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26-28 SALEM STREET - BUILDING JACKET 2��v -, ter. COMMONWEALTH OF MASSACHUSETTS SUFFOLK, ss. Board of Building Regulations and Standards Docket No. 2010-344 City of Salem, ) Complainant ) V. ) Daniel Botwinik, ) Respondent ) HEARING DECISION Procedural History This matter is before the Board of Building Regulations and Standards ("Board") as a result of a complaint filed by Thomas McGrath("McGrath"), in his capacity as a building official on behalf of the City of Salem, MA, alleging that Daniel Botwinik (CSL Number 101737) ("Botwinik") violated 780 CMR with respect to an alteration project at a multi- unit building located at 26-28 Salem Street, Salem, MA 01970("Complaint"). In accordance with 780 CMR,notices of the Complaint and notice of hearing were provided to the parties. A hearing was held on December 29,2010, in which McGrath and Botwinik appeared. McGrath testified via telephone conference call. Exhibits The following Exhibits were entered into evidence: Exhibit 1: Copy of the Complaint,received by the Board on October 23, 2010. Exhibit 2: Copy of the response from Botwinik. Findings of Fact The following findings of fact and conclusions of law are supported by substantial evidence, based upon testimony, documents entered into evidence, and administrative records of the Board. G. L. c. 30A, ,¢11(2), ,¢14(7). 1. McGrath was alerted about an allegation of the construction of a dwelling unit. After investigation, he discovered that Botwinik was supervising construction to create different rooms,rather than dwelling(s), in the basement area. Because McGrath had concerns about Botwinik, based on prior dealings with him, he filed the Complaint. However, Botwinik fully complied with McGrath's orders, obtained a building permit for the basement construction activities, and the work was inspected to McGrath's satisfaction. (McGrath's testimony). 2. Botwinik readily admitted that he should have obtained a building permit prior to the construction of the partition walls in the basement. He explained that the building had already undergone substantial renovations pursuant to prior building/ electrical/plumbing permitting. He had thought, incorrectly,that his subsequent work was relatively minor. (Botwinik's testimony; Exhibit 2). Discussion The general issue is whether Botwinik failed to comply with 780 CMR, meaning the 7th Edition of the Massachusetts State Building Code (780 CMR) ("Code"). 780 CMR 110.R5.2.8(3). The Code requires the CSL holder"to be fully and completely responsible for all the work"being supervised and to "be responsible for seeing that all work is done pursuant to 780 CMR." 780 CMR 110.85.2.15.1. . Any violation of 780 CMR in the work the CSL holder is supervising can be grounds for"reprimand, suspension or revocation of a license." 780 CMR IIO.R5.2.8. There was no doubt that the erection of partition walls in the basement area required a building permit. It shall be unlawful to construct, reconstruct, alter, repair, remove or demolish a building or structure; or to change the use or occupancy of a building or structure; or to install or alter any equipment for which provision is made or the installation of which is regulated by 780 CMR without first filing a written application with the building official and obtaining the required permit therefor. 780 CMR 110.1 The construction of partition walls, even if they are not load-bearing for the level above, does not constitute "ordinary repairs" for purposes of the Code. See 780 CMR 110.3(4). Administrative Penalties After finding that the CSL holder has violated any part of 780 CMR or 780 CMR 780 CMR I IO.R5), the Hearings Officer may issue a reprimand to the CSL holder, or suspend the CSL holder's license for a period of time, or permanently revoke the CSL holder's license. See 780 CMR IIO.R5.2.8; 110.R5.2.9.5. In addition, "the hearing officer may order the license holder to retake the CSL examination." 780 CMR 110.R5.2.9.5. Although construction activities commenced without a building permit, the problem was readily addressed to the satisfaction of the building official. Further,there are no other 2 records of complaints on file with the Board against Botwinik, and Botwinik fully cooperated with the building official and the Board. Conclusion Accordingly, the Complaint is hereby DISMISSED. SO ORDERD BOARD OF BUILDING REGULATIONS AND STANDARDS By its designee, CHRISTOPHER N. POPOV Hearings Officer DATED: March 7,2011 Any person aggrieved by this decision may, in writing,request review of this decision by the Board. The filing of such a request shall not stay any the disciplinary action specified by the Hearings Officer. The Board may review the decision at its discretion. If the Board decides to review the decision,the review is an administrative review that shall be based solely on the administrative record and is not to be construed as a second hearing on the same complaint. After such review, the Board may either deny the request or remand the matter to the Hearings Officer for further proceedings, as directed. The filing of such a request with the Board shall serve to toll the timing provisions of G. L. c. 30A, §14 until such time as a final decision is rendered by the Board. 780 CMR 110.R5.2.10. In accordance with.G. L. c. 30A, §14, any person aggrieved by this decision may appeal to the Superior Court within 30 days after receipt of this decision. 780 CMR I 10.R5.2.10.1. 