207 WASHINGTON ST - BUILDING INSPECTION (2) CITY OF SALE
PUBLIC PROPRERTY
DEPARTMENT
wMIN RIF.Y TAUK:OLL
M.vvsat 1=V A%C%dr0N STREET*SALEM.WASSvct n.v:rn 01970
'fsL_97V?45.9595 •FAX:9711,740-98e6
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElsMrlcfans/Plumben
Applicant Information / Please Print Leaibly
Name tau-incsw'organizatioNlndiv,dual): 1"'e V CI ..S G o n S r for c—t i p l)
Address: 1 +T- L c-n ;L Av t-
CityiStareiZip:S�va,ansco Hi ISS. t7 Phone #: l�[-
Are you an employer?Cheek the appropriate box: 'Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full araVor part-time).* have hired the sub-contractors
2.to I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling
/ ship and have no employees These cab eontgctora have 11. ❑Dernolition
working for me in any capacity. workers' camp6 insurance. q, ❑ Budding addition
[too workers'comp. insurance S. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
roquirt.tl.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t :mploycas. [No workers' 13.0 Otherfrl t7—
comp. insurance required.]
'Arty+pplwanl that clicks boa el moss also lilt uul ate section Winer slowing tbeir workara'corpeaaliun puticy iu6anrtiun,
'I1W slwnen who subatil this amdwit indleating they ar doing s11 weak and thm him Outside coolness must suIvnit a new amdavil indiaaing such.
:Cuntrwwrs the check this box onust anaehod an addiliaml Am Jawing the nano of dw aubtontracloes sad their worker'Ou'np.policy information.
/am an employer that is providing workers'compensadon htaarance for my employees. Below is the policy and job Bile
informariaa.Insurance Company Name: 16r4%t /P("J. e
Policy#ur Sclf--ins. Lie.#: W C a 3 15 - 3 3 Q .9..(�3(� Expiration Date: 9' f- or
Job Site Address:, 7 b(/4.S ,`ngtr3h Sh. City/stawdzip:Sa��sIl
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.IGL c. 152 can lead to the imposition of criminal penalties of a
tin: up to S1.500.00 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 maybe forwarded io the Office of
lav %iigations„f the DIA for insurarcc c0v:ra,,c vcritication.
/do hereby certify under the pains and petraides ufperjury that floe iufarmallon provided above is Irmo and correct
Si,•:,:wtrc _.. . / X ( L3N� hX.tn,...t,.- Date• Seaj-• y / 07
Phs,t.c#: IV .s R( by.)-u ( e_ ( 1 7kl ? - Sri3Y
Of leial use a,dy. Do not write in Mix area,to be completed by c/ry er town o/jleiaL
City or Town: __. \ Permit/l.leense q
Issuing Authority (circle one):
1. Board of Health 2. Budding neparnnent 3.City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Pcrsmt: _ Phone #:
Information and Instruct
ions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute.an ewpfoyee is defined as"...every person in the service of another under any contract of him
express or implied,lied oral or written."
An eatp/oyer is defined m"as 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
resaiver or tnarttx of as iudiviehtsl,partnership.association or other legal entity.employing employees. However the
vim not more than them apartments and who reside therein.or the Occupant of the
owner of a dwelling house having e work on such dwelling house
dwelling hate of another who employs persons to do mainreaenc°•construction or repair to�an employer."
or on the grounds or building appurtenant thereto shall not became of such employment be deemed
XIGL chapter 152. §25C(6)also states that"every state or local licensing agency shag withhold the issuance or
or rmlt too rate a business or to construct buildings to the commoawealth for say
renewal t a e hats
!x P°
applicant wise has not produced acceptable evidence of coenptluee with the Insurance coverage Additionally. required."
