11 WEST AVE - BUILDING INSPECTION -------- — -- - I he l +41111iow.l.e;dth (11 "llas,,Rhll NCIIS -�---
t Boald +,l Building RCL!ulallonri and S(and'ilds I I Ilt
t .y \l:u a hu.rtl Slalr Building Code. "SO ( NIR. 7"' ��Jul+m i \II .�li ;ii \I i I 1
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\@ Building Pet mil :\ppli cal ion ru ('unsuua. Repair. f2Cnrn lie lhI)rin„li,h .1 /L „ •/ r,i.i+„i.
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BuJdutg Permit Not er. _ Dale .\ppheJ: _ -•_10 eo'6.. .
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SEC"'TON I: SFI'F: INFORM:\ PION
1.1 Properh Yddress: 1.2 \Ssessurs flap & Parcel Nunlbc
t' AWESt- PtJ6• - 1 teM--M -- 01370 — •
\lu ..\uniher I'.n.:I \umhCi
I Ia 1S Ihu .m aCcepmJ ,Ircet' %e, _ _ it,,
i.3 ."Zoning Information- i 1.4 Property Dimensions j
__.-______..__. —_ —_._._.-_. .._,
1.5 Building Setbacks (ft)
Fr..et Yard I lid, Y.irds Rear Y:nJ
R ay!ul Cd i PrUUJCd Rcyu it Fr,,.ulcd Rnluu CJ I Pu, iJid
1.6 \ti'ater Supply: 1..1.G L c. 10. §51; 1.7 Flood Zone information: 1.8 Sewage Disposal System: j
1 Zune: __ Outside Flood Zone:' I
PuhLC ❑ Pncate❑ Check it yee❑ \lurn"Pal ❑ On ,fie Ji,pu,al ,e,iCm ❑
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SECTION 2: PROPERTY OWNERSHIP'
2.1 O1..'m iof Record•
\ ? Q \)C iI WEST,r seA VG, 5 LEP1
--- -- q7,? — Li ,6,3 - 7648 _-.. .
Sign,turf Tclephune
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New CunstrLICtiun ❑ Existing Bit Wing ❑ Owner-Occupied ❑ Repmre(S)S) \IterwunlSl .\JJnr.-:! ❑
Demulitinn ❑ Aece SSury Bldg ❑ Number of llnns 7 Lother ❑ Spccil7
Brief DCScrn;n,m ,i;1 Proposed W'urk".— C aMh L NE. 2ND $ 3QD P=1-00K5 li\1T0--S(NGLt
r SECTION 1. ESTIMATED CONSTRUCTION COSTS
Eonmau Coots:
Item I Official Use Only
� ILuhur anJ NlacernJSl
I IiuilJine $ �� I Qq I. Building Permit fee: 5 O Indicate h+,�% ICC 1. dClCf 10 nCd:
❑ Standard Cil WJ'uwn Appiwan+m Fee
' Flennral 3, �` tJ _; ❑ -rotal Project Cost (item 6) x multiplier ____ x
J Plurnbmg S 21 -50' I '. (Aher Fees: S
1 Me",hamcal 01V \CI S List' _
.\1e'h.uuCal (Fire
1u + v e„i,mi ! S
_LL__
l'heCk No JO l�lteCk .\nt,nuv� Z3_.p._(�.nh \ni,n,nl
b fatal Project Cost laid in Fall 0 [)lie
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SECTION 5: CONSTRuc rION SER%'ICES
;.1 licensed Construction Sti er.isor I('SI.) Lit I?/aolz
,awic i CS]. ll,,IJcr --- U
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5.2 Re i.terrd Home Impruvemenl Contractor (MC) 16002
i01 rN
MC ('11,11I n Nut or MC Rrgistrint Name Regl,uuuon Number
32
OsP,oftNE 54 SRLFYj HA 01970 611711010
-
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� � 781 -913 abfb _ F.a{,uuu,.., Date
]Iguature reiepttune
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance at must be completed and :ubmi tied wilh this appl icm ion. I-,ulure n, pro,1de
this alfldivit will result in the denial of the Issuance of the building permit. -
Signed Affidavit Attached'! Yes .......... ❑ No ❑ -
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject pr,Iperty hereby -I - - -
authorize to act on my behalf:-in all m.uters j ...
re!ative to w,nk authorized by this building permit application.
SI¢nature of Owner Date
SECTION 7b: OWNFW OR AUTHORIZEDAGENT DECLARATION
1 as Owner or Authorized Agent hereby Jeclare
that the statements and information on the foregoing application :ie true and accurate. to the best of my knowledge and
j behalf.
Pant Name -
Sienawre of Owner or Ruthonzed Agent Date
1 tic mid under the sun and penalties ul rru 1
NOTES:
Owner who obtmns a building permit to Jo his/her own work, or an,"%ner a,ho hires an unregl,let Cd k sutra, tin 1
(not registered in the Home Improvement Contractor IHIC)-Program), will not have access it, me .uhitratu j -
program or guaranty fund under M.G.L. c. 11'_A. Other onportanl intLrmation tin the Ill(' Prneram and j
Construction Supervisor Licensing WSL) c.)n he totmd in 7SO(AIR Regu Luton% I I0.R6 end I 10 R5. re,pectoO,, j
' When ,uhstantial work is planned. pio.iJe the mGamation below: - -
rIual floors area iSy. 1:1,1 Imcluding garage. finished ha.ement/aulcs. decks ur pooh,
Gros h%me area 1 Sy. Ft.) Iiahllable room count ---.------- -,
Number of nreplaces Number tit hedli,ult),
NUMbel or hathnn.ms Nunther tit h.;lliKoh, -
I\I,r �if beannp ,v,lcm _.__ Number "IJeaka/ p,-i.he, -
�
i_ Tuta Project Square Puutuge" rn.n be ,ab,unned ill( 17 nal Prolect Co,f'
CITY OF SALEM
y PUBLIC PROPRERTY
DEPAKTMENT
r,•i r. C; \C.�,i u�.�,.,�N>r Lf r • >.\1 i m. Sln•;
978 '4.'R844,
Construction Debris Disposal Affidavit
(rcquired li)r all demolition and renovation work)
In accordance � ith the sixth edition of the State Building Code, 780 C1v1R section 1 1 1.5
Dcbris, and the provisions of b1GL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal 13cility as defined by MGL c
111, S 150A.