3 Department of Public Safety Board of Building Regulations and Standards One Ashburton Place, Room 1301 Boston, MA 02108 Cc: Building Inspector Thomas McGrath 120 Washington St Salem MA 01970 RE: Complaint against Dan Botwinik, CSL 4101737 Subject Property Address: 26-28 Salem St, Salem MA Complaint Number: 2010-344 Hearing Date and Time: 12/29/2010 10:00AM I am responding to a complaint filed against me for work that was being performed at the above-referenced property in Salem, MA. The three specific complaints I will address are that 1) alterations were begun without a permit 2) I have hired unlicensed sub-contractors 3) I have not removed construction debris Regarding#l, I had originally purchase&this building Vacant in 2009-with an outstanding order from thebuil"din"gdepartmenf that theliuilding could not:be'occupied without their sign-off. I hired`a structural_engineer, Rehe Mugnier Associates in Cambridge, and- pulled a permit to make alterations in line with his suggestions. My subcontractor John Davis carried his own'GL and worker's comp. The building department was satisfied with our renovations and the building has since been occupied. In August of this year, I had another major issue with the building—I hired Roto Rooter to unclog a drain and in the process the 100 year old main sewer pipes collapsed. I hired licensed drainlayer Thomas Mackey and Sons out of Salem MA to excavate and we had to hire a police detail and dig up the street. $15,000 later, the drain was repaired and licensed plumber Pat Riley had the interior'plumbing working. Licensed electrician Jeff Atkins also performed some minor work to comply with the electrical inspector's request that we neaten up the wiring. As a result of the collapsed drain and the necessity to put the tenants up in a hotel during the repair, the Board of Health was closely involved with the project. They informed me that I needed to sanitize the basement due to the sewer backup, which I did with a licensed cleaning company"Clean as a Whistle" out of Stow, MA. It was also apparent through discussions with the'tenants:and:a housing inspector from Community Teamwork that for safety We'rieeded to limit tenant accessto only those,areas-of the basement where it was necessary—the hot water heaters and electrical boxes. r. It was in no way my intention to make any alterations to the basement without the permission and approval of the city inspectors. We still had an open electrical permit, and I thought that adding a partition was something that was in the spirit of the work being performed. When Mr. McGrath informed me that he wanted me to pull a separate permit for this work, I did so immediately and have asked him to come and inspect the work before moving forward with the finish. Regarding 42,that I have hired unlicensed subs, after a couple painful learning experiences when I was new to the business and took subs at their word that they were licensed and insured, I now require proof and verify all documentation before signing a contract. Everyone working on this project has been licensed from the beginning. Unbeknownst to me, John Davis let his worker's comp lapse earlier this year, and as a result I took out my own worker's comp policy—but I am still only hiring subs with their own licenses and insurance. Regarding #3, the removal of construction debris, I always seek to do this in a timely manner. This is often a challenge in this neighborhood where parking is very limited and there is no place to put a dumpster on the street, but I now have relationships with trash removal companies that quickly remove any debris that is created and I work hard to make sure that all properties that I am involved with are well-maintained and free from trash as I believe the Board of Health will attest. As one final matter, my wallet was stolen and I do not yet have a replacement CSL card. I will seek to obtain this before the hearing. I look forward to continuing to cooperate with the city officials going forward and hope to put this matter behind me. Regards, Dan Botwinik 703.980.7518 dbotwinik@gmail.com evin e/ �Ol>7//lLG��G� L7ld.PA, KBurke Secretary Ulf e.//P�/LQgcf/lJLP//I i. eJ"ZG/NCG.�� Thomas G. niP.E. Commissioner e�T/O�/ P�vY7LGL2 �i� ��'.��2 Gary Moccia,P.E. Deval L.Patrick _ �T Chairman Governor,' " . / / p °"G"�LZ{GX'tC'IL ce, c��0WFI �UO/ Stanley Shuman,P.E. .Timothy P.M 'Glaurray ' ' Vice Chairman Lieutenant Governor .�iFoese /617/7P7.9POD Jaz/61>/PP>-1l'.5�! Thomas St. Pierre 120 Washington St. 3rd Flr Monday,November 01,2010 Salem MA 01970 NOTICE OF HEARING Complainant: Thomas McGrath 120 Washington Street Salem MA 01970 Registrant/Co ntracto Daniel Botwinick 20'Washington Avenue, #1 - Waltham MA 02453 Construction Supervisor: 101737 Subject Property Address: 26-28 Salem Street Salem IVIG Complaint Number: 2010-344 Hearing Date and Time: 12/29/2010 10:00 AM Greetings: Pursuant to 780 CMR 1 I O.R5 and/or 110.116, a hearing will be held based upon the information contained in the above referenced complaint. Your attendance at the hearing is mandatory. The hearing will take place before a hearing officer at the office of the Department of Public Safety, One Ashburton Place, Boston,MA at the above noted date and time. Please report directly to the hearing room on the second floor overlooking the main lobby. (Go through the double doors after exiting the second floor elevator and take a left). The hearing will be held in order to determine whether administrative action should be taken against the Construction Supervisor's License. Violations of the law or regulations which are substantiated at the hearing could result in the imposition of a suspension, revocation, or reprimand of the registration and/or license, and the assessment of a fine. The complainant must be prepared to present evidence to support the allegations described in their complaint. The registrant/licensee has the right to be represented by an attorney at the hearing and may present written and oral testimony and any other relevant evidence to mitigate the claims made against them. Any