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10 WHITE ST - BUILDING INSPECTION (7) CITY-oF 1 PUBLIC PROPERTY DEPARTMENT KI%MFJU"DRSCWL t y/ -4.;�� 120WASMNG0NSriEsr.Ste;,%aNLst1s01970 ' TEL 97e.735-gS9S•FAY;97e.74o.9U6 APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTLiRF OR BUILDING 1.0 SITE INFORMATION Location Name: j..1 a _ — jz Nk Building: ` Property Address: /Q e 61#17C- S%- Property is located in a: Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land ` Name: ¢ Address: ST- _ t CJ Telephone: 7 - 3.0 COMPLETE THIS SECTION FOR WORK IN EXICT1Nrs BUILDINGS ONLY b Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: Mail Permit to: ?Vr,abra- STv tzl�c What is the current use of the Building? It dwelling,how many un'�ts?-- Material of Building? '�!�� Asbestos? Wig the Building Conform to Law?�- Archhed's Name ( ) Address and Phone / ! o 0 Machanic'sNams / !Z! P nnn �!9!� (9�8)zz3-S6Sg Address and Phone lDi oa HIC Registration# Construction Supervisors License fs Permit Fes Calcination Estimated Cost o Prol Ste— Estimated Cost X$71$l000 Residential Permit Fee$ Estimated Cost X$11/51000 Commercial 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 tQ b 'Id to the above stated specifications. Signed under penalty of perjury /� I Date � � I a 1 o. - w - OIL �- - CITY OF SALEM i PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WAsHNGToN STREET a SALEM,MASSACHUSETTs01970 TEL.978-745.9595 ♦FAX:978-740.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 9� /n 774 fro n /\yj/j O City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time)." have hired the sub-contractors 6. New construction 2.t�/ I am a sole proprietor or partner- listed on the attached sheet, t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in an capacity. workers' Ycomp. insurance. 9, Building addition[No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised thew 10.❑ Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152. §1(4),and we have no 12.1 Raof re sirs insurance required.] t employees. (No workers' comp. insurance required.] 13.�Other It e *Any applicant that checks box pl must also fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and dim him outside contractors must submit a new affidavit indicating such. tConuactore that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site information. �// Insurance CompanyName:_p =ld�Zf7L� /i'/tt7ye �NS p�pAN / Policy#or Self-ins.Lic. #:_ l Qd C 7—�3 0 � Expuation Date: Q Job Site Address:lo 411yIrC �� - 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 25A of MGL 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 form of a STOP WORK ORDER and a fine of up to S250.00 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 insurance coverage verification. I do coy certify er a pains a enaldes of perjury that the information provided above is true and correct SienaNre: jS O� Date: Phon : ct( z 3 — Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town 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 fore nee of hire, Pursuant to this statute,an employee is defined as"...every person in the service of another under any 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 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 produced2 acceptable5C( ) tates"Nether the oce of mmonwealth nor an of its political iance with the insurance coverage required." Additionally,MGL chap for the performance of public work until acceptable evidence of compliance with the ina„*a"ce • enter into any contract 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 number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC worLimited [mitedoLiability o Partnerships(LLP)with or employees thin�the members or partners,are not required to carry employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial l Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should is being requested,not be returned to the city or town that the applicationquestions regarding the lafor the permit or w license if you are required toobtain a the workers'ent of Industrial Accidents. Should you have any compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate litre 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permidlicense 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 afidavitmust 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 bum leaves etc.)said person is NOT required to complete this affidavit you in advance for our cooperation and should you have any questions, The Office of Investigations would like to thank y Y Pe 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 5-26-05 www.mLss.gov/dia T� Board of Buildisg Regulatlods and Standards 9'--HOMEIMPROVEMENTCONTRACTOR", Registra1, 151899— iratia_er—x_3/2008 _. It � #OICKSON HOME�I 6. Cc x� LOTHROP ST ARTS - BEVERLY, MA 01915�� Deputy AdmiuLstratorF �_. CrrY OF SALEM PUBLIC PROPERTY DEPARTMENT .MAVM 130 WAMW=M Star•SAIM MAMACFL'MM 01970 TU.97a US-ft"•I?Ax WL74&%K Construcdon Debris Disposal Affidavit (retittired fot all demiitios and renovation work) In accordance with the sixth edition of the State Building Co"780 CUR section 111.5 Debr*and the provisions of MGL a 40,S Sot Building Permit N is issued with the condition that the debris marking ftos this wort shall bs dispoaad of in a property licensed wants disposal tLcility as dented by MGL o 1L1.StSt)/1. The debris will be transported by: (Hams a[luulsr) The debris will be disposed of in:y (name of facility) (addmu of facility) sizaaam of paimit VpLkam /,I 11 A dug Dickson Home Improvement 90 Lothrop St. Beverly, MA.01915 )978) 223-5658 dickson @hotmail.com Client: Hawthorne Cove Marino 10 White St. Salem, MA.01970 S�o2ftGC � PACt: Z6 bwq 1 -(J t� u MH/WICAL �M O 17AT1{ cL f- I/ X& bC STORPGE CZ OO E�rnuNer' r` ZS"poeQ_ / OFFNCe A ZeA �RO� �nyy,+cE