The debris will be transported by:
PloyyCN
1 name of hinder)
The debris will be disposed of in
(na11me of facility)
Swarmpsc P-d 5At uh
(uddress of t6cdity)
C
slenalm'c ofpc rmw applicant
(og -
--�� late
.� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
NIA"'R A \'i it?:,I!,I\S I RI f I it S.il! M, MAC A, !li 'i I
111: 9-8-74;-.5,i; • 1:\\. 9-8-74:-9844,
\Workers' Compensation Insurance :Ufida%it: Builders/Contractors/Electricians/Plumbers
i rplicant Information Please Print Le2ibly
\:title llivana., ()rg.mi�ahun lnJnt.ht,tl t: w10 ARCH
\rlilress: 38 O Sg�✓R NG 5�-
c ity. st:lleizip: 5ALr=q 0610 Phone 41 it qu &06
%re you an employer? Check the appropriate box: "rope of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 - 6. New construction
eat to gees(full and/or art-time).' have hired the sub-contractors
p y P' 7. Remodeling
'. I am a sole proprietor or panner- listed on the attached sheet
these sub-contractors have 8. ❑ Demolition
shill and have no employees
working for me in any capacity. workers' comp. insurance. y. ❑ Building addition
No workers' cum insurance 5. ❑ We are a corporation and its
r e P officers have exercised their 10.0 Electrical repairs or additions
required.]
3.El I ❑m a homeowner doing all work g P
right of exemption per MGL l LE Plumbing repairs or additions
myself. (No workers' comp. C. 152, §1(4), and we have no 1_2.❑ Roof repairs
insurance required.] t employees. (No workers' 13 ❑ Other
comp. insurance required.]
*Any applicant chat checks box 01 must also till out the section below showing their workers'coinpensution policy in formal ion.
t I lomeuwners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit anew affidavit indicating such.
�CIIWIaetors that check this hux must attached an additional sheet showing the name of the sub-cuntractors and their workers'comp.policy information.
l pin Ott employer that is providing workers'compensation insurance fir my employees. Below is the policy and job.site
inJ'orination.
Insurance Company Name:.
Policy At 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).
railure to secure coverage as required under Section 25A of SIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to }kioo.00 andlor one-,year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to j250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Intcetieations of the DIA for insurance a»wage ccrificmion.
/do hereby"erti/j-under the pains and pe nalties q/'perjury chat the injoratution provided above is trite and correc
J t
�i_nuntrc: 10 Date: D7 / O
PI: n -781 41 r�6
t ylicial use on/y. Do not write in this area, to he completed by city or town ojjiciaL
City or Iocsn: _ —_-- _ Permitil.icense #_--- _---
Issuing .%uthority (circle one):
1. Beard of Health 2. Building Deparunent J. Cih7rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ---- — —
Contact Person: —_-_. -----— Phone
Information and Instructions
\lassac huscus General I..a%S Chapter I5' re,luues all cmploNers to prow ide workers' compensation for their entplo ees.
I'ursuant to this stauue. .ur rmphrree is dclined as ". ce ery person in the service of another under any Contract of hire,
Lyrics or implied. oral or written...
.\n employer is defined as "an indi%ideal, p:uvtership, association:Corporation or other legal entity. or an} two or more
tlhe lorC¢oing Cngaged in a loint cntcrprise. and including the legal representatives of a deceased cmployer, or the
rcceiv cr or trustee of an individual, partnership, association or other legal entity, employing cntployees. I lowever the
o%%ncr of a dwelling house having not more than three apartments and who resides therein, or the OCCupant of the
dvv elline house of another who entplOvs persons to do maintenance, construction or repair work un ,uch d�%elling house'
„r on the ,rounds or huilding appurtenant thereto shall not because of such cntplo)ntent be deemed tO be an employer." .
\1(il- chapter 152, g25C(tf also states that -cvcry 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, M(;L chapter 152, S25C(7)states "Neither the commonwealth nor any of its political subdivisions shall
cntdr into any contract for tits perfonnance of public work until acceptable cvidence 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-contractor(s) name(s), address(es) and phone number(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 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 permiulicense number which will be used as a reference number. In addition, an applicant
that must submit multiple perntitilicense 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
(own)." 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
1 i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
fhe f)trice Of Investigations would like to thank you in advance for your cooperation and should you huge any questions,
please do not hesitate to give us a Call.
I he Dviiartntent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
OfOce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Itcv tsCd 5-_'0-U5
www.mass.gov/dia
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Boadoi dr fBui gReions and✓vStandards
License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR
before the expiration date. If found return to:
- Registration 160008 Board of Building Regulations and Standards
Expiration:417/2010 Tr# 269718 One Asbburton Pace Ron 1301
Type: DBA Boston,Ma.02108
PIONARCH
MICHAEL SZYDOWSKI -
38 OSBMA E
SALEM.EM,MA 0197970 l.otani rator
Admi Not vali�wito gnature 1------