party may present witnesses with relevant information in support of their case. The complete complaint file is available for review,upon reasonable notice and at a mutually convenient time, at the offices of the Department of Public Safety during regular business hours. All requests for information or motions must be addressed to the following address and shall be in writing with a copy provided to all parties: Department of Public Safety ATTN: Hearing Officer One Ashburton Place, Room 1301 Boston, MA 02108 Telephone calls relative to pending cases will only be returned in cases of emergency. Due to the great number of complaints being processed through the program,a hearing date will only be continued under extraordinary circumstances. Any motion to continue a date shall be made in writing at least ten(10)days prior to the hearing date. All parties must bring proper identification to the hearing. Construction Supervisor's Licensees must bring their license to the hearing. Thank you for your anticipated cooperation. Very truly yours, BOARD OF BUILDING REGULATIONS AND STANDARDS <%/ O Kevin Burke c/fLPiZ�jJO�Iq/J7Z0/LZ'Cki/ QjQ��.�ff Secretary A e!/�LQ// /17ZP//T i O�cI�LG(�LLG c70I�LP/�i Thomas G. nis,P.E. O Commissioner %�GGZpif.Cll'ITiJ, CljjT.CY Z02d,11//rCLd� Gary Moccia,P.E. Deval L.Patrick / OO Chairman -Governor � /p��CP, /J�' Stanley Shuman,P.E. Timothy P.Murray Vice Chairman Lieutenant Governor, gold, "L Thomas McGrath 120 Washington Street Monday,November 01,2010 Salem MA 01970 NOTICE OF HEARING Complainant: Thomas McGrath 120 Washington Street Salem MA 01970 Registrant/Contracto Daniel Botwinick 20 Washington Avenue, #1 r. Waltham MA 02453 Construction Supervisor: 101737 Subject Property Address: 26-28 Salem Street Salem MA Complaint Number: 2010-344 Hearing Date and Time: 12/29/2010 10:00 AM Greetings: Pursuant to 780 CMR 110.R5 and/or 110.R6,a hearing will be held based upon the information contained in the above referenced complaint. Your attendance at the hearing is mandatory. The hearing will take place before a hearing officer at the office of the Department of Public Safety,One Ashburton Place, Boston,MA at the above noted date and time. Please report directly to the hearing room on the second floor overlooking the main lobby. (Go through the double doors after exiting the second floor elevator and take a left). The hearing will be held in order to determine whether administrative action should be taken against the Construction Supervisor's License. Violations of the law or regulations which are substantiated at the hearing could result in the imposition of a suspension, revocation,or reprimand of the registration and/or license, and the assessment of a fine. The complainant must be prepared to present evidence to support the allegations described in their complaint. The registrant/licensee has the right to be represented by an attorney at the hearing and may present written and oral testimony and any other relevant evidence to mitigate the claims made against them. Any party may present witnesses with relevant information in support of their case. The complete complaint file is available for review,upon reasonable notice and at a mutually convenient time, at the offices of the Department of Public Safety during regular business hours. All requests for information or motions must be addressed to the following address and shall be in writing with a copy provided to all parties: Department of Public Safety ATTN: Hearing Officer One Ashburton Place, Room 1301 Boston, MA 02108 Telephone calls relative to pending cases will only be returned in cases of emergency. Due to the great number of complaints being processed through the program,a hearing date will only be continued under extraordinary circumstances. Any motion to continue a date shall be made in writing at least ten(10)days prior to the hearing date. All parties must bring proper identification to the hearing. Construction Supervisor's Licensees must bring their license to the hearing. Thank you for your anticipated cooperation. Very truly yours, BOARD OF BUILDING REGULATIONS ANDSTANDARDS cc: Building Inspector This document contains important information. Este documento condene infornmddn importumexj-'[��j�- Please have it translated immediately. Por favor,hdgulo traducir de imnediam. Dokiman silo genyen enfomasyon ki enp6tan. Questa documento condene informarioni intportmdi pW&A,WAi8 Tanpri fe on moan aadwi I you on imedyalman. Quesm modido va tradodo imenediatamente Este documento contim informaSdes imporlantes TW Wit ndy boo gdm m8ng tin quan trong. Deve ser tradu¢ido promameme. Am dish ban ndy ra ngdn ngu cum quy vi ngay. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4".FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAY(978) 745-0343 MAYOR DGRF.LNHAUM@SALFNf.COM DAVID GREFNBAUM A(-.TING HFAun I AGF,NC August 11, 2010 Puma Partners, LLC Cio Dan Botwinick 20 Washington Avenue, Unit 1 Waltham, MA 02154 Re: 26-28 Salem Street Salem, MA 01970 Dear Sir or Madam: In accordance with Massachusetts General Law, Chapter 111, Sections 127A and 127 B and 105 CMR: 410.000: Chapter II, State Sanitary Code, Minimum Standards of Fitness for Human Habitation, an inspection of your residence at 26-28 Salem Street was conducted by Building Commissioner, Thomas St. Pierre, and Acting Health Agent, David Greenbaum for the Board of Health. Based upon determinations made by Acting Health Agent David Greenbaum and in accordance with 105 CMR 410.831, the Board of Health determines that the danger to the life or health of occupants is so immediate, condemnation is ordered immediately to the entire dwelling and the hearing requirements of 105 CMR 410.831B and C are waived. All occupants of the apartments are ordered to vacate the units