70 WEATHERLY DR - BUILDING INSPECTION CITY OF SALEM
` PUBLIC PROPERTY
DEPARTMENT j
KI\IBF.RI.EY DRI5COLL
MAYOR 120 WASHINQTON STREET♦ SAL EM,MASSACHGSETIS 01970
TEL 978-745-9595 ♦ FAX:978-740-9946
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY,FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION _
Location Name: Building:
Property Address:j p-- 1W (Y��
W�.
Property is located in a; Conservation Area YIN AJ Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Lan
Name: c c1�_ 2
Address: wQ 5� Mm i a r
Ji� 2 �o5D
Telephone: I — — 6-0
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
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
BLief Description of Proposed ork:
Shyer �e-asv-f
Mail Permit to: C 6 n (' �
What is the current use of the Building? o ",I A J 1180
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name C.Vatl A 0 J;n 0
Address and Phone far^^S i n n n2 C T� 4 Cb0R�� m �I n g
Supervisors Li HIC Registration
i 3 $�S
Construction SuPcense# 9
tration#� D�O
Estimated Cost of Project$(J�G S Permit Fee Calculation
Permit Fee $ ! Estimated Cost X$7/$1000 Residential
Estimated Cost X $11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
I o
N
O
u
a d a a d y
1
)
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOU
MAYOR 120 WASHINGTON ST REEr• SAt.t'M,ML ASSACHUSETIS 01970
TEL 978-745-9595 • FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
a t licant Information 1� Please Print Le iE bly
Narrie (Business/OrganizatioNlndividwi):
Address:(nr - Ca�nS�r��,�ne�-
City/State/Z Phone #: 4 R���U
,iirc y u an employer? Check the appropriate box: 'type of project(required):
4. ❑ I am a general contractor and 1 6 New construction
I. 1 am a employer with�_ ❑
employees(full and/or part-tine).' have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.:
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9, ❑Building addition
INo workers' comp. insurance 5. ❑ We are a corporation and its equired.] of 10.❑ Electrical repairs or additions
rficers have exercised their
right of exemption per MGL I I.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work !;b P
myself.(No workers comp. c. 152, §L(4),and we have no 12.�(Rouf repairs
insurance required.]t employees. LNo workers 13.❑ Other
colnp. insurance required.]
-Any;,plicant that checks box rH most also lilt out ate section heluw showing their worktas'compensation pulicy infnrrnttion.
'homeowners who submit this affidavit indicating they are doing all work and then hire outside contneton must submit a new affidavit indicating xtich.
!Contracoxs that check this box must attxhed an additional sheet showing the nano of tha subcontractors and their wurkers'comp.*icy information.
1 ani un employer that is providing workers'eumpensation insurance for my employees. Below is the pulicy and job site
iaformution.
Insurance Company Name:_��J.4-�s�—�.�7�p .__.-4—rU. �-
Pones 4 or Self-ins. Lic.#::— C� J� d 7l 1 ._� �� Expiration Date:
Job Sire Address: (1 LLl►\e.�l P t /�� 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 NIGL c. 152 can lead to the imposition of criminal penalties of a
Fine 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. Be advised that a copy of this statement may be forwarded to the Office of
lavesugauuus ul ilte DIA for insurance coverage verification.
1 du hereby cera y uader die pid s mid penalties of perjury that the inforinallon provide abo a istrrue arid!correct
Phtnc / n � 10
Official use only. no nol write in this area,to be completed by city or town ofjiciaL
City or Town: . ..__—
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing inspector
6.Other —
Contact Person: _.__.__ .-_---- _-- Phone#:
ry
Information and Instructions
Ddassachusetts 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,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
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 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 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-contrdctor(s)name(s),address(es)and phone nurnber(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
he returned to the city or town that the application for the pennit 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 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure ro till in the permit/license number which will be used as a reference number. In addition,an applicant
that must su6rit multiple pennidlicense 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 tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
1 i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. ,
l'hc 011ice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OIHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMOERLEY DRISCOLL
MAYOR 120 WASHINGfON M-REEF ♦SALEM,MASSACHUSETCS 01970
TEL:978-745-9595 ♦ FAx:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# ___ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
T 1 ,(name of ha ler) q
1'reti nsb f� 1
swilll b be lsposed of in
(name of facility)
(address of facility)
6��Lsignature of permit applicant -
date
dcbni affduc
BOARD of BUILDING REcuu►noNs
Cleanse• CONSTRUCTION SUPERVISOR
v+ Ntunber. CS:. 085086
•
Fx .
