141 WASHINGTON ST - BUILDING INSPECTION .
• Citp Of abaf�m, AiamWbuoetts
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BRING GRANTED
Building Permit Loatios of Bunang
Appliatioa For.
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Additio Alteration. /RapLoe,Fougdnioo Ody,Wrecking
Otter.
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IM PROCESSSING
Totbobvism
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a CITY OF SALCM, MASSACHUSCWS
PUeUG PROPERW DEPARTMENT
' 120 WAsmiva ON S ltmm, 3RO FLOOR
eALuk KA OI Y70
TEL. (976)74E-98M EXT. 300
FAR (978) 740.94"
STANL6V J- /G11 USOWICZ- JR.MA
DISPOSAL OF DEBMI AFFWAVff
in aeccedaoce with ths.providcos o(M(II,a 331,I aelmowledp chat d a caedition
dBn�Peewit ti .all darts raultiop S+om the coaativedon activity
psvamed by this Building Pem b abv be disposed din a peopa<ly Ueeneed solid-waaoa
dLpow aw tlr,ere dsdmd by 11 M a I L ISOA.
13s be disposed dae � , \�'�-�G�S S
Location dPaeiUty
3i dPermit AppUeast
FULLY eosspi the h1lowinS infoemsdow
OU ASB PRwr Y)
�GC�i j 1
Name oPPelmit Applicant
�;fmName�;fa�► f� \
Addreft City State O1Clni
The above sums requires that debris 6om the damoliuM reoovauM rehab or other
alteration otbmldinp or structure be disposed in a property-Iicrosed solid-waste disposal
fadlity as defined by MGZ dM 3150A, and the building permits or licenses are to
mdiate the ioeat oo of the fficuty.
Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
Name (Business(Organization/Irdividual):
Address: —'\:] \�1 �
City/State/Zip: ✓� t , �, a1°� one#: � ��l-����o2jl
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
2Aemployees(full and/or part-time).* have hired the sub-contractors
I am a sole pmprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required,] officers have exercised their ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. a 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that ebecl®lax#1 must also fill out the section below showing their workets'compensation policy information'
t Homeowner who submit this afSdawt indicating they are doing all work and then bne outside wnttactots must submit a new affidavit indicating such
tCont wum that check this box must attached an additional sheet showing the name of the sub-contractors and their workm'comp•policy information.
I am an employer that Is providing workers'compensation Insuramefor my employees. Below is the policy and job site
Information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$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$250.00 against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of d11,DIA for insurance cov verification.
I do hereby certify the and perjwy that the Information provided ab4c Is kue and correct
Si tore: �n (� � 1 Date:
Phone#: `� U—'�-1(,� / 4J I
O,Q&ial use only. Do not write in this area,to be completed by city or town o,0letaL
City or Town: Perna tMeense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. s`.
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,corporation or other legal entity,or any two or rmre
of the foregoing engaged in a joint enterpriK 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, §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 buddiugs in the commonwealth for soy
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
. . "Neither the commonwealth nor any of its political subdivisions shall
2 25 states
Additionally,an,MGL chaplet e ,§. C(7)
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 the boxes that apply to your situation and,if
necessary, supply sub-eontractor(s)name(s� address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LILY)with no employees other than the
members or parmers, 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
Industrial Accidents.. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the DeparVnent at the number listed below. Self-insured companies should enter their
self-insurance license number on the to line.
City or Town 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
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 Dopy 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. Anew affidavit most 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 bum leaves etc.)said person is NOT,cquaed to cv rplete this affidavit-
The Office of Investigations would bike 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 member.
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
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
Real Estate Revitalization
June 23, 2006
Tom St.Pierre
SALEM RENEWAL LLC City of Salem Building Inspector
141 Washington Street 120 Washington Street
Unit C5 Salem MA 01970
Salem,MA 01970
Phone:978 979-9278
I Fax:978 741-7443 The Distillery at Lawrence Place Condominium,Unit 5 Deck
Email:dpabichasalemrenewal.com'
Dear Mr. St.Pierre:
As the Sole Trustee of the Distillery at Lawrence Place Condominium(The
r Distillery),I hereby grant permission to Michael Wenzel,owner of Unit 5 at
The Distillery,to do minor modifications to the existing deck adjacent to his
Unit. The existing deck is 8'6"wide by 11'6" long. The modifications will
entail adding 5' to the deck's length,while the width will remain the same.
The modif will be surrounded by a railing.
Ple feel free call me should you have any questions.
Sincer
David A.Pabich,P.E.
Manager, Salem Renewal LLC