immediately for living purposes. If any person refuses to leave the dwelling they may be forcibly removed by the Board of Health or by local police authorities on the request of the Board of Health. The Acting Health Agent cites 410.750(F) of the Massachusetts State Housing Code. There is currently no working plumbing in the building and raw sewage has backed up into the first floor bathroom. In accordance with the 105 CMR: 410.000: Chapter ll, State Sanitary Code, Minimum Standards of Fitness for Human Habitation and Massachusetts General Law cited the Board of Health orders condemnation of your property. No dwelling or portion thereof, which has been condemned and placarded as unfit for human habitation, shall again be used for human habitation until written approval is secured from, and the Board of Health removes such placard. No person shall deface or remove the placard, except the Board of Health shall remove it whenever the defect or defects upon which the condemnation and placard action was based have been eliminated. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. inc rely, Davi Gr en aum Acting Health Agent Cc: Mayors Office Bob McCarthy, Councillor Ward 1 Dr. Barbara Poremba, Chair Salem Board of Health Thomas St. Pierre, Building Commissioner David Knowlton, City Engineer Richard Rennard, Public Works Director Community Team Work, Inc. Salem Housing Authority North Shore Community Action Programs Delivered in hand Thomas G.Gatzunis,P.E. Commissioner YY"11 l.Gl1�Lf.G J !v._T(irTi Alexander MacLeod Q / / ,R.A. Deval L.Patrick / 1JrfCb Chairman Governor ��/� (5;01 /rj Gary Moccia,P.E. JP, Vice Chairman/J � Timothy P.Murray taC Lieutenant Governor Robert Anderson 0290�96�� Administrator Thomas McGrath 120 Washington Street Wednesday,October 27,2010 Salem MA 01970 Contractor's name: Daniel Botwinick 101737 Property Address: 26-28 Salem Street Salem MA Complainant: Thomas McGrath Complaint Number: 2010-344 Greetings: The Board of Building Regulations and Standards has received your complaint about the above named Construction Supervisor License holder("CSL"). The complaint has been forwarded to the CSL for response. The CSL has been directed to forward a copy of the response to you. Once the Board receives the CSL's response,the board will determine whether a hearing is required. You will be notified in writing should your attendance at a hearing become necessary. Please keep the Board informed of any change to your mailing address. To ensure the fairness of the proceedings,all communication between you and the Board about this matter must be in writing and a copy sent to the other parties. Please be certain to include the above-listed complaint number and CSL's name in any such correspondence. Thank you for your anticipated cooperation. Very truly yours, BOARD OF BUILDING REGULATIONS AND STANDARDS Thomas G.Gatzunis,P.E. Commissioner �' vL/�LQ//r/IJLP/lLfi CZ cl�t(T7GLG e7(l�fv.�iri Alexander MacLeod,R.A. Chairman Deval L.Patrick � / � Gary Moccia,P.E. Governor Vice Chairman Timothy P.Murray Robert Anderson Administrator Lieutenant Governor (/� e // _ / O��OD��iD Thomas St. Pierre 120 Washington St. 3rd Flr Wednesday,October 27,2010 Salem MA 01970 Contractor's name: Daniel Botwinick 101737 Property Address: 26-28 Salem Street Salem MA Complainant: Thomas McGrath Complaint Number: 2010-344 Greetings: The Board of Building Regulations and Standards has received a complaint against the above-listed CSL License holder("CSL")To assist the Board forward any documentation about the above-listed property and/or complaint. Please reference the complaint number in your reply. Thank you in advance for your.invaluable assistance. Very truly you;s, BOARD OF BUILDING REGULATIONS AND STANDARDS CITY OF SALEM j PUBLIC PROPERTY DEPARTMENT KIMBERLEY DRISCOU MAYOR 120COASI-RNG`PONS"I'i2EEr+ SALEbI,MASSACIR%F.'rI5 01970 - TYL:978-745-9595 ♦FAR:978-740-9840 STOP WORK ORDER Property Location 26-28 Salem Street October 19, 2010 C�pY Dan Botwinik Cougar Capital LLC 20 Washington Avenue#1 Waltham, Ma. 02453 Dear Mr. Botwinick The above listed property has been posted with a Stop Work Order due to being in violation of the following State Codes and/or City Ordinances. " 780 CMR Massachusetts State Building Code, Section 118.1, regarding violations of the construction code, states that it is unlawful to add, alter, or construct any structure without the proper permit to do so. Work is being done without a permit. No further work may be done until such time as the order is lifted. Any person who shall continue any work in or about the building or structure after having been served with a Stop Work Order, except such work as that person is directed to perform to remove a violation or unsafe condition, shall be liable to a fine of not more than $1000, or by imprisonment for not more than one year, or both for each violation; with each day constituting a separate violation. If you have any questions regarding this letter, please contact the Building Inspectors Office at (978) 745-9595 ext. 5644 Sincerely, Thomas McGrath Assistant Building Inspector cc: file, Mayor's Office, Fire Prevention, Police Dept., Health Dept., Electrical Dept., Plumbing Insp. Tache Flea 1 Estate BenuoaS Carol St. Pierre Direct: 978/740-5151 Office: 978/745-01< 2004,978/578- Fax: 978-741-5583 e/fax: 866/431-8553 carol s@tache.coan FAX COVER SHEET DATE: TO: 1901'7rz. V4e FIRM_�—Z� NUMBER: _ G— iFe�� l RE: 02 G TOTAL NU not including cover Sheet) IF YOU DID NOT RECEIVE ALL 0F '1 mS TRANSMISSION, PLEASE CALL ML. SPECIAL, INSTRUCTIONS: aZe oe vOr 208 Derby Street,Salem, Massachusetts 01970 J A. DATE, Juhe 13,.2009 M City Of Salem,TOM St Plarte,Building Inspector RE 26-2SSalem Street,,%AternMA 01970 Please be advised that I am purebasin.9 the