60 WASHINGTON ST - BUILDING INSPECTION 2J7 -
PUBLIC PROPFAT�
OWil KI
N K I 7Z,IN I
F-APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT IAND 2 FAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page
SITE INFORMVTION
Location Name Building
Property Address 40W.46ft
Map#_ V
Located in: Conservation Area YYN Historic district YiN
Use Groups
(check one)
Residential(3 or more Units) R2
Type of improvement Residential (hotel/motel R1
(check one) Assembly(churches) A]
New Building Assembly(nightclubs etc) A2_
Addition Assembly(restaurants, recreation) A3_
Alteration t/- Business B
Repair/Replacement Educational E
Demolition Factory(moderate hazard) F1 —Mow/Relocate Factory(low hazard) F2—
Foundation Only High Hazard If—
Accessory Building Institutional (residential care) [I —
Other(describe) Institutional(incapacitated) 12—Institutional(restrained) 13
Mercantile V!
Storage(moderate hazard) Sl —
Storage(low hazard) S2_
OWNERSIIIP INFORMATION(Please I) or Print Clearly)
I
OWNER Name 0,640-e-7- -J,0C-1Jh1V
Address
Telephone
DESCRIPTION OF WORK TO HE PERFORMED
ESTUMA FED CONSTRUCTION COST
t
CONTRACTOR INFORMATION _
Name
Address
Telephone
Construction Supervisor's Lic #
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #.
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all infonnation stated above is trite to the best
of my knowledge under the penalties of perjury
Signed
Date
r l = CITY OF SALEM
PUBLIC PROPRERTY
?` r' DEPARTMENT
.I I li NI I'Y:)ali('.t n l
WA9HISC.IO:\SIXLLr• SAIENl,MASS.\Olt Nl:I I,6197^
11J.:978-7i3-9595 • I:.ss.978.741^-)s46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricianan Pnnt Lebers
PleasA ) ylicant Information
Organir;uioNlndro ufuuh:
&4GLAFC# CFA/' -lne z
Naive tdu<iocss/
V 7r5— 77
City,Stara%ip:�—,
:\re %au an employer? Check the appropriate box: 'Type of project(required):
I.❑ I am a employer with 4. ❑ 1 mn a general contractor and 1 6. ❑ New construction
have hired the sub-contractors 7 ❑ Remodeling
employees(full and/or part-time).' listed on the attached sheet.
2.❑ 1 ;un a sole ven o employees
to partner- These sub-contractors have K. Demolition
ship and have no employees ). ❑
working nix me in any capacity. ,vorkers' comp. Insurance. ( Building addition
5. ❑ arp
We are corporation and its
IKn workers' comp. insurance 10.❑ Electrical repairs or additions
officers have exercised their
11. in re pa or additions
right of exemption per MGL ❑ plumbing �,p.
3.❑ required.]1 ion it homeowner doing all work C. 152, j 1(4),and we have no 12.❑ Roof repairs
myself. LKo workers' comp• cm lu cc, Ko workers'
insurance required.] ' P Y - ( 13.❑ Other
comp. insurance required.]
:,io:,pphcanl thm checks boz BI n10f1 Alto IIII out ate ection WOW showing their workos cumpensarion policy inturmuoun.
` I Iummlwrw:n who sulunil this nnidavn in(li,:aung they Jm doing all work[tic nten ntc of the subtonirncton And their\tt wlrken'cornp.polity infutrmation.
( at Ili I cl 'k tl'r box moot adwiwd an addiliunal.aluet h m g -
1 am or employer that is providing)vorkers'c•omrpensanon hisurancefor toy eurploy ees Below is the policy and lob site
information
�t u �ifr� Co -Irourancc Company Vane:
fob + `Tj7�p� - Expiration Date:
Pulicv a ur Self-its. Lie. r: /i, / yf
Job Sits -\ddress:
0W ..1KfOL(� ` City;SwteiZip "'+--(
\tt:tcb It copy of the workers'compensation policy declaration page (showing; the policy number and expiration date).
as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
•coverage . . anti a fine
Failure to secure c S 9
nor one-year im risonmcnt, As well as civil penalties m the Conm of a STOP WORK ORDER a
tiny up to SI.S 0011 d an, Y P
t to violator. 13c advised that a copy of this statement may be, turw JrdcJ to the Olticc of
' I ro 5250.00 a Jay abuinst I
nttp
I nc.,u,Juuo;of the UTA for io,ural;ce a,veragc \eritiatliun.
l do herehy certif ceder d pains and penalties uffpperj*ary that rite rufonnutlon prowd(.d above is true and correct.
11':Gil ore
c ry GC(� CC)� Dat•:
Pl, I • = Q�� 3 3 7--46
()fficial m.se only. Do not write in this area, to be completed by city or tolvn official.
permit/License X_ _ _.
City or'I'm yn: -
Issuing :\ulhurily (circle one):
t. Board of Ilcalth 2. Building Department 3.Cits fossn Clerk 4. lilectrical Inspector 5. Plumbing Inspector
6. Other -
Phone tt:
Contact
Information and Instructions `
...Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an replan¢ is defined as "...every person in the service of another order 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
or the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of :ui individual,partnership, association or other legal ennty, 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 (rouse 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."
`1GL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license ar 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 workuntil acceptable evidence of compliance with the insurance
requirements of(his 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 nuniber(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 Offlcials
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 pennitllicense number which will be used as a reference number. In addition, an applicant
that moat 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. it dog licen.Se of omit to burn leaves etc. said b P ) d person is NOT required to complete this affidavit.
I h, 0i(lee or Investigations w'oUld like to drunk you in advance for your cooperation and should you have any questions,
rleaae do not hesitate to give us a call.
I
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
;e;%;sed 5-16-05
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
.j PUBLIC PROPRERTY
30
"' r
: = ' DEP ART'.1vIENT
Construction Debris Disposal Affidavit
(reyoired Ilor all demolition and renovation work)
In accordance %%ith the sixth edition of the Slate Building Code, 7S0 CMR section I 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit if 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
I 11. S 150A.
The debris will be transported by:
/ _/`e.vlc tie,
(nary a of hauler) _
The debris will be disposed ofin
I namr ul I'aeility)
IuJdress of l'acilitvl
,ignuturc of permit applicant
,lalr
Y
So fBmft�tfa ad6`'91Yifftlsf
Construction Supervisor License
• License: CS 21273
Birthdate: 10/31/1943
Expiration: -10131/2009 Tr# 6044
-Restriction: 00.
RICHARDC WALLACE
4 BRAMAN ST
DANVERS,MA 01923 Commissioner
�//ee"�oaavneaoeuiva./!/ a�./l/aaiac�u�.oeCla
n, Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration: 104777 One Ashburton Place Rm 1301
19j, Expiration: 7/15/2010 Tr# 271391 Boston,Ma.02108
Type: DBA
WALLACE CONSTRACTING ^^^777
Richard Wallace 2
4 Braman Street ,».G7-aa-` ��fNot vaLC.+
Danvers, MA 01923 Administrator Not valid without signature
CITY OF SALEM
s BUILDING LICENSE
>
This is to certify That 4_ l
RICHARD C. WALLACE
4 BRAMAN ST. 5}.,DANVERS
- .Mass., ,
Has been granted a license b The Buildin Inspec}or as a
GENER-AT XONTRA(
Attesf:
5/12/93 <cL cc_/�1�'f< y
(Issued) Building Inspector