92C WHARF ST - BUILDING INSPECTION C PUBLIC PROPERTY
DEPARTMENT
A1NMFJLLEY DRISCOLL
MAYOR i2D WmmNmrw STREET -
(O Tt---978-745-959S*FAY:978-740.9846
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: 4--�7 Building: !4D IZLIZ
Property-Address.
14Z- G w4-�AW-F� 074��
CI tw✓I MA
Properly Is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land W _ A
Name:
Address: Iq0 f2(046/a&fr-
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation 1 umber of Stories Renovated
Change in Use Gf � Na New
Demolition Existing
i
Approximate year of �W Area per floor (sf) Renovated
construction or renovation O
X-IC—
of existing building New
Brief Description of Proposed Work:
W�QbVMU6 LAWr W 1'I4 Mir—� W
ti� DING , d%r 1 SH W N ROWS -POE
Di�dFS
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Zo
54
Mail Permit to:
or,l _-
What is the current use of the Building?
I NrI' '
Material of Building? W01kJ If dwelling, how many,units?�
Will the Building Conform to Law? Asbestos? h1
Architect's Name '� � 1
,��^, 0 n D4((�� C��G571 P i �D
y
Address and Phone I �- U y SKMO9 F ( ) GJ�J' ly' � S¢ X
Mechanic's Name D
� n ✓nn n..P'r J� �t ll'h�1'il1N1�}' Ligl5 1j1 L&31'
Address and Phone , O r n
Construction Supervisors License# C,��O HIC Registration#
Estimated Cost of Project Permit Fee Calculation
Permit Fee `t 01 Estimated Cost X$71$1000 Residential
- _ - - - -- - — -Estimated CostX$1'II$1000 CommerGal ------
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date
N
L y D
C
O w
Cy, 4
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ics+tiisatat oaxscou
MAYOR do WA0m4GWN SUM a$ALM4 MASSAC14USI M 01970
TEL 97a.745-9595 a FAX-.97$-7459$46
Workers' Compensation Insurance AiSdavit: BnIIders/Contractora/EkeMctans/Ptambers
Applicant Information Ple ew one rly
Name(Busima/Orpniauonnndividual): V 1MIC170,kll. 0
Address: )qO ELF-A5 �T
City/SuteiMp: K6,2&--r-L1eADMA- Ph Dl9�j
� one#: 19 L /o.�:Sq - ��7-7
Are you an employer?Check the appropriate boss
1.0 I am a employer with_/0 4. [3 I am a general contractor and I �of
(��):
employees(firll and/or part-time).• have hired the sub-conaactore 6. ❑�New construction
2.❑ 1 am a sole proprietor or partner, listed on the attached sheet t 7. �odeiinp
ship and have no employed These sub-rnntesctosa have $. ❑Demolition
working for me m any capacity. wodcas'comp.U'URRInce. 9. Building addition
[No workers'comp. insurance S. ❑ We ate a corporation and its
required.] oftlem have exercised their 10.❑Electrical repairs or additions
3.01 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp, c. 152,§1(4),and we have no 12.(]Roof repairs
m auanee required.)t employees.[No workers, 13.❑Other
H
comp.inurance required)
;Any awow a chat ahab?tat e1 mart Wo aU art the soctlw?Wow?harks tliatr warkam'
mtanrma rho auhmit nds anldwit mdlestlas dtay Sol dens all wait sad dim tdm
rCaetra oamds aaaeaexon mnit aPolicy ka new efEdrvh[eNmW�roil.
Aaa that shack We as addldaoal.hoot a6owbs ae aams of d w mh,00mneton and dtdr wattm•comp,poaov in16r�
last an easpbsyer that Isproviding workers'cowpausedow Wumwg for my eatploysea 9elow 4 tha poUry andJob Misr lajormatlat q�� ,�
Insurance Company Name: a%UM (F.Fs
Policy#or self-in..Lie W CC ,�UU I,�<# 7 D 1 Z/� 24v _ Expiration Date:
Job Site Address: 4W-F S- _l:?— city/state/Zip:C
Attach a copy of the workers'compeaatlon policy declension pap(showing the policy number and expiration dab).
Fsihue to secure coverage as required under Sectiea 2SA of MGL c. 152 can lead to the imposition of criminal penal
of a
fine up to$1500.00 and/or one-year impriwnment,as well as civil penalties in die form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for ia.,.rance coverage verification
Ida hereby cergO under the pains and penalties ojperjm*that the Injorsradow provided above Is boa and tarred
sismaru= ,-`2 �"'— Da w JAN - 5 2007
Phone N, 7 6W 7777
O,Q?elal use only, Do not write in this area,to be cosspfetad by c4 or taww ad"L
City or Town: Permlt/Lkense M
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/rowo Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone N•
Information and Instructions y
Chapter 152 all employers to provide workers' compensation for their employees.