Addr y.i MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shag
ever into say contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of ibis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavitcomPktely+by-checking-the boxes tint apply_to your situation and,if
necessary.supply sub-contractor(s)nan*s),addresa(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLG7 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 retained 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 low or if you an 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 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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must subunit multiple permitilicense 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.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Otiicc of Investigations would line to thank you in advance for your cooperation and should you have any questions,
plcusc du not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Deputment of Industrial Accidents
O®ee of lavesdgedooa
600 Washiaghm Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax Al 617-727-7749
Revised 5-26-05 www.man.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
'a DEPAR'TM. ENT
..I.V:::111 r.Y'''Aft-011
\L�� tit 1 : 11%,404
Construction Debris Disposat Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cods, 7SO CNIR section l 11.5
Debris,and the provisions of viGL c 40,S A.
Building Permit 0 - _ is issued with the condition that the debris resulting ftom
this work shall be disposed of in a properly licensed waste disposal facility as defined by.%IGL c
111.S 130A.
The debris will be transported by:
NQ Ctti Sides Lar 11101
(O.�ICQ J(haulit) � I
The debris will be disposed of in :
Wgod !e L,(414 E✓er'eTt"
to or rxiilty)�
..lt.
4.0 PROFESSIONAL DESIGN SERVICES:.
4.1 Registered Architect
Name: S+ev 2 L j e rAore Seal and Signature=
Address:
Ik. i+-. Mo2AoJ�
zz vJ�51+ i Cr-roo Sr
a _ ,
T ! ,�g Fa)e `cl wo- `flccl
U Re&Wmd Protesslood Engineers: to adet wW draft If neeeemy ar d.asach a applikallm)
Name: Seat and Swwp":
Address:
Telephone: Fax
Area.__Rasponsbili— -
Narne: Sea!'and t3fgnahoa'
Address:
,
Telephone: Fax
Area of Responsibility:
Name: Seal and Signature
Address:
Telephone: Fax
Area of responsibility:
3.0 DESIGN AND CONSTRUCTION UTILIZING.MGL C 112 SECTION SIR EXEMPTIONS
(See note below)
Contract"Nam e��l LS v'eCa n
Address: c1 l ,,,j ^e'
SvJa--MPsco -ti � '"lam Qlc1� "�
Area of responsibility:
'Ucense Number Date of Expirad=
Telephone: Fax,
Contractor
Nartrei•
Address:
Area of responsibility.
license Number. Date of Expiration:
Telephone: Fax
Contractor
Name:
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax:.
Note: For portions of work utilizing exemptions of MGL c. 112 s.SIR complete,the sectlon above.
Use additional sheets if necessary and attach to application.
6.0 PROFESSIONAL CONSTRUCTION SERVICES-
6.1 General Contractor V e-(— Mcr r)
Address:
Ave- .
Telephone: l q S g `b 1 Fax:
Responsible In Charge of Construction:
S� eye S\�verr�o n
i
7.0 CONSTRUCTION DOCUMENTS -to be prepared by applicant
Item d as Applicable
7.1 Plans (Note 1 this page) Submitted Incomplete Not Required }
7.1.1 Architectural ✓
7.1.2 Foundation ✓
7.1.3 Structural ✓
7.1.4 Fire Suppression ✓
7.1.5 Fire Alarm ✓
7.1.6 HVAC ✓
7.1.7 Electrical ✓
7.2 Specifications ✓
7.3 Structural Peer Review ✓
7.4 Structural Tests & Inspections
Program
7.5 Fire Protection Narrative Report o
7.6 Existing Building Survey e
7.7 Workers Compensation Insurance /
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note 1 Areas of Design or Construction for which Plans are not complete at the time of
this application must be identified herein. Work so identified must not be commenced until this
application has been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
8.0 COMPLETE THIS SECTION FOR NEW CONSTRUCflON ONLY ;
For BuildingsProceed to Section 9.0
• Existing
Number of Stories above - - Number of Stone law
Grade Grade-
Story Height Floor Per Floor
Total Budding Height ToQ,Building Area Above
above Grade rade
Total Building depth below, Total Building Area Below
Grader_ Grade
Brief Description of Proposed W
&2 USE GROUP AND CONSTRUCTION CLASSIFICATIOW(New Construction Only),
_ USE GROUP'' : USE GROUP SUBCATEGORY '-doksToRUCTION
0.?a aPP.gble as app6cab: CLASSIFICATION
q Assembly A-1 A-2'` A ,_ A 1A
B Business 113
E Educational 2A
F Factory F-1 F-2 28
H High Hazard H-1 H-2 H-3 H11 2C
I institutional 1-1 1-2 I-3 3A
M Mercantile 3B
R Residential. JR-1 R-2 R-3 4
S Storage S-2 5A_
U Utility 58
Sp
Mx Mixed Useeciy"
Sp Special Use Specify.
9.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
For new construction com I to sect o
v-
Addition - Wnq
- - -
Renovation ✓ Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of `Area per floor (sf) Renovated
construction or renovation
of existing building New>
Brief Description of Proposed Work: _
**-USE GROUP AND CONSTRUCTION CLASSIFICATION(Exi Kjf,,BuildTnjs OnW --1
EXISTING -•PROPOSED Change. "CONSTRUCTION
USE Groups► m - 'CLASSIFICATION
Use. Hazard Use .- Hazard. H x
(now Na°1»- Group Index `iraup Index a `` (J# Ill
y
A Assembly
B Business ✓ s 1 B'.:z
E Educational . 2A-
s
F Factory 20 : ;
H High Hazard
1 Institutional. 3A
M Mercantile 38
R Residential 4
S Storage 5A
U Utility 56
Mx Mixed Use Hazard Index
Sp Special Use
' Note: Include Hazard Index Modifier for Construction Type as applicable
9.0 CONSTRUCTION COSTS(See 780 CMR Appendix L)
Total Construction Cost Building Permit Fee Check Number
(1) s(1)X$0.001
�Ql SDD .-
10.0 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BUILDING
PERMIT (when applicable)
1. . on behalf of the audwizing State
Agency or Authority. hereby authorize, to apply
for the building permit for project number,
Signature Date
11.0 SIGNATURE OF BUILDING PERMIT APPLICANT
Yll yerM.ae 0 'f 1-77y
Name
Signature Date
12. Certificate of Occupancy required on completion of project? _Yes _ No
Inspectors Notes:
Application for Permit to:
Location `
Permit Granted
Izap
Ap ved,
Inspector uildings
CITY OF S.u.&Ni, Ni LksSACHUSETTS
• BuamLNG DEPART.%c&NT
120 WASHiNGTON STREET,P FLOOR
TEL (978) 745-9595
FAx(978) 740.9846
KI\t$ERI.EY DRISCOLL qq6
,MAYOR THOuu ST.PEERRB
DIRECTOR OF PUBLIC PROPERTY/BUMDING CO%L%MIONER
APPLICATION FOR THE CONSTRUCTION;REPAIR,RENOVAT16K CHANGE IN USE OR
OCCUPANCY,OR DEMOLITION OF ANY SUII:DINO OR STRUCTURE
This Seetlon_fw ONkisl Use Only
8yildinq-inrlpsCborf:. . .
Dater start End:,
EslimaEg Profert .
Comrnems
1.0 SITE INFORMATION
r Lmation Names L• V I IV G=I 'LAje LL - 1}--p. 8u0ding t ,-�w�7horn e Y31
Propeif/Address ZO Ica z b� e�rt S
Assessors MapSlodc Lob W=k 3
211 QWNR$1i1 ,lyFORMATION
2.1 Owner of Land
Narrls: 1—I_G-
Address: Sr- i00
So me c kle N(A
Telephone: C�
2.2 Owner or lessee of Md/&V or s&uetun
Name
me- cL-5,. 030vve-
Address
Telephone:
3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name: L-- v t �,i c-vJ < <
Address: Zo ScW+Tc-L S T-
'
t-Atk�Z—ice.: t AO t �'� 0
Agency Project Number.
Project Manager Name- �c- 6o (ZcG2f'V� (lo e u 4