84 WHARF ST - BUILDING INSPECTION CITY OF SALEM
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APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL 13UILDINGS EXCEPT ONE AND 2 Fit MILY DWELLINGS
IMPORTANT: Applicants must com lrte all items ou this page
SITE INFORMAT ONE —'
Location Name V\L\<XL A, 4 ' ";,ding ` \
Property Address
84y w\-\&� 4\. S A\Y;; NM
Located in: Conservation Area Y/N Historic district
APPLICATION DATE �JZs-. oq
Use Groups
(check one)
Group Homes R3 RJ_
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) R1 _
(check one) Assembly (Theaters) At_
New Building_ Assembly (restaurants& clubs) A2r_A2nc_
Addition Assembly (churches) AI _
Altetation Business B
Repair/Replacement_ Educational E_
Demolition ✓ Factory(moderate hazard) F1 _
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) - 13_
Mercantile M_
Storage Sl _Moderate 1-lazard 1
Storage S2_Low Hazard 'It
OWNERSI1111 INFORMATION(Please h a mr Prinl Clrarly)
OWNER Name
Address �\-
Telephone
Signature -_
DESCRIPTION OF WORK TO BE PERFORMED
ES'I IMATF.D CONSTRUCTION COST 3 ��
cONrtt:xCrOtt tNFOWNUXTRry
Name \��t>/V✓
Address
Telephone & --eA-^A
Construction Supervisor's Lic # GS V-401. �
Home Improvement Contractor# ciocKn
ARC►►ITEUT/ENI;INEER INFORMATION
Name
Address
Telephone,
Muss. Registration #
A
PERMIT FEE CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned applicant does hereby attest that all information stated above is frge to the best of my knowledge
raider the penalties of perjury
Signed _ (owner) (agent)
/f 1
APPROVED BY :
DATE APPROVED: L/ / /� c�) �! y
APR--02-2009 01 !09 PM HOSPITALITY SOLUTIONS 978 927 SS99 - P. 02
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CITY OF SALEM
* , ,jc i PUBLIC PROPRERTY
DEPARTMENT
:.I\IL.'R!.I:Y DRIS(:ul.t.
1.\II oR 12CWASHINt;n0NSi1<LLT0SAtICbt,M.\SS.�ClItit%IltiG197,^,
978-743-9595 0 Pax:978-74C)846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
%oplicant information Please Print Legibly
Vame(13udncss/Or;;anizatioMlndivldual): \ G � \'--�C"]V� ���� C"`'r
City,State,Zip, \jr%A��NA NA— Phone •'': ctK'G�`��iX "�!Z�/S
Are yo � employer with employer? Check the appropriate box: 'Type orproject(required):
1. 1 am a
' 4. ❑ a a I m general contractor and 1
� 6. ❑ New construction
employees(full unXor part-time).* have hired the sub-contractors
2.❑ I tun a sole proprietor or partner-
listed on the attached sheet. t ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑.Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
lNo workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per fv(CL 11.❑ Plumbing repairs or additions
myself. [No workers' cwnp. c. 152, §1(4),and we have no 12.❑ Ruof repairs
insurance required.) t employees. LNo workers' 13.0 Other
comp. insurance required.)
-Any,yplieant shut chucks box 9I must also till out the section Wuw atowing(heir wurkus'cumpenwtion pulicy inlinmatiom
r I lomcowneo who submit this ea7davit indicating They are doing all work and then him outside conlmetors must auhmil anew ai r.davit indicting such.
�C'ontra tun that check this box must ailach<d an additional sheet xhuwiag the name of the sub-contractors and their svurken'comp.policy information.
l nor mr eory)foyer that is providing workers'coanpetrsrttion insurance for my earployeas. Below is the policy and job site
information.
Insurance Company Name:-- -- "' - —__.
I'olicv A or Self-ins.
.LLii�e, ri: —.__... _... ..____A_`_ r .A Expiration Date:
Job Site Address: O S <'/� `biityiStatei"Lip: �1�
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.MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or une-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 may be forwarded to the Office of 1;
In\csti.alions of Lhe DL\ for insurance coverage ecritication.
l do hereby certify cruder the pains cord penalties of perjury that the infurination provided above is true and correct.
Sie:laolre: _. .._ Datc-
1'h,n:e:':
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:_ Permit/License
Issuing:kuihurify (circle one):
I. Board of llcalth 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing inspector
6. Other _._..
Contact Person: __.._ _ -.---. Phone#:
f
s
Information and Instructions
\Massachusetts 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 ail individual,parmership,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
01,011 the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
AMGL 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, 'vIGL chapter 152, §25C(7)states"Neither the conum6nwcalth nor any of its political subdivisions shall
enter into any contract for the perfommnce 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-contractors) name(s), address(es)and phone mmniber(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 retunmd 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 rile 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 permit/license 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 oir 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 homeowner 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.
I he Otlice of luvestigations would like to thank you in advance for your cooperation and should you have:my 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised i-26-05
WWW.maSS.gOV/d18
CITY OF SALEM
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Ak' PUBLIC PROPRERTY
DEPARTMENT
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I_'� A.\iI II\1,.,!V Sf'it I:IT * ti.\I I M. \1.\,i.V .I'. it I .
I I I 978-745- i95 ♦ I .\s: 978.174_9846
Construction Debris Disposal Affidavit
(reyuircd for all demolition and renovation work)
In accordance with the sixth edition ofthe State Building Code, 780 CMR section 11 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
s (name of hauler)
The debris will be disposed of in
(name of luclhty)
Gc� Y\T.C vCl�
laddress uI'facilim
tiiel?c of prnnit applicant
date
I r In I IJ i.u.
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