20 WEST AVE - BUILDING INSPECTION ILi'1 �17�
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APPLICATION FOR PLAN N KAMINAI ION.. \ND BUILDING PERMIT
ALL STRUC'TUiRF.S E,"�CEPf-i• 4ND.1 h 9MILY DWELL I.NC;S
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IMi'ORI.\NI':APE licants must cam dcfc all items on this ra re
SITE INFORMATION
Location Name '2C) wog- Am- Building_
Property Address .20 r did At-- 11F2 _
Map N
_ I
Locuted in: Conservation Area YjN ._-Historic district YIN__,
Use Croups
(check one)
Residential(3 or more knits) R2
Typg,ofamprovetn ell t Residential(hotcVmotel III _
(check one), Assembly (churches) Al _
New Building Assembly (nightclubs etc) A2_
Addition Assembly(restaurants, recreation) A3_
Alteration - Business B_
Repair/Replacement--V—/ Educational E
Demolition_ Factory (nwderatc hazard) FI
Move/Relocate Factory (low hazard) F2
Foundation Only High Hazard If_
Accessory Building_------ Inntilutinnal (residential care) I I _
Othcr(describe) Institutional (incapacimmd) 12
Institutional (restrained) 13
Mercantile Ni_
Storage(moderate hazard) S I _
Storage(low hazard) S2_
U\\'NI.usull' INI-oui%\LION(11Icase 1)pv or Print Clearly)
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0WNIi1Z
;Address ?x) wor Avti 2 __
relepholle 979 59y 6-39
B ESCRI III ION 0 RV)IlK'IU BF.' 1'F:RPUR;\IFan
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CONTRACTOR INFORAL%HON
Name au Ab&E3
Address 20 cjc!i ' Aae.
Telephone f7A 5W 09
Construction Supervisor's Lic # Il34p0 r
Home Improvement Contactor # : _+
,%RCIII'I'EC'IYF.NGINEER INFORMATION
Name AIIA-
Address
Telephone
Mass. Registration # _
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $l l/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information .stated above is true to the best
of my knowledge under the penalties of perjury
Signed
Date /l U
? 60 �^ "
\ V
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
hI-I: 478 '4 -'7i,F • 1:sS: 978-'4.-'IH46
Workers' Compensation Insurance Af ida%it: Builders/Contractors/Electricians/Plumbers
1 t licant Information Please Print Legibly
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�.Illll tltusmc.. lhguntcmun. nJt�tdu.tl l: i
City,ytate7ip: MCA 01q70 Phone ..#:
%re you an employer?Check the appropriate box: Type of project (required):
I.❑ I all, a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and:'or art-time)." have hired the sub-contractors
P' 7. ❑ Remodeling
?.❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have Is. Demolition
working for me in any capacity workers' comp. insurance. y. ❑ Building addition
[No workers' cum 5. El We are a corporation and its
P insurance officers have exercised their 10.0 Electrical repairs or additions
re d.J
3.[� I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. C. 152, $1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. (No workers' 13,M OtherltirO6tr, t?DJSt PO
comp. insurance required.) I —
•Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
-Contraclors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
1 atn in employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.
Policy # or Self-ins. Lie. #: Expiration Date:
.lob 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 '_5A of�IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one--year imprisonment. as well as civil penalties in the tixm of a STOP WORK ORDER and a tine
„f up to S250 00 a day against die violator. Be advised that a copy of this statement may be forwarded to the Office of
In%c,tieauons of the DIA for insurance coverage Verification.
l Jo hereby certify under the points and penalties u%perjury that the injortnation provided above is tare and correct
;j�,n:nur
Dale UJoe
Pl; t 918 3'y1-/ 536ti
U(/idol rise only. Do not write in this area, to he completed by ei y or town o/fitiae
Cily or Town: . ---_---- _ Permit/License #----- ----—
Issuing .%whority (circle one):
I. Board of Health 2. Building Department 3. Citp town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other —_.__---- —___ -
Contact Person:.-__--_- —_ ---.-- Phone #:----__---.