above-ngmej.poperty th W is currently vacant. . As::noti-fi,ed,this Property rdt"ins repairs or improvements,that were completed�without. permits,4 agree to qbtairr oroupaut7y - I-n uie Build- --Ert -- - , permits rr6 in -pattnent before allowilig OCCUP811%to Move into the building, Buy t COMMONWEALTH OF MASSSACHUSETTS Essex".Ss June /7 2009 Then personally appeared beforr Tne the abr�ve-narued Who documented his identity to me by "ek"�117'neise— anti - aekno%leged the foregoing statement to be bis Free act:and deed. vz2 Notky July 13, 2009 Mr. Daniel Botwinik 20 Washington Avenue, #1 Waltham, MA 02453 Re: 26 — 28 Salem`Street, Salem, MA= Dear Mr. Botwinik: The purpose of this visit was to inform you whether a beam was necessary on top of the first four columns in the basement. Upon proceeding to the basement, we noticed that the columns were supporting only a few joists. On the first floor, other joists were not supported and were spanning 12' and were all 2 x 8's measuring 7'/<" x 1%". It is our professional opinion that the joists have the proper capacity to span 12'; therefore, a bearing partition or a beam is not necessary at this location. We strongly recommend that the columns not be removed, as at the present time, they are preventing some deflection of the joists they are supporting. Removing the columns would force the joists to deflect creating some cracks on the floor above. This assumes that all floors were built the same with the exception of the columns as on the first floor, which is the only floor where we could observe the framing above. This was the limit of our involvement in this project. If you have any questions, please feel free to contact our office. V g Principal ASSOCIATES, INC. RMfjp DATE: Juice 11,2009 TO: City Of Salem,Tom S.t Pierre; Building Inspector RE 26-28 Salem Street, Salem,MA 01970 Please be advised that] am. purchasing the above-named property that is currently vacant. As notified,this property contains repairs or improvements that were completed without permits. I;agree to obtain occupancy permits from.the Building Department before allowing occupants to move into the building, Buy COMMONWEALTH OF MASSSACHUSETTS Essex;:ss June2009 ` Then personally appeared before me the above-named �i A/ Sg� , ,2, Who documented his identity to me by Aq y;ver's /,'cense and acknowleged the foregoing statement to be his free act and deed. Not 'y Public Commission Expires: ° CITY OF SALEM, MASSACHUSETTS t !� BUILDING DEPARTMENT 120 WASHINGTON STREET, 3" FLOOR TEL. (978) 74$-9$9$ FAX(978) 740-9846 K NMERLEY DRISCOLL MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLVIISSIONER June 18, 2009 Mr. Brad Spinosa By email brads202@gmail RE: 26-28 Salem Street building code violations Dear Brad: Thanks for sending the pictures yo took when we examined the building earlier this week. There are several conditions listed below that need to be remedied before the building is sold. Permits must be filed and work inspected (by Building , Wiring and Plumbing Departments) for the corrective work. • Third Floor Rear Porch Remove entirely or rebuild to code. • Basement Kitchen and Bath Remove entirely • All remaining Kitchens Correct as req'd to meet plumbing code • Basement Structural Install properly sized beam, columns and footings or replace bearing wall that has been removed Please call me if you need to discuss this further or need more information Sincerely Thomas McGrath AIA Assistant Building Inspector City of Salem cc: Thomas St. Pierre CITY OF SALEM a PUBLIC PROPERTY DEPARTMENT KIM6EKLEY DAISCOLL MAYOR 120 WASIIINGI'ON STREET♦ SALEM,MASSACHUSETTS 01970 TEL:978-745-9595 ♦FAX:978-740-9846 June 11, 2009 Mr. Brian Dapice Keller Williams Realtors c/o bdapice@kw.com Q� Y RE: 26-28 Salem Street Dear Mr. Dapice, Our review of Building Department records indicate that the building at the above address is a legal non-conforming three Family Dwelling. A recent inspection of the property revealed that an illegal dwelling unit has been created in the basement and a third floor rear porch has been constructed, all having been built without permits at or inspections. In order for the proposed sale to take place we will require that the new owner to: 1. File building Permits and arrange inspections for the complete removal of the basement kitchen including capping of plumbing behind the finished wall. 2. If the buyer intends to keep the basement bathroom, have licensed tradesmen arrange for plumbing and electrical work to be inspected including removing finishes sufficient for inspectors to see the work. 3. File building Permits and arrange inspections for the complete removal of the third floor exterior porch including removing finishes sufficient for inspectors to see the work. 4. Submit a signed and notarized affidavit that he will not occupy the building until all work itemized above is completed and signed off by this department. Si re , T mas McGrath Assistant Building Inspector cc: file � �� o�►zmans�eac��o� � c �M 97fR/tN7?. *Wdq/MaUirierale* -VO&4v, ��rsoe�fo 02708-7678 -9%onw(677) 727.3200 56V(677) 727-5732 .°I8W(677) 727-0079 r%etsce Construction Supervisor Supervisor License (CSL) Complaint Application • TO FILE A COMPLAINT AGAINST A CONSTRUCTION SUPERVISOR LICENSE HOLDER(CSL),THIS FORM Ml1ST BE COMPLETED IN ITS ENTIRETY. • INCOMPLETE APPLICATIONS WILL BE RETURNED TO THE APPLICANT. • ALL COMPLAINTS MUST CONTAIN AN ALLEGATION THAT A CSL HOLDER HAS VIOLATED AT LEAST ONE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE(780 CMR). • APPLICANTS WILL BE NOTIFIED 1N WRITING IF A HEARING IS SCHEDULED ON THE MERITS OF THE COMPLAINT. 