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0035 WASHINGTON SQUARE NORTH - BUILDING What is the current use rOf the Building? Material of Building? .LN — It dwelling.how many units "I,the Building Conform to Law? Asbestos? Architeas Name Address and Phone ( ) Mechanics Name Address and Phone Consbuction Supervisors License 0 Hlc Registration i{ Estimated Cost Of�Proj6d S Pik Fee Cftlation Permit Fee S_51 j;- o Estimated Cost S7/51000 Residential Estimated Cost X S41/$1000 Commerciat --- --- - - _ -. a An Additional$5.00 is added as an Administrative charge. \\ Make sure that all fields are property and legibly written to avoid delays in processing. i dq i The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penally of perjury ;ao Date N ro � a `d 3 C �- -- - EI'I rop— - PUBLIC PROPERTY DEPARTMENTq�2P& %IAVM 130 WwvuNG"!MEU . ..... MASIAQI(;SGY13 01970 APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION DEMOLITION,OR CHANGE OF USE OR UC Y FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION , . Location Name: Building: -- - Property Address 39 - �------ Property In located In a;Conservation Aree Y/N Historic Dishict Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: ✓ P7 Sri Address: Telephone: 4)7 8 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use Neer Demolition Existing Approximate year of /9�S Area per floor (sf) Renovated construction or renovation of existing building New Brie[Description of Proposed Work: LY�� ---- -- ----Mail Permit to: --- CITY OF SALEM PUB R P PUBLIC P O RERTY �.4 �_ DEPARTMENT wN1111`RIr.Y DMAX311. MAY<>R 12r nsru1%Gr0lvSTRrf7•SAtE,w.M.sZ.vun.*l n0197;: •ref:971.7454M •FAX:971.740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anallcant Information Please Print Leeibly Name Address: J lBnvix2ss/Organintcio�dln�dilv�luAun: �� ^ City/starc/Zip:�/�222 �r� l'itone A,reyou An employer?Check the appropriate box: 'rype of project(required): 1.CZ I am a employer with la 4. ❑ 1 am a general contractor and 1 6. ❑ New construction employees(full and/ur part-tints).• have hired the sub-cumractors 7 2.❑ I um a sole proprietor or partner- listed on the attached sheet. • 2 Remodeling ship and have no omploya" Theta sub-contractors have a. ❑Demolition workin for me in an capacity. workers'comp.insurance 8 YtrW 9 ❑ Building addition [No worker'carp. insurance S. ❑ We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.(No workers comp. c. 152,§t(4),and we have no 12.0 Roof repairs insurance required.l t employees. [No workers' 13.[ Other comp inwrance rcyuired.] .Alp Vplwa d lint ChL&s hot 01 musi alw rill.nit ate section below dowias their workms'tarmpenuuioa pulley ini rovak i, 'I10 owners who subndt this allldavit indicating they are doing all wort and then hire outside eontracoom muat aUhnil a tow amdavis indicating wch. -ContrxvKa that chuck this box mat anaehod an additianal Akio Aowina the name of the sub-contractors and their wurtm'coop.policy infamatiue. I um an employer that is providing workers'compensatlon Ltsurance for my employees. Below is the pu/fay and job site irrforwrarwn. Insurance Company .Name: 1'olicy q or Self-ins. Lic.ti: Ads/ __�//�y�_._ Etp ration Date: JobSitc.address: 3 /c. 'G!/ VO t City/Slate/Zip: SE*147_ , i Artaeh a copy,of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure w wcurc coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a tlnc 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. Ile advised that a copy of this statement may be forwarded to the Office o Y f Inresngaumts of the DIA for insurance covcra.,c v xiticatiun. I do hereby certi y a d re t%poi t d penul ire of perjary Mar the information provided above is true and correct. 7,7 Of lc ial use only. Do not wrire in Mils area,to be coxWeled by city or town o/j7riaz City or Town: _-. Permit/Llcense A Issuing Authority(circle one): -- 1. Iluard of llealth Z. Building Department ).Cityffotsn Clerk 4. Electrical Inspector 5. plumbing Inspector 6. Other 11 Contact Person: -- Phone p• Information and Instructions Ntastachusetts 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.corpotatios or other legal entity,or any two or atone 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 then than aparmteab 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." NlGL chapter 152.125C(6)also states that"every state or local lkeru(ag agency shag withhold the issuance or renewal of a license or permk to operate a business or to construct buildings is 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 aor 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 eompktely by checking the boxes that apply.to your situation and,if necessary,supply sub-contractor(s)name(s),addresa(es)and phone number(&)along with their certificatc(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 worker'compensation insurance. If au LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 worker' 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 Tows 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. Phase be sure to rill in the pernitllicetise number which will be used as a reference number. In addition,an applicant affidavit indicating current 'von ear,need only submit one i g that must submit multiple permitllicense applications in any given Y y 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 tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Ot ii,x of Givestigations would Ise 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 levesdrildens 600 Washington Street Boston.MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax S 617-727-7749 (evened ;-26 os www.man.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT w.u'::M I r.1t•'�.tll L Tn.W84454S" •Fm-o7i7+69{K f Construction Debris Disposat Affidavit (required fix an demolition and renovation work) In accordance w ith the sixth edition of the State Building Code, 7SO C IR section ill.5 Debris,and the provisions of M- GL c 40.S 54; Building Permit 0 _ _ is issued with the condition dtat the debris resulting Item I this work shall be disposed of in a property licensed waste disposal facility as defined by%1GL c l L L.S 1.50A. j The debris will be transported by: ' tnarae ut luuled _!/ me debris will be disposed of in : (name ut'fxlGt Y) i..d.:h's. �lt'fxiLty) --- i Board of building Reggulaiioas and Standards HOME IMPROVEMENT.CONTRACTOR Registration: 110147 Expiration: 10/9/2008 Type: Partnership MONACO JOHNSON GROUP CHRISTOPHER MONACO - 3 ELM PL MA.RBLEHEAD, MA 01945 - Deputy Administrator � � � V>�P LOfJI�Qrt03rL'CILI[iL ��ZJMt%R6 lb BOARD OF BUILDING F at _" K I License: CONSTRUCTION i � Number:_CS 013075 d , Birthdate: 10/26/1954 4 ; Expires: 1026/2007 Restricted: 00. CHRISTOPHER A.MONACO 3 ELM PLACE MARBLEHEAD, MA 01945 Commissioner s- +I