a defined as"an individual,partnership,association,corporation or other kgal entity,or any two or more of the foregoing engaged in a joint cnterprise,ad including the legal representatives of a deceased employer,or the receiver or trnstee of an individual,partnership,association or other legal entity,employes empbyees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occapaot of the dwelling house of another who employs persons to do maintenance,construction or repair wort on sack dweDmg bonse or on the grounds or building appurtenant therein shall not because of such cmpbymem be deemed b be an em ployer.- MGL chapter 152,§25C(6)also states that"every sloe or local licensing apRcy aiau withhold the issaance or renewal of a license or permit to operate a business or to condrad boUdlap I•the commoaweda for sty applicant wb has Rat produced acceptable evidence of compliance with the Insuran a coverage required." Additionally,MGL chapter 1S2,12SC(7)states"Neither the Commonwealth nor any of its political subdivisions " enter into any contract for the perfotmanoe ofpublic work until acceptable evidence of compliance with the instarance requirements of this chapter have been presented to the camractiog anthority.» APplients Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contrxBor(s)name ft address(es)and phone mrmber(s)along with thew cadficate(s)of roan == Limited Liability Companies.(LLC)or Limited Liability Partners members or armem are not required to � )with mr emploes hav ter than the p tegair carry workers'compensation insurance. If an LLC err LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Indusorial Accidents for ceefrn ation of insurance coverage. Also be sure to sip and doe the amdavtt. The affidavit should be returned to the city or town that the application for ihe 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' en compsatiop poliy,please call the Dcpmtment at lib member listed bebw. Self-insured comgmm should enter thcir self-insurance license n enbef on the appropriate lino. (Yty or Town Ofndais Please be sure that the affidavit is complete and prinked lc&br. The Department hm-provided a space at the bottom of the affidavit for you to fill out in the even the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permiNicense number which will be used as a reference number. in addition,an applicant that must submit multiple permidlicense applications m any given yeas,wed 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 stangred or marked by the.city or town may be provided to the applicant as proof that a valid affidavit is on file for tunas permits or licenses. A new affidavit mast be filled out each year.When a home owner or citizen is obtaining a license or permit not related 10 any business or commercial venture (ice a dog license or permit to burin leaves etc.)said person is NOT required to complete ihfs affidavit The Office of Investigations would hies to thank you in advance for your cooperation and should you have any questiomt, please do not hesitat i to`give us a call. The Department's addras,telephone and fax comber: The Commonweahh of Massachusetts Department of Industrial Accidents Office of Invesdgadom 600 Washington Street Boston, MA 02111 TeL #617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised S-2fr05 wwwmass.gov/dia CITY OF SALEM, MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR MINE SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 97 8-740-9846 Salem Building Department Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. The debris will be disposed of in: C A aa4 r,) (Location of Facility)S w A MN Signature of Applicant 11 - 2X- os Date �0 T • gjt' _ P n �e+nma d� Salem Historical Commission 120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970 (978)745-9595 EXT 311 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving 'JA Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property: 49-51 Warren Street Name of Record Owner: Norman & Margaret Roberts Description of Work Proposed: Repair/replace ftow porch wood steps to replicate existing. No changes in color, material, design or outward appearance. Non-applicable due to being in kind maintenance/replacement. Dated: October 20, 2005 SALEM HISTO(R�IICCAL COMMISSION By: The homeowner has the option not to commence the work (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work. go T Salem Historical Commission 120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT.311 FAX(978)740-0404 CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: Construction ❑ Moving ❑ Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other work as described below will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire — Address of Property: 49 C 1 Warmn Street Name of Record Owner: Norman & Margaret Roberts Description of Work Proposed: Restore roofporch per c1930 photograph in all wood. New upper balustrade to match existing lower level balustrade. Bottom width of posts of new balustrade to match upper width of existing lower level columns and new posts to taper slightly upward Roof porch to be painted to match first floor porch. Dated: October 20, 2005 SA4EM HISTORICAL COMMISSION By: Ipm,16,C4 v " The homeowner has the option not to commence the work(unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals)prior to commencing work.