1. Construction Supervisor License (CSL) holder's information: A. Name: 0 FL— N «, D. Consti Diction Supervisor License (C.SL)number: 0 (may 6e looked.up on wwN.mass. *ov/d is) - ---- C. Business address: _ Woz�-,Hl&�� _A-UoKjU� 9 D- Telephone number/email address: 20-'7 - 1g?O 2. Your information: p A. Name: "` W� B. Are you a buil'diinn.- official? yes no ❑ C. Address: SIA( .E-m 0 -D. Address of property at issue: L. Telephone: (.-a n Pax: ( p - - - - mail: 1��6� iN wl�l. i,GCvI x e�& 3. Narrative. in order for this complaint to be processed, you must provide a detailed description of the situation that led you to file this complaint. The description should identify the specific seclinil(s) of the Building Code that you allege have been violated. (For example: "The CSL holder began consu,110ion ofnM addition to a single fancily dwelling at 10 Main Street prior to appl)bzg for a hermit, in violation of 7R0 C'A4R 5110.1, lrcshector Bones issued a stop work orderizursuant to 780 CMR 5119.1, but discovered the nc��t clay Mat wo-k Was continuing."). The Building Code can be found at www.mass.gov/dps. Additionally, please provide a letter or report from the building inspector, an engineer, or architect explaining the Code violations. In the Board's experience, the vast majority of all viable complaints against CSL holders are accompanied by such a report. Additional pages maybe attached as needed. Code sections violated: 780 CMR 110. 1 780 CMR 780 CMR 780 CMR J41v()Vb 4Wjjq_-7-(12-5=� .fit�1 IW U*�� ?o 4. Exhibits. Please attach any documents that you want to have considered as part of this complaint. For example: - A copy of the building permit application, building permit, inspection reports, documentation on file with the building official, plans, affidavits, and other permits that applied to the project under the supervision of the same conimctor. - Phol:ographs iEngineering reports - Contract:between homeowner and contractor 5. Verification, zero affarnt under the lmins and penalties ofperjuty that all the information contaiMed iM this comlz ainx ac%age r.'s true aMd accuraw to the best of nzp knowledge and belief. Io - I c Signature of applicant Date E printed name of applicant t 6: E'iling. Pleasc forward the complaint package to: Board of Building Regulations and Standards CSL Complaint Program 2 The Commonwealth of Massachusetts Department of Public Safety .Massachusetts;tate Building Code(780 CMR)Seventh Edition City of Salem Building Permit Application for any Building other than a 1- or 2-Family Dwelling (This Section For Official Use Only) .1& rQ Building Permit Number: Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available) 20-28 SOe•..- S�- S.,(ev~ 0 t 2 0 No.and Street Citv /Town Zip Code Name of Building (if applicable) SECTION 2: PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building ❑ Repair 0 Alteration ❑ 1 Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change Of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? - Yes ❑ !11 Brief Description of Proposed Work: 2el.-- 5,� off. �, _ ,w�`r �ro_� aaC�`ys �-o.+ �^� r_o Ac >d S✓ OCA i� nccor hitsir✓clrvw( eSECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADN,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): 1• Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No.off loors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area (sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B. Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile ❑ R: Residential R-10 R-2 ❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2 ❑ U: Utility ❑ _ Special Use❑ and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: U rench Permit: Debris Removal: Public❑ Chuck it outside Flood Zone❑ Indicate municipal rench will not be Licensed Disposal Site❑ Private❑ or indentifv Zone: oron site sx..stem ❑ uired O ur trench or:pecilymit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: XIA I li,h,ric C...nni..i,m IZro ir,c Pna•..; Ao:t,,Applicable❑ Fs Structure thin airpnr[apprnach area:' I. their review completed? I'll C nn>cnLto Biiild enclosed ❑ ` ^ f. ,-Yes ❑ or:No❑ Yes ❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Editinn of Code: Lse Gnn:p(N): Tvpeof Con.truction:- Occupant Load per Flour: Does the building;cnntain an Sprinkler System?: Special Stipulations: C�v9�� SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner P,,,Ma Pa k zc- z9 Solew Sl_ ;10 AAA of t yj3 Name (Print) Nu.and Street City/Town Zip P�rupertNpO,.ner Contact Information: N�}n' I J'("w..n.�� >l'i�w.v�.� �03 _ 4ca -7 S I g .2, t� Title Telephone No. (business) Telephone No. (cell) e-mail address er If applicable, the property owner hereby.authorizes Name Street Address City/Town Stale Zip to act on the propertv owner's behalf, mail matters relative to work authorized by this building permit a p plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (if building is less than 35,000 cu. ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.0 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name: S 3 ame of Person Reyungqible for Constructiun License No. and Type if Applicablle� �- o wa l h � LN/a l�_ ��c 0 ') 4s reet Address City/Town State Zip 3 p 77 —— T le hone No. (business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the i suance of the building permit. Is a signed Affidavit submitted with this application? Yes Mr No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item and Materials) Total Construction Cost(from Item 6)_$ 2��O O 1. Building $ 2 O 15 O 0 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) I5. Mechanical (Other) $ Enclose check payable to 6. Total Cost $ 2-0 S a O 9 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Please print and sign name Title Tel one. 611te f Street Address City/Town S to ip Municipal Inspector to fill out this section upon application approval: �� Name Date CITY OF S.ULE.NI, ,'L%LkSSACHUSETTS \ BLAMING DEPARTMENT 120 WASHINGTON STREET, 3w FLOOR I4JL (978) 745-9595 FAX(978) 7404M K,.