Information and Instructions
%I:iss:rrhuscus (icnertl I-atrs ch;tpler I " rcquucs all employers to pro%ide workers' compensation for their entpIolccs.
Pursuant to this ,tatutc. .ut rntphgYee is defined .is "._ct cry person in the service of;mother under any contract of hire.
c yrtcss or implied, oral or driven...
.\n rrnplurer is defined as "an indit iduul, p.unwi-ship, association, corporation or other legal entity. or;n� two or more
,.I the Iorcgoing engaged in a joint enterprise, and including the legal represcntatit es of a deceased employer. or the
receiver or trustee of:n individual, partner hip, association or other legal entity, employing employees. I lowever the
,ns ner of a dwelling house hat ing not more than three apartments and w-ho resides therein, or the occupant of(he
dw clling house of another tvho employs persons to do maintenance, construction or repair work on such dwelling house
,m on the _rounds or building appurtenant thereto shall not bCQause oEsuch rntploymen[ be deemed to be an employer."
\1(;L chapter I S?. �_'SC'1(1) 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'C'dntmn1ne'calth for any `
applicant who has mitproduced acceptable evidence of compliance with the insurance coverage required."
Additionally, %i(;L chapter 152, �_'5C(;) states "Neither the astutonwe:ihh nor any of its politi27$I-a4divisions shall
rtuer 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-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 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 permitilicense 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 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.
Ilie ()dice of Investigations would like to thank you in adNance for your cooperation and should you have any questions,
please do not hesitate w give us a call. - -
I he Department's address, telephone and fax number
'The Commonwealth of Massachusetts
Department of Industrial Accidents
4.
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Rrtiscd �-'6-US
www.mass.gov/dia
ell, CITY OF SALEM
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' PUBLIC PROPRERTY
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DEPARTMENT
..,I ❑ II\i..,`\11.41.1'T * SAII M. t1A ,%i
I'\Y: 'i7% 'J=9841,
Construction Debris Disposal .affidavit
(required for all dcmolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 C'MR section 1 1 1.5
Debris, and the provisions WAIGL c 40, S 54;
Building Permit ff is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
�6 Alt`i12030 /
I name of auler) - - -
The debris will be disposed of in :
(name of facility)
laadrea of Iacllitvl
4
•narurc oaf permit .applicant
11110e
,late
WALDO BROS . COMPANY
202 SOUTHAMPTON ST 595 NUTMEG RD. NORTH
BOSTON, MA 02118-2789 www.waldobros.com SO. WINDSOR, CT 06074-2461
617-445-3000 • FAX 617-427-5691 860-289-9500 • FAX 860-291-8500
BRICK • CONCRETE SPECIALTIES • BUILDING MATERIALS
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WALDO
BROS.
SERVING THE CONSTRUCTION INDUSTRY SINCE 1869
WALDO BROS . COMPANY
202 SOUTHAMPTON ST. 595 NUTMEG RD. NORTH
BOSTON, MA 02118-2789 www.waidobros.com SO. WINDSOR, CT 06074-2461
617-445-3000 • FAX 617-427-5691 1 860-289-9500 • FAX 860-291-8500
BRICK • CONCRETE SPECIALTIES • BUILDING MATERIALS
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WALDO
BROS.
SERVING THE CONSTRUCTION INDUSTRY SINCE 1869
Natalava's Condo Associavr-
umx owners of the Natatava's condo association agree to commence
work on the second floor porch and roof. The work will be preformed by the second
floor owner Jay Alberts and a group of his friends. All work will be done to code and
will be inspected by the building inspector of the town of Salem,Ma. By signing betiov
you allow Jay Alberts the owner of the second floor condo to pull a permit and
commence the demolition and replacement of the second floor porch and roof.
15 �� Dots
F 0or --�
-7//S/ GDate
Oee6nd Floor Owner
' 16Z ' Z /o Date
Third Floor Owner