92D WHARF ST - BUILDING INSPECTION I
PUBLIC PROPERTY
DEPART IVIENT
KIMBERLEY DRISCOLL
"AYOR //f 120 WASHINGTON$-MEET
6 U �/y O� S^LE,4�fnasACHt:SE,'rs U,97e
E Tti 978-755-9595*FAY:97&740.9g"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building: i
-----
Sgt4E
4 A 01220
Properly is located in a; Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land A+ _
L
Name:
Address: P �/IT-
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EX12lTMG BUILDINGS ONLY
Addition Existing
Renovation Io- �(Gr Number of Stories Renovated
N
Change in Use -2 PP New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation oc�
of existing building `L �w6_ New
Mef Description of Proposed Work:
0,15,ivOVM7 M5 u1� rr w iTt4 NF-W �rWVJ
&AT14 aVMs
I\jr-,w 'DOD gs) «-> �
.per iNC�S
Mail Permit to: otJbtS M-C-m bw
What is the current use of the Building?
Material of Building? w�n
l�i�+�! � If dwelling, how many units? I lni 1 1
Will the Building Conform to Law? Asbestos? &JO
Architect's Name ��M /(� LTD
Address and Phone S U VV
Mechanic's Name V1 n o r .�.lCmr, 7OA
ivoi�
Address and Phone i�i� L� � �A �l 45 , ' g
1� HICRegistration#
Construction Supervisors License#
Estimated Cost of Pro act$ Permit Fee Calculation
Permit Fee$ i(O'0',J Estimated Cost X$741000 Residential
- _--- - _- - - - - — �� Estimated-Cost-X$11/$-1000 Commercial
u � 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.
1 �
The undersigned does hereby apply for a Building Permit to build to the above stated
Xspecifications. Signed under penalty of perjury
Date /7
i
on
C
w CS .r O Y.
a a a
JOA4
.- - - -- -
2 D CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xnaaeusY natsca t
MAYga IM Wa20=MS MT a SJUEte,MAS&ACt .WM 0IW0
TEU VS-7459595 a FAIL 978-740.9W
Workers' Compensation Insurance Affidavit: Bullden/ContractorsMectrlcianyplum6ers
Applicant Information I �1 PIe ��
N3nle(Bu6neWOrganindou/fn&W&W): V l Uil L,7 (/'�j�� Q� /�c
Address:_ ! C10 TelTi'PGa'
Cityiststrszip: M6�g� i Mh-•O�g4-5 Phone l 03y �
Are you as employer?Cbeck the appropriate bow
1.® I am a employer with !D 4. 0 I am a general contractor and 1F�3=w :
employees(&II and/or part-time).• have hired the subcontractors redon2.01 am a sole proprietor or partner listed on the attached sheet t gship and have no employees These sub-contra tore have working fee me in any capacity. workers'comp,insurance.[No workers'comp. insurance J. 0 We am a corporation and itsdition
required.] officers have exercised their 10.0 Elpairs or addidona
3.0 I am a homeowner doing all work right of mcmnptkm per MOL 11.0 Plupain or addldonsmyself.[No workers'comp. a 152,11(4),and we have noinsurance required]t employees.[No workers' 12 0 Rocomp.insurance required] 13.0 Ot
-AnY VPUNs the drdsad b el mart also Mut th nut Medan baler Amine 16dr wake
Hawowaaa who w6mk box&Mdmut su chog n a dry a doioa as r o*Md dr kin aaWds roam emn num sa6m6 a ew sind"Ian
a n e that eyed[ththisat
bad aural athe6ed as ddwmal that d owkq th asd of the aabeotlbamw and diet wake•'emp. 6dbrma loo,
ij sae an employer lief B provUL"9 workers'coNpenrOdom htearancefOP Ory earployeaL Below bs the pogey eadjob silt
InjormorioA.
Insurance Company Name: ;/A Af�l�T/Fl%j
Policy w or Self-ins.Lic.N_� i5�I 7�/ D`a _ Expiration Date: 9- //-0 7 Y
Job Site Address: g-2 22 -W Ik12�� ciWsmtwzip. M �l9
Attack a copy of the workers wmpeandon policy declaration page(showingeke policy number and expiration dabs
Failure to secure coverage as required under section 25A of MGL c. 152 can lead to the
fine up to$1.500.00 and/or one-year ion imposition of criminei p6ZWd"of a
y imprisonment as well as civil penalties in the form of a STOP WORK ORDER of up to 3250.00 a day against the violator. Be advisedw��*�• that a copy of this statement may be f and a tine
orwarded to the OtDER Investigations of the DIA for in coverage verification
/do hereby eerrijj ender th peim and Rene/des djper/wy that the lljoremdew provided abovels due and correct
Da• JAN — 2007
Phone#- -7 0 34 7-7 77
O,dleid use only. Do not write 1n this area,to be compkIed by chy of town oh*&L
City or Town: Perroluuceau M
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.CitylPowa Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other
Contact Person: Phone 0:
Information and Instructions
Massachttsem General Laws chapter 152 requina all employees to Provide workers' compensation for their employers.