G Birthdate• 0723/1979 .:
Expires:07/Z IM7 Tr.saw 85086
Restricted; 00
STEPHEN H OBRIEN
56 FITCHBURG RD#531 """"��-" 'r_✓:.
TOVMSEND, MA 01469 - Adminisbator
v
./fte TOaGVHem�[U/¢¢ll�. o�!la`wlltGtu4¢�
-. 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
a _ Registration: .133895 One Ashburton Place Rut 1301
Expiration:-"8/2212007 Boston,Ms.02108 .
Type: Public Corporation
0.1C.CONTRA CTING INC.-
LEONARD NTINE' R.
62 CONSTANTI A OR S- � ��� —
TYNGSBORO,MA 01879 Administrator lYoYvalid without signature
This is a test print to see if it's going to work!!!!
a
v
f
08/03/2006 10:35 FAX 6036448716 1A 001/001 -
38
AMERICAN HOME•ASSURANCE COMPANY 3883z-DDC17 wc - ----- 1. --
13781 013-82-1205-00
,,, , NEW YORK
,.
MC CONTRACTING INC I O I fAember Companies of
62 CONSTANT I NE DRIVE w-leriCan International Group
TYNGSBORO. MA 01879-0000
EXECUTIVE OFFICES:
70 PINE STREET. NEW YORK, N.V, 10270
SEE NAME AND ADDRESS SCHEDULE - WC990610
Lon M �•
XS BROKERS INS AGENCY INC
WORKERS COMPENSATION AND EMPLOYERS PO BOX 690355
LIABILITY POLICY INFORMATION PAGE QUINCY. MA 02269-3324
INSURED IS PACVIOlJS POLICY N11MdFa
CORPORATION RENEWAL 0063278
OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME SAND ADDRESS SCHF ULE WC 9 9-(1610
REM t POLMY PCAIOD 1r:D1 AM.stmloma 16nw.1 the InsuraP'i
mD;nnn.adrnss FROM 12/27/05 TO _12/27/06
ITEMS A. Worker, Compensation Insurance: Part One of the Pnllcy Opp11e5 to the Workers Campenaatipn Lew of the States listed
here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to the work In each st:tc listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident S 100,000 each occident
Bodily Injury by Disease I; 500,000 policy emit
Bodily Injury by DISCOS* 9:,.� 100,000 eocn employee
C. OTher States Insurance: Pon Three of the policy applies to the states. It any, listed h0'e:
AK AL AR AZ CO CT OC DE FL GA HI IA 10 IL IN KS KY LA MD PE MI P,N MO MS MT NC NE NH NJ
NM NV NY OK OR PA RI SC SO TN TX UT VA VT WI
nEMa The premium for this policy will be determined by our Manuals of Rules. ClassifIcAtlenC.-Rates and Rating Plans.
All Information required below is subject to verification and change by Audit.
E.:m.led f01e1 Rate Per Eilrrn.l.d
coda Number R.ronnOwnu^ 3100 OF no. wen.mm
fmxxilknfe.a rr--�� munemilDn
a Ar noal l�f ]YDir O Mnu.l 3 YP.r
SEE EXTENSION OF INFORMATION PAGE - WC7754 $699
TAXES/ASSESSMENTS/SURCHARGES
CXPCNSE CONSTAW I"CEM WHERE APPLICADLC RY STATEI S 284 MA I
MINIMUM PREMIUM $SOD MA _ TOTAL CSTIN-Aril)PREMIUM
H ind Cored DplOw. In1aPm.alnxlmnnn 01 AlDmlbm Ca011 bD T109 ---
3nmr Ann0srlT Oue•ler ly MOMaIY DEPOSIT PRIM tam ..—.
EHOORSF,MENTS(FOAM NIIMDER) SEE ATTACHED FORM SCHEDULE - WC990612
11/07/05 PARSIPPANY _ 82
txann Oate "'.i"Office // .1UTAon,etl Reprbientallve WC 00 all el
109G1 ��
III _