22 WILLOW AVE - BUILDING INSPECTION `CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERI.EY DRISCOLL
MAYOR 120 WASHINGTON S1REEr♦SALLNI,%LA,SsACHu.%mTS 01970
TEL 978-745-9595 ♦ FAx:978-740-9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.O SITE INFORMATION
Location Name: Building:
Property Address: as (t7
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: eo a r— ---_._
Address:
Telephone: 9�79--f) Y 9o290
3.0 COMPLETE THIS SECTION FOR WORK IN EXISIING BUILDINGS ONLY
i Addition Existing
Renovation Number of Stories Renovated rf
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: c2Nj 1"e!)
t'41 x I s` ij C! o L~ & S lGw r 1 F(a-t- r o o-2,
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add a �hdeVsov, CvJ _Iq `3 w � , , occJ
C3� 1�1e�u (�Do�C �3�e\v rs oc/�- `t-,rtte walAs
Mail Permit to: 20�,o -o -t, ') fs fp- i,�s�+�� opa
olQ�y
What is the current use of the PBuilding? h u v!. .r
Material of Building? e j on If dwelling, how many units? r�
Will the Building Conform to Law?—LJ Asbestos? 1J0
Architect's Name
Address and Phone ( )
Mechanic's
Address and Phone�,� �et.�ow� 6�1. ol4d
Construction Supervisors License# CS—C7 (c`� HIC Registration # (tJ Sal'j
Estimated Co5 of Project$ 1(D 020t Cj Permit Fee Calculation
Permit Fee$ /2 11, Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 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 to�build tto�the above stated
specifications. Signed under penalty of perjury X� u�
Date
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0
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOIL
MAYOR 120 WASHINGrON SIREEr♦ SALEM,MASSACHGSEI-1S 01970
TEL:978-745-9595 ♦ FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
applicant Information �j (� Please Print Leaibly
?Jame (Business/Organppizationllndividmi): T�D-w� V
Address:a a AAe S QtT�A S�
C ityt StateiZip:
L' y.�otM 1v\s. O 1114 Phone 9: 01°*'_ SO
Are you an employer"Check the 9propriate box: Type of project(required):
LEI I am a employer with 4. 0 I am a general contractor and 1 6 0 New construction
�
m to ces full and/or art-tine).' have hired the sub-contractors P Y ( F 7. [ZRemodeling
2.tK+ ' ;Ira a sole proprietor or partner- listed on the attached sheet.t
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity, workers' comp. insurance. 9, 0 Building addition
(No workers'comp. insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.0 I 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 12.0 Roof repairs
insurance requited.] t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any.y plicant that checks box 81 ntuat also fill out the secoan Ma ow showing their workeri compensation Policy infunmtion.
'liomcuwnea who sobmil this affidavit indicating they are doing all work and then him outside contractors most submit a new affidavit indicating such.
-Contmtors that check this box most attached an additional sheet showing the nano of the subcontractors and their workers'comp.policy information.
I our an employer that is providing lvorkers'compensation insurance jar my employees. Below is the policy and job site
inforrnutioa.
Insurance Company Name:
Policy 4 or Self-ins. Lie.f1: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
I.,ailure to secure coverage as required under Section 25A of NIGL 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
luvcsl(gations ol'dte DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ujpefrjuryythat the information provided above is true and correct.
Si lainic � \
f Itun•:7:
Official use only. Do not lvrite in this area,to be completed by city or town official
City or Town: -.___-..._ Permit/l.1cense ti
Issuing Authority(circle one):
1. Board of Ilealth 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other _
Contact Person:-_ __ Phone 8:
Y
Information and Instructions
-lassaclmusetts 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 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."
NtGL chapter 152, g25C(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 not 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 confirmation 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till 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 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Gftice 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
OtHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Re -i>ed 5-'_6-os www.mass.gov/dia
SO a
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET♦ SALEM,MAS.SACHUSEITS 01970
TFL:978-745-9595 ♦ FAx:978-740-9846
Construction Debris Disposal Affidavit
(required for-all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR 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 MGL c
111, S 150A.
The debris will be transported by:
I (name of hauler)
�nThe debris will be disposed of in :
y� -etL(C�
(nutle of facility)
(t�%r 4t1 ow v� llJtlUt� .
address of facility)
signatu o permit a .nt
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slate
dcbmafr.doc
`TONS _
D OF BUILDING REGULAiSOR. -
BOAR, TION SUPER
License: CONSTRUC
058267
Numder pU411944
BirlhdaLe _,,.:, 7r.no; 21415
bEx *!'1412Q08 .
pves�,�
F;ALPH.J FtOSAT,O�`e
Com
T issioner
W ENHAM, MA 01984' - m
P .y � .. pGTifePnue�.eaiei�rall/c a�✓f
Board of Building Regulations and StA&rd8
HOME IMPROVEMENT CONTRACTOR
Registration 111597
Expiration `j 0/15/2007
- Individual- _
RALPH J.ROSATO
RALPH ROSATO .
78 PLEASANT ST ,__,-emu✓,;
WENHAM, MA.01984 Administrator -
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85 EXCHANGE STREET SUITE L12 a LVNN. MA 01901-140b o TECHEVOLUTION.COM - TEL 781-595-2640 a FAX 781-459-5988