17 NORTH ST - BUILDING INSPECTION v'
'^ hl'131 .IC PIZOI'I �.IZ1'1'
I I I 9-8--li Oil).; ♦ 1'U 'I-B18.16
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWT:LLINGS
IMPORTAN'r: :% ) licants must cum Mete all items on this )age
SITE INFORMATION
Location Name Building
Property Address
\'-1 rJ u r:T-k-\ S�
Located in: Conservation Area Y///N Historic dstrict
OF
APPLICATION DATE `\-"L`� G
Use Groups
(check one)
Group Homes 123 Ita_
Residential Q or more Units) R2_ -
Type of improvement Residential (hotelhnotel) R- _
(check one) Assembly(Theaters) Al _
New Building_ Assembly(restaurants &clubs) A2r_A2ne_
Addition Assembly(churches) AI
Alteration Business B_
Repair/Replacement_ Educational - E_
Demolition� Factory (moderate hazard) FI _
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12
Institutional (restrained) 13
Mercantile M_
Storage Sl _Moder;nc I-lazard
Storage S2_ljm ILizad
0%%%V RSI UP IN FORMA"FION(I'lease type or Print(,Iearlp)
OWNER Name c 1 � 0 S\ f LLC
Address:R, '37
Telephone 3 lZ
Signature
uhscuu•rumf>F«uRh To BE FDRnut j
\� O\tine. \l of
I-IS IINIA 11•:1)CONS1'RUC'r ION COST \ SI 0 O
t:uNIIOC'IORINFORMAFION
Name W V\
.address -1 2 Cha c,�2t f � i�Q Cly t SC.
Telephone ( (;U 0 O
Construction Supervisor's Lic #
Home Improvement Contractor #
A RCIII'FFCIYISNGINHF.R INFUINIA'7 A, 4 e , a�
Name e `2
Address
Telephone
Mass. Registration # -- --.------- ---_ --_- --
I'BINI T FET CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
CONINIGNTS
The undersigned applicant does hereby attest that all information stated above is trite to the best of my knowledge
outer the pen ties of erjury V v �
Signed (owner) (agent)
APPROVED [3Y :
�'' DATE APPROVED: Va 9 /09
r'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
W,Isl unto I,^i GOLLT • Sxt f st,M.tvs.%I III a I IN 3197--
1
197-l i.l. 97t-713-1393 • 1:Ix 9711.74" 1.446
\Yorkers' Cumpensation Insurance %if Visit: Builders/Contractors/Electricians/Plumbers
%imucant Inrorination Please Print Leeibly
V:1InCtuu.ll,e.Ynrp]n1,.uinNlnJl,�.luull: \A�t' � �-'
Address: Q r, �,—,—�
City,St:ores%ip � 1�V`\Q S(� ll . VAC\ Thune ;, —I C I ell,
.arc sou All employer?Check the appropriate box: 'Type of project (required):
1. Lp..l .1111 a employer with 3 4. ❑ I alis J genufal l'UltlraCWf and I ft. C3new construction
I imployres(full and/ur part-gnu).• have hired the sub-cuntrac tors 7. [3 Remodeling
2. EJ1 .on a sole proprietor or partner- listed on the anachcd sheet.
,hip ani have no employees These sub-contractors have S. %Densolition
Dorking lir me in any capacity. ,vorkers' comp. Insurance. g, ❑ pudding addition
No workers'coin insurance 5. ❑ We are a corporation and its
I P 10.C] Electrical repairs or additions
I
required.] Officers hrvc exercised their
). ❑ 1 ,Im it homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself.[Ko workcn' comp. c. 152, p 1(4),and we have no 12.❑ Ruuf repairs
insurance required.) r .mpluyccs. [Ko workers' 13.E] Other
comp. insurance required.)
•�I.% .p16amtl nwt checks boa 0I Must:Ilbu jilt tan the ,clian IW 1ua,aJlYwllta Ihelr wurkui sunipentusion Iwh y mwrn nom
' I L+meuwl,en who uabma this atTJavit mdieatina nher are doing all,wrt 1.1d(bcn hire uubtde caurxtun must.ahn,it a new atrda.a mdiulma.IIeA.