Pursuant to this statute'an 8=*Yse s defined so"...every person in the service of another under any coatrsd of bite.
express or implied'oral or written." _ _
as"aa individual.partnership,association.�PQNfM er other legal 'or ny a,o of
r the
An mPleYer defined m a oint eotaprisa.and ineludiog the legal representatives of a deceased employer,However the
of the foregoing engaged 3 association or other legal entity.emPloyial t mployaa Ho
receiver Or trusice of an indivWf the
owner of s dwelling house having���II du00 apartments and who resides work on such Or the Occupant odwelling hots
dwelling bourse of another who employs p�to do maintenttce. be deemed to be in employe."
or on the house at Wilding appurtenant thereto shall not because of such employment
MGL chapter 152,42SC(6)also stave that"every s buildings shy wlthbeld the batana or
to operate a bushaa in the eommoswakh for aay
renewal of•tlrasse or ptumht aeeeptabla evWesa of eompgatee wUh the hnaurance eoverags regrind. _
applicant who has net predated states"Neither tits commonwalth not MY of its Political subdivisions with the iamieattce
Additiomlly,MGL chapter 132, ftman of public work until acceptable evidence of compliance
enter into MY centreot for the performance to the cotunaeting sudtonty'
requirements of this chapter have bias presented
Applicants
nopcosation affidavit completely.by checking the boxes that apply to your situation and'if
Pleats fill out the�o r(s s),addresr(es)and phone number(s)along with their tutus)of
necessary.supply or Limited Liability Partnerships(LLP)with no employes other than the
insurance. Limited Liability Comfemes not required to carry orkas' insurance N an LLC or LLP does have
members of Partners,
Be advised that this at8devit may be submitted to the D Wbncnt of Induea t
employees, of insurance coverage. Abe be sure to sign and date the atd"'-iL The affidavit stuotild
Accidents returned w the a� i that the of
application for the permit Or a m if you am r being requested,not the Department
Iudueaisl Aa�ts, Should you have any questions a nun regarding to obtain a workers'
compensation Policy.plem call the Dapaetinent ltsms�° lister below. Self-ianaed eomQonies should eater their
self-mamma license mu*w on the
city or Town OAfelab
lets and printed legibly. The Department has Provided s spacer at the bottom
Please be sure that the affidavit is comp Investigationsoffice of the He"of the affidavit for you to fill out a whit will be used as a reference number. In addition. Applicant
Please be sure to fill in the Patm't4kenaa number
any given year,need only submit one affidavit indicating current
that must submit multiple Permiviieense applications should writs"all locations in----(City°r
policy. (if necessary)and under"Job Site Address"the applicant: the l or town may locations
provided m the
of the affidavit that has been officially stamped or marked by city
town)."A copypenn or licenses. A new af"-&vu must be filled out each
applicant ere proof that a valid affidavit is on file for fixturelicense pew not related to any business at commercid venture
year.Where a home owner or citizen is obtaining a NOT required to complete this affidaviL
(i.e. a dog license or Permit to burn leaves etc.)said person
The Officer of Investigations would like to dank You in advance for your cooperation and should you have any questions'
please do not hesitate to give us a ca1L
The Deparmseot's address,telephone and fax number.
TM COMMwedth of ggachusetta
" Deputnwl of 1i1&WW A=&nta
offin of lavaatlpdoOa ., .-
n 0 . p 4,.t
600 WUhifIP2 Street '``
Bostoq MA 02111
Tel. N 617-727-4900 ext 406 of "77-MASWE
Fax#617-727-7749
Rcvised 5-26.05 www.IDa=Vv/dig
i
CrrY OF SALEM
PUBLIC PROPERTY
DEPAXrMFNT
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1s eooaab�wWe dw sisb sMm olds Shea lloU&M Codk INCUR sedan 111J
odde6 and dwp mWom a(UM s 406 0 54
guums re a Is booed will de.aoeMM dot dw debris easddog Am
cMe eras!drll bo dtsDoed otbt a peWw�►gceoeed scree dtgoul�>.deAntl by D�ItL•
11t.�1JM.
Tb*dewswill b.ftaVmhd by
w..erbreMil
The dews will be disposed of in:
(sari o<�f
ca�raa er heiltry)
Twswi� olann.�pplsas
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NOTICE NOTICE
r T
TO O
EMPLOYEES EMPLOYEES
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 i I j�,,
NEAREST AND BEST MEDICAL FACILITY I ( 1 l 10-'
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER