1 WINTER ISLAND RD - BUILDING INSPECTION (5) Q� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
snanreu:v uRlsc:ut.!_
MAYOR 12C W Ast-u.NG I ON STREET •SALEM,MASYACI n cshsris 0197
'FEL 978-743-9595 9 FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Nil= (BuciiassiOrganizatioralndividml):
Address: 3S C-0 S\ c�S SL
City/Stare/Zip: ��c-y) c c_" `ham O�qZ� Phone /t:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 91 am u general contractor and I h ❑ New construction
employees(full and/urporrt-time).• have hired the sub-contractors ,--,/
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : 7• LIQ Remodeling
ship and have no cmpluyucs These sub-contractors have S. [Demolition
working for me in any capacity. workers' comp, insurance. 9. [;_erguilding addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.[[Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.[1plumbing repairs or additions
myself. (No workers' comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.j t employees. [No workers' 13 ❑ Other
comp. insurance required.]
'Anyapplicant that checks box MI most also lilt out the section W-uw bowing tlmir wurkesti cumpenwtion pulicy infurmmiun.
' Ilomeuwnon who submit this affidavit indicating 1My are doing all work and then hire outside conaraeton must auhmil a new affidavit indicting etch.
�C:,mtmtnn that check this box must aaached an additional sheet showing the nano of the sub-contractors and their workers'comp.policy information.
I am an employer that tv providing workers'compensadon insurance for sly einployeay. Below is the policy and job site
iuforioutiun.
Insurance Company Name:
Policy At or Scif-ins. Lie. ria ___... _. ._._— Expiration Date:
Job Site Address: City/StateiZip:
Attach a copy of lite workers'compensation policy declaration page (showing the policy number and expiration date).
Failure to,secure coverage as required under Section 25A of.'vIGL c. 152 can lead to the imposition of criminal penalties of
fine 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 5250.00 a day against the violator. He advised that a copy of this statement may be forwarded to the Olhce of
Invcangaliuus of the DIA for insurance coverage vuiticatiun.
I do hereby certify under.4 a sins mrd penuries of perjury that the inforinallon provided above is true and correct
�i�•aawro�:
Ftn:•ti � 19�2- .. l
-1777
Oficial use only. Do not Ivrire in this area,to be completed by city or town ofJici iL
City or'rovs'n: PermitiLicense#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Persoin __ _ Phone #:
f
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 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
apput ant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor 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-contractors)name(s),address(es)and phone number(s)along with their certificates)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 Ofticials
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 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. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l he Oiticc 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
Ofllce 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.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
IIC W.%ituv::JNS:REET 0 5.au y,
To:978-7459595 •F.%.(:97111-74C-9846
Construction Debris Disposal Affidavit
(required for all demolition azul renovation work)
in accordance with the sixth edition of the State Building Code, 730 CNIR section 111.5
Debris, and the provisions of MGL a 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 1.50A.
Thedebriswill be transported by:
( latae of hauler)
1'lie debris will be disposed of in
(name of facility)
i..d�ac5n of 1'uil,l./) .
LaPointe Custom Homes
Tina Menolakos Addition
exterior
22'-0"
5'-2" W-5" W-0" T-5"
Deck
o�
exterior
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s
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5'4” W-8"
Kitchen
Electric:
Wall outlets per code HVAC:
One ceiling light in living area Tie in to existing forced air system
One ceiling light in bedroomMicsellaneous: - to supply adequate heat throughout
One wall light over pedestal sink Flat,rubber roof w/deck addition.