Massachusetts General Laws chap req m the service er another under any contract of hire.
Pursrent to this statute,an exW16ye is defined as"...every person .of
express or implied,oral or written
aWWW oo,cotporation or other legal entity,oc any two atmore
An earpfoyo is defined es"an individual,partnashrR ves o[a deceased employer,of the
of the foregoing engaged in a joint enterprise.and including the legal rat ees However the
receiver a trustee of an individual.partnership.essomanon a other Ind entity.employing employ Or the Occupant of the
owner of a dwelling house having not moss than three maintenance.
enan ands� an such dwelling hots
dwelling bona°of another who em*Ya pins to do maintensnc0. be deemed to be an tsnptoyer--"
or on the Vounds or building appurtenant thereto shall not because of such employment
MGL chapter 152,1�(6)�o states that"every state er local deeming agsney shag wit6�td ee W°iOee or
too a business or to construe buildings V the eomraonweakh for any
naewal of a deems or permit pia ls ovideace of eompdana wkh the insurance coverer requbv
appdesu►t cobs bes net produced aeeeptab
Additionally,MGL chapter 152.12WA7)states"Neither the commonwealth nor any of its Political subdivisions shad
pafbrmance of ile work truly acceptable evidence o(eomplisnce with the iasutrance
enterinto any reqnuctuaft chapterf do have him presented to the contracting audwflty
Appllesnta
Please fill out the welters'compensation affidavit completely,by checking the boxes that apply to Your situstion and.
necessary.srrPP$! s)nsme(s),address(a)and phone number(:)along with their certifies*$)of
or Limited Liability Partnerships(LLP)with no employees other than the
insurance. Limited Liability Comp�ntes(LLC) inuffanctL If an LLC or LLP does have
members a p are not required to carry workers'compensation
employcM&policy is required. He advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sin to sip and data the&UW&vlL The affidavit s Of
hould
returned to the city or town that the application fee the permit or Uccose is being requested,not die Depart
be n a
be returned
k Acoi Shand you have any questions regarding the law if you are required to obtain a worketa'
at
number listed below. Sett-insured companies should enter their
compensation policy.ply cad the Dept lino
sett-itumancs license number on the
city or Town Offieisb
b The Department has provided a space at the bottom
Please be ere that the affidavit is complete and printed le gib of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be core to fill in the perMI'Micenso number which will be used as a reference number. In addition,an applicant
applications in any given year,need only submit one affidavit indicating current
that must submit multiple permit/kicense
policy information(if necessary)and under"Job Site Addrose"the applicant should ware"all locations in__(crrY or
or marked by the city a town may be provided to the
town)."A copy of the affidavit that has bean officially stamped mits or licenses. A new aPbdavir must be filled out eseb
applicant as proof that a valid affidavit is on file for alicense ee permit not related to any business or commercial venue
year.where a home owner or citizen is obtaining u NOT required complete(i.e. a dog license or permit to burn leaves eta said person to co lete this affi&Vit
The Otfiu of investigatiom would like to thank you in advance for your eooperanon and should you have any questions.
please do not hesitate to give us a call.
The Departments address.11 telephone and fan number•
The Commonwalth of Massachusetts
VOW, " ,
DeputmeM of b u VW Atxitlents
of&*of Vvadgatlen
600 Washington Shvd
BoM%MA 02111
Tel. K 617-727-4900 CA 406 or 1-977-MASSAFE
Fax N 617-727-7749
Revised 5-26.05 wwwxumgov/dia
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T}w debts will be dispoad oi'in:
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NOTICE NOTICE
TO x TO
EMPLOYEES EMPLOYEES
f
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-7274900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you
notice that I(we) have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED EMPLOYERS INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON MA 01803-0970
ADDRESS OF INSURANCE COMPANY
WCC 5001342012006 03/11/2006 - 03/11/2007
POLICY NUMBER EFFECTIVE DATES
24 Federal Street 4th Floor
Boston Insurance Brokerage Inc Boston, MA 02110 (617) 556-7000
NAME OF INSURANCE AGENT ADDRESS PHONE
Village Construction Inc 190 Pleasant Street Marblehead MA 01945
EMPLOYER ADDRESS
01/13/2006
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish
adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act.
A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.
The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary
and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that
the insurer has arranged for such attention at the /
NEAREST AND BEST MEDICAL FACILITY u,4 "
NAME OF HOSPITAL A16DRESS
TO BE POSTED BY EMPLOYER