\jBERf FY DRISCOLL MAYOR 'ItlohtAs ST.PBJtRs DIRECTOR OF PLBLIC PROPERTY/BV DLNG CO.\L\RSSIO,%ER Workers' Compensation Insurance AITMdavit: Builders/Contractors/Electricians/Plumbers analicant Information / / Please Print Legibly Naine (Busim. organiranonlnLbvtdual):///rl`/'.f - Address: 'ST. city/State/Zip:4>"A.s i f2 ,< 9 60 7— Phone/f:/-7�i .C-Sa fdb Are you an employer?Check the appropriate box: Type of project(required): I.gD am a employer with a — 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or pan-time).' have hired the sub-coruracmn 2_❑ I am a sole proprietor or partner- listed on the attached sheet : ?• remodeling :hip and have no employees These subcontractors have 8. Morvolition working for me in any capacity. workers'comp. insurance. 9. O Building addition (No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised the 3. n 1 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 required.) t employees. (No workers' 13.❑Other, insurance required.] .Any applicant thin sisaclts ban Of must also fill wl the section below showing their worker•compenaasion policy infoMaarn 'I I.wtwowner who submit this anldrvk indicating they are doing all work and then hire ouhlow eantreeors must suhmh a new aflldavil indicating suck :(-.volmurs that check this box mine attached an additiud Shen showing ae name of don,nsla rn uacbn and their woskon'uanp,policy infarmauon. I am an employer that lr providing women'compensadon Insurance for my employees..Below ht the pollay and fob slfe information. Imurance Company Name: /ti��c��f l'�RC✓B-� 1^�Sti r HNS-? /��. �P�C� Si✓L° Policy q ur Self-ins. Lic. H: W C' 7 g 7 0� .Z Expiration Date: Job Sire Address:__� 6 S7 , (�) /2 70 City/State/Zip: V)AM, Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirstlom 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. Ile advi(ed that a unity of this statement may be forwarded to the OIPce of Irtvcsugaliorta of the DIA for insurance coverage verification. /do Itereby cortijy Mildipf the pains u nu/Iles ujperJury that the information provided above is true and corrtrt crvrr t tr ' I)atc• Lf_ Zom 9 Phan �: /� �� a•7® iOfcia/use only. Do not write in this area,to be cutrip/eted by city or town official City or ruwn: _ Permit/I.Iceme q Issuing Aulhority (circle one)- 1. Iluard of lieallh 2. Building Department 3. City/Town Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: _ __. ___ Phone 4: CITY OF SALLM ;l^ PUBLIC PROPRERTY DEPARTMENT .. :.,I .. ,: , . I:: U . . r,. .., .>::Ilr � tilll �I. \I\..\I •. I . . .I - Construction Debi-is Disposal Affidavit ocquircd fur all demolition :old renovation wurk) In accordance %%ith the sixth edition of the State Building Code, 7SO CNIR section I 1 1 5 Dc1 r1 s i , and the provisions of:tiIGL c 40 S 54• building Permit N is issued with the condition that the debris resulting front this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c I11. S 150A. The debri vi11 he transported by: Cc, s -� Coast h_'P -- 1 (namc ot'hauler) I he debris will be disposed of'in : (uamr u(I aclhly) Iaddrr,< of larllily) NLIItl1Ul l• Ur I)illl 111 .1hhlIl J111 file -Y .AP414 � 9 l The Commonwealth of Massachusetts Department of Public Safety J�j 4 a' % \LI..,la hu�eu>Tl.ltr Budding C,Idle C80(..\IR) enth E.hhun I I City of Salem Building Permit Application for any Building other than a 1- or 2-Famil wr ing (rhls Sacnun For Official U.r Unly) /�— Iluilding Permit Number: Dale Applied: Building Inepectur: SECTION L LOCATION (Please indicate Block s and Lot s for locations for which a street address is not available) No. and Street Inv /Tuwn Lip Code Name of Budding pf.ipphCablr) SECTION 2:PROPOSED WORK If New Construction check here[],it check all that apply in the two rows below E.m tin g Budding Repair O Alteration Addition❑ Demolition O (Please fill out and submit Appendix 1) Changeuf Use ❑ Changeuf Occupancy O "" ❑ Specify: Are building plans and/or curolructiun documents being supplied as part of this-permit applicattun? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: c ou p r`I- -�- +^-�`Y s-e '� -+ `='��• ao e)K . SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Croup(s): Proposed Use Croup(s): t' Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4: BUILDING HEIGHT AND AREA ExistinR3R,-14 Proposed No.of Fluors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(scl.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a lieable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ Educational ❑ F: Facto F-I ❑ 12❑ H: HI Hazard H-1 ❑ H-2❑ H-3 H-5❑ 1: Institutional I-1 ❑ 1-2 ❑ I.3❑ 1-4 O M:-Mercantile O R: Residential R-1❑ -3❑ R-1 ❑ S: Storage S-1 ❑ 5-2 ❑ U: Utility❑ Special Use❑and lealow: tipraal U.vr: SECTION b:CONSTRUCTION TYPE(Check as applicable) Ito ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ Ilia IV v0 ❑ I SECTION 7: 51TE INFORMATION(refer to 780 CSfR 111.0 for details on eaWater Supply: Flood Zone Information: sewage Disposal: Trench Permit: is Removal:Pubhc❑ O"hviL it uu bide 16w•J Grin•❑ 1 JIC.itemu ICIPa1 ❑ :\ trench wdl nut 6rUi.)",.,il far ❑ regwn•J ❑or trench �'r�)•cCitc. III Ikmv Cl ar u+dcnld\ Z Inv:_ ur on sale•c.lem ❑ i prrmd i.cnClu,rJ ❑ _ __ I Railroad rightuf-way: Hazards to Air N'avigalion: \I\ 1 I....... 14——, t'--: I \,•1 \/)•h..i 1,1, ❑ L Vrucim, i,,I hm.nr p,al.i l`)`u Lech.i n•,i' L their iruc++ a •inl•I.I-1, ..r t •n-cnl u, Hui III c,I,t, .,J ❑ I 1r.❑ �•r Nu❑ 1r. ❑ \„ ❑ SECTION H:CONTENT OF CF.RTIFICA rE OF OCCUPANCY I ,Idnm .•ll . ,.lc .___ ��c l., vi)n-I _ (,)b I 1 .n,-Ini.lpn ___ liccul`.uLL , .i.l )cr lu, i _ ' IL.,- She l•uilJinq. mLi u+.in �I•nnAlrr?�.Icm' .. `)`,-C iel �upul.ib„n. ___ .____ __.