76 WHARF ST - BUILDING INSPECTION (2) What is the current use of the Building? K es�rs—f
Material of Bukft?
W�p If dwelling.how many units?
WIN the Building Conform to Law? y c S Asbestos? �----
ArcWdeds Name
Address and Phone 1
Mechanic's Name
Address and Phone s o9i�3� 7 Hic Reglstrawn d 4a 13�C
cweuyion Supervisors License o
Estimated Cost of Projed= —� Permit Fee Calculation
Permit Fee= - Estimated Cost X$7IS1000 Residential
Es*m ted Cost X:11/tN0oo6om mercia4------.
An AddfBonal $5.00 is added as an
Administrative charge.
Make sure that all flelds are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit lid to the above stated
specftatkms. signed under penalty of Perjury
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EIT.StOFSALE1�
!-J PUBLIC PROPERTY
DEPARTMENT
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APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DE.yIOLTTION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:-------- -
� c.rk ,
Property Is located ins;Cormervadon Aros YM tj Historic District YM tJ
2.0 OWNERSHIP INFORMATION
2J Owner of Land
Name: o - 6 IC2lr 1
Address
c
Telephone: c,'j - -)
3.0 COMPLETE THIS SECTION FOR WORK IN EXIAMM BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
1
Change in Use ��- New
Demolition Existing
Approximate year of tR L
a per floor NO Renovated
construction or renovation avo t New
of existing building
Beef Description of Proposed Work:
J fir- r ,? , 7„ A i
—_- -- Mail Permit to;
< CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
nlslIVWXY )XI-WOLL
MAY(w 12^�WASHLNC;LON STREET• SALF-4,MASSACIItali'I-fSQ197.',
TlaL 978-74.5-9595 a FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r licant Information Please Print Le iblit
NiMe(Busiiwss/OrganizatioNlndividuaq:
Address: -7 (-,:;, U) r c4r
City/State/Zip: fiPtnn d Vf4-- Phone lk
Arc yt an employer' Check the appropriate box: 'Typo of project(required): I
I. 1 am a employer to er with a} 4. [11 am a general contractor and 1
P -�— 6. ❑ New construction
employees(full and/or part-time).` have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : 7• FlIernodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q. ❑ Building addition
INo workers' sump. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. (No workers' comp. c. 152,j 1(4),and we have no 12.❑ Ruof repairs
insurance required.] t employees. LNo workers' s
comp. insurance required.] 13. Other `Y• 'on er
'Any applicant that checks box pl must also,lilt our the section hdow showing{their workers'compensation policy information.
' lteme,.wrs who submil this atTidavil indicating they arc doing all work and then hire outside contmetom must submit a new al'Ldavil indiuling such.
:C'ommcmn that check this box mtonaoaelied an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l mar on employer that is providing workers'compensation insurance for my,employees. Below is the policy and job site
informatiom
Insurance Company Name: --_-Nc V.ws_.. �.- �,A�
Policy #or Self-ins. Lie. #: D 1 xk �O 5a 3b a. ,>.Q'T Expiration Date:
Job Site Address: 716 W� SDI_ 5al64-City/State/Zip: jr�'r
Attach at copy of site 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
tine 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$230.00 a day against the violamr. Be advised that a copy of this statement may be forwarded to the Office of
hnvesugatiuns o r c DIA for insurance coverage verification.
Ida hereby cent order the tits at pet /tics of perjury,that the information provided above is true and correct.
Sie:,alure: _ aa oat : / V
Phone a U: d
Official use of tar write im rhi.r urea,to pleted by city or town ofJic'iol.
City err Town: _- _. _...._-..__ Permit/License#____
Issuing Authority(circle one):
I. Board of Ilealth 2. Building Dcpartoncnt 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: -_--_.-. .-- . -- — Phone#-.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their cii1ployees.
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."
:1rt 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-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 continuation 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 till in the pennitilicense number which will be used as a reference number. In addition,an applicant
that most 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 tilled 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
fhc Office of Investigations would like 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 number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Otflee 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
1
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\l.�riK 11C W.\91tN(':0N)iREET •5AU%1, St.\S].\<:7n iLl'I5v'i97'.
TEL:978-743-,)595 # F.�`t:978.7+G9846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,780 Cb1R 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 v1GL c
i 11, S 1.50A.
The debris will be transported by:
ts--O `1
(name of hauler)
the debris will be disposed of in
l uo 11
(name of cility)
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<ng Regulations and Stards
hburton Place - Room 1301
Won. Massachusetts 02108
H vement Contractor Registronxr
f e6 t tr -1491`39
k4ie:= DBA
9;cPirffii64. 1128/2007
RNA REMODELING
RAYMOND D'AUTEUIL _
9 RIVER STREET
BILLERICA, MA 01$24: -; ---- -.-
i97t4�eason for change:
.-CAI"O s =oaios-pcaoae : - p . �, rl '� -i mint 'U Lostc.
a 0ie �ino„.nauaeiil 'o�✓` aaer�ae
90
'-License CONS'fAUCTION SUWEAVI IS40.;i
Numbek ,C� 093377
Biatida� 11. lD ,l958- - r -
s t7�" 69 Tr.no93377°.
RAYMOND J DAfPTEEiiG.
9 RIVER ST
f .[ BIIL�fdi�A,.MA 018'1'li
1
ENDORSEMENT
Date Prepared: 3/12/2007 FEIN: 43531463
Name of Group: MA Retail Merchants WC Group Inc.
Name of Member: Finz
Stonehenge Tavern, Inc.
Address: 76 Wharf Street
Pickering Wharf
Salem, MA 01970
Policy Number: 014005030297107
Policy Period: 1/01/2007 - 1/01/2008
Effective Date: 1 /01/2007 Carrier #: 34355
INTENT OF ENDORSEMENT (INDICATE ONLY ONE ACTION PER ENDORSEMENT)
( X ) 1/1/07 Exp Mod Revision
INSTRUCTIONS:
For changes, indicate below the name or I Indicate below the new name or address
address prior to endorsement. Each item I after change or the name and address of an
on the left must correspond with an item I addition or deletion. For deletions give
on the right . I disposition.
I
1.0000 - 01/01/2007 I 0.9200 - 01/01/2007
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Agent : 704 - New England Heritage Ins. Agency - Stone
Requestor: DKEESLER
STATE INSURED FILE AGENT LC
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