One ceiling fan light in bathroom
Phone and cable in living area and bedroom
LaPointe Custom Homes
Tina Menolakos Roof Deck
w
x -N
C� -a _ i- Up from lower deck
o z
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22'-0" (Rail)
w
Q) '
Q) DECK
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22'-0" (Rail)
Deck Constructed of Floating 5/4 x 6 pressure treated decking
Posts will be 10 ea 4x4 pt colonial ball top
Railings will be pt 2x4 with colonial spindle balusters
Pressure Treated Furring Materials
LaPointe Custom Homes
Tina Menolakos Addition Deck
4'-6"(Rail)
Down to ground level Up to Roof Deck
Deck Constructed of Floating 5/4 x 6 pressure
treated decking
Posts will be 10 ea 4x4 pt colonial bag top
Railings will be pt 2x4 with colonial spindle balusters
Stairs from ground to addition deck and addition deck
to roof deck will be two, single runs on the left side co 0
of the garage/addition �
6'x 6"pressure treated post finished with 1'x 6"pine o DECK Attached to addition over existing
C garage
to m
4'-6"(Rail)
Existing Dwelling
R*
i
LaPointe Custom Homes
Tina Menolakos Addition
exterior
22'-0"
5'-2" 8'-5" 6'-0" 2'-5"
Nom,
Deck
a / �
exterior
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4, 'i i§ �anno4S
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_5' _ __ ------ - -
5'-4”
-4" W 8"
Kitchen
Electric:
Wall outlets per code HVAC:
One ceiling light in living area Tie in to existing forced air system
One ceiling light in bedroomMicsellaneous: to supply adequate heat throughout
One wall light over pedestal sink Flat, rubber roof w/deck addition.
One ceiling fan light in bathroom
Phone and cable In living area and bedroom
A
.oc-E.
4
LaPointe Custom
Homes
Tina Menolakos Roof Deck
w
-. s Up from lower deck
o S`
O
o _
22'-0" (Rail)
� I
W
DECK
o v !
i
22'-0" (Rail)
Deck Constructed of Floating 5/4 x 6 pressure treated decking
Posts will be 10 ea 44 pt colonial ball top
Railings will be pt 2x4 with colonial spindle balusters
Pressure Treated Furring Materials
LaPointe Custom Homes
Tina Menolakos Addition Deck
4'-6" (Rai!)
Down to ground level Up to Roof Deck
Deck Constructed of Floating 6/4 x 6 pressure
treated decking
Posts will be 10 ea 4x4 pt colonial ball top
Railings will be pt 2x4 with colonial spindle balusters
Stairs from ground to addition deck and addition deck
to roof deck will be two, single runs on the left side m o
of the garage/addition
6'x 6"pressure treated post finished with 1'x 6"pine o DECK Attached to addition over existing
m
garage
3
4'-6"(Rail)
Existing Dwelling
l '
kitchen b
wl I
eII
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I
out to addition 9
living room Zd
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rdining
room
49'W
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PUBLIC PROPERTY
DEPARTMENT
AI\MFN N pal
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130w' bTw=i �4an:se��s01970
1t7:9'6 7ii9S9S FAS 9767+496%
APPLICATION FOR TAE REPAIR RENOVAI N a CONSTRUCTION
DEMOLITION. OR CHANGE OF USZ OROC FANCY FOR ANY EMSTIN
STRUCTIJItp
OR 8-113LDING_
1.0 SITE INFORMATION "
Location Name: Build(ng:
Property Address_ - on t-�?i �t R C
Property is located In a:Conservatlon Area YM Hkrtarlc Ohtrir2 YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land as
Name:
Address: 1
w r,LZ 'boa d
Telephone: 9'1 3 _
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTiNg BUILDINGS ONLY
Addition ✓ Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition ✓ Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation I $1,2007
of existing building New
Brief Description of Proposed Work:
S - .dCAo coo Imo: c r
— - Mail Permit to: - -
What is the current use of the Building?
N dwelling,how many units? --
Matetist of Building? Asbestos? --_—
Wig the Building CanWm to Law?
Archited's Name ( 1
Address and Phone
Mechanic's Name
Address and Phone 0 1I S FS
Construction SuDeNWWs UC* to-AL-11-211-2HIC Registration
Estimated Cost of Prosed S-394 O— Permit Fee Calwlatlon
Estimated Cost X$7/51000 Residential
Permit Fee 5 Estimated Cost S11!$1000 Commercial--
An Additional $s.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 Penury
Date
i ,