--___ I SECTI N9: PROP RTY OWNER AUTHORIZATION \'.tyyye,uiJ AdUlrys.ufle (hvnrr / N,nnr lPnnU No.,nd Slra•et Ca% ; fu+en — Liji I'rnF•erlc (/..nvr Contact Inhirmaniin fitly 1-,Lai- rviephone No. Ibu,iness) rrlephonr No. Icell) r-mail a.l.fn•�. If.tpphcil+lr, the)•rnprrl% im ner heretw authorizes Name Strad Acldrens Citvi To+vn Slate Zip tu.id on the proi,vm uU•ner\behalf, in Al tapers r(•Iauve to Ueurk,orthanta•d by this buddin • •erma.t + lication. SECTION 10:CONSTRUCTION CONTROL tPlease fill out Appendix 2) (11 bud.bn•is Less than 11i,(xNcu. ff.ut endued••ace and/or nut under C...I,IrL.01Un Cunlml then check here O muj •ki +Se.evn It)1) 10.1 Re istered Professional Responsible for Construction Control Name(Registrant) Telephone No. a-mad address Regislratiun Number Street Address City/Town State Lip Discipline Expiration Date 10.2 General Contractor -Company Name: �1 2-a •_-j Z l� �-- 7'\a--e�- 1 GS 1 O 17 3 7 Name of Person Respimsible for Construction License No. and Type livable w'a I -�- if Apt.s-- Street Address City/Town State Zip Telephone No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'CONWENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) 1. Building S 2-7 n C Building Permit Fee=Total Construction Cost x 2. Electrical S 3 UO g _(Insert here appropriate municipal(actor)=S 3. Plumbing S 4. Mechanical. (HVAC) S Note: Minimum fee=E (contact municipality) 5. Mechanical (Other) S Enclose check payable to h. Total Cost S 5 0 C) U (contact munict alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Hy entering my naive below, I herebv attest Under the pains and penalties of perjury that all of the nhurnation inn Lune) w this applicanun is true ja�nd accurate In the beat of my knovOedge.ind under,landing. {{�� TOM IVii,,print .ind •ign fimna• fitly .._— _ _ ._ 1,1,phi,ne \ elr �n rct lilJrc.. � Municipal Inspector n fill out this section upon application approval: !� CITY OF SiU.F.Nlr NAXSSACHUSETTS BuILDNG DEPART\tE:iT t 120 WASHLIIGTON STREET, 3w FLOOR TEI_ (978) 745-9595 F.tx(978) 740-9846 to\[BERLEY DRISCOLL THOtiEAS ST.PIE.RRH MAYOR DIRECTOR OF PUBLIC PROPERTY/BCI1.Dt`G CONI]MISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1plicant information Please Print Legibly Name tBusinxess,Organiratiow Individual): ice-- City/Statc/Zip: AfR 02IS3 Phone #( Are you an employer?Check the appropriate box: 'type of project(required): 1.❑ I am a employer with 4• ❑ 1 am a general contractor and 1 6. ❑New construction ro In ees full and/or part-time)." have hired the sub-contractors �� P Y ( p 7. ❑ Remodeling 2.1_1" 1 am a sole proprietor or partner- )fisted on the attached sheet. t ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition No workers'corn insurance 5. ❑ We are a corporation and its l P• 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.) •Any applicant duo chucks box At must alss,ell out the section below showing their wort us•compamadon policy im'umutioa t I h+meuurnen who submit this affidavit indicating thq am doing all work and then hire outside contmctora most submit a new affidavit indicating such. :Camracturs thug check this box mans attached an additional sheet showing the more of the sub-eontractoo and chair workers'comp.put icy information. lam an employer that is providing workers'compensation insurance for my employees. Below Is the policy and fob site information. Insurance Company Name: Policy H or Self-ins. Lie. d: 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). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ftnc 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$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 insurance coverage verification. I do hereby c• / r\wider the pains and penaaldees of perjury that the information provided above is true and correct. c;er.. ...... (�.-._- ._✓ �` Date: _ I b Phone 4' of)icial use only. Do nor write in this area,robe completed by city or town official I City or Town: ... Permiul.itense Issuing Authority(circle one): I. Board of Ileallh 2. Building Department 3.City(fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other _._...-- ------ - - Contact Person: __...____. .__ Phone#: [ Information and Instructions f Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statue, an employee is defined as "...every pet:son in the service of another under any contract of hire, evpress or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more or the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the i ecelver or trustee ui :m 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. v+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 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 GII out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)nume(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:md 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. Pk:asc be sure to till in the permitllicense number which will be used as a reference number. In addition, an applicant that must submit multiple pennitllicense 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. I he of lice tat Investigations would Rice to thank you in advance fur your cooperation and should you have:my 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 Office of Investigations 600 Washington Street Boston, MA 02111 Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE Fax M 617-727-7749 acvined 5-2rm-us www.mass.gov/dia CITY OF SIU.&M. NLUSACHUSETTS • BUILDLNG DEPARTMEINT • 120 WAsHNGTON STREET, Yo FLOOR TEL (978) 745-9595 FAX(978) 740-9W KI�tBERLFiY DRISCOLL MAYOR THottAs ST.PtERRS DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONDIISSIONER 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 cohdiiion that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c ill, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) signature of permit applicant I J '7iP � a date n.nd�,ird«