-f,mtcwu,n
that shock this boa mtwt arbched.m ueJltiunal nlwel.huwinjl Ilk name of the sub-eontmiars and(heir wurtm'comprnnccy mibarianon
/am un c,npluyrr tltut it providing rvurkcrs'eutnpmrvntiun insurance/ur sty rutplayecs. Behnv is rhe pulicy olid job.Aire
in�urntulinn. � �dT��A1/,�f�\t��n
I'nlicy a or Self-ins. Lic. R: L� �� Z ..0 �l (- �_Z Expiration Date: ��� S�Z U�
Job She Address: k F (
\ O
Y ""\ �� S ll `� � CIty;SlatuZtp:
Attack it copy of flit workers' cumpensatlun pudic) declaration pulse(showing the policy number and expiration date).
Failure to secure cuserage as required alder Section 25:\ui':•IGL c. 152 can lead to the imposition of criminal penalties o(3
rine op to 5L5oo.00 and/ur one-year imprisomncnt, as well as cis it penalties in the Iuno of a STOP WORK ORDER and a fine
of till n) i250.00 a Jay against Ilse violator. lie advt.aed that a copy of this malcmcnt may be Iurwarded to the Office of
I:n:ani<amms ul 'l e OI,\ for io,m.ircr aner.lge tailisal:an.
I Ju herebycertify under the/Dim mJ p t ullia•c erj /Fur the in/urmuden provided above is true sad correct
tJ(/iris/use mdy. Do not wrire in this arca, tube run,y/iyed by airy up lawn u/lio iu/. I
( its, ur 11twn: —... __. Per mit/I.ieense l
Issuing .\ullturily (circle nuc):
1. Illrari of llvalth 2. Oudiinq Dcpartiocul I. l.11y.'f win Clerk J. Electrical Inspector i, Plumbing luspcctor
6. 1)Iher _
Conlacl Tonus: -. _. Phone it:
Information and Instructions
ala>s.t I,uiett) Gcneral Laws chapter I i2 requires all employers to provide workers' compensation for their employees.
Ptir"Lull to Ynis ,talule, an empfuree is defined.s" esery Pelson in the service of anunher under ally contract of hire,
vpren or implied. oral or carmen."
An .onpluy.•r is detincd as"in individual, partnership, .ssocianou, corporation or other legal entity,or any two or more
,.t the I„rceowg engaged .n a print enicrpnse, and including the Icgal representatives of a deceased employer, or the
receiver or trustee of .ul lildivndual, paitnershlp, association or other legal ennty,employing employees. However the
owner ofa dwelling house having not more than three apartrnenu and who resides therein, or the occupant of the
,Iwcllmg Iiuuse of another who employs persons to do maintenance,construction or repair work on such dwelling house
,x obi the.rouods;or building appurtenant thereto shall not because of such employment be deemed to be in employer.”
.%IGL chapter 152. $25C(6) also stares that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate o business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
AJdiuonaily, NiGL chiipter 152, a25C(7)crates'Neiihei the conimonwealth nor any of its political subdivisions shall
enter into any contract for the perfomhance ofpuhlic work until acceptable evidence ul'cumpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s) namc(s), addressl 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 amid date the affidavit. The affidavit should
he retuned no the city or town that the application for the permit or license is being requested, not the Department of
I nJustrial 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
Jr-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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
I'laase be sure to rill in the pcnnit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pernitllicense applications in any given year,need only submit one affidavit indicating current
policy information lif 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 is proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
vear. Where a Koine owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I h.: I hlicc of Illi estigatlun) \suuld line to thallk you in aevtance for your cooperation and Should you Ilaic sty questnonli,
please do not hesitate to give us a call
ncc Dcparuncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
cd i-'l,.ui www.mas3.gov/dia
II
CITY OF SALEM
l PUBLIC PROPRERTY
DEPARTMENT
Construction Debris Disposal Affidavit
(icyuired for all demolition and renovation work)
In accordance \%ith the sixth edition ofthe State Building Code, 780 CMR section 111.5
Dcbris, and the provisions of fbiGL c 40, S 54;
Building Permit tt is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I I L S 150A.
The debris will be transported by:
CESS �\ � W
(name of hauler)
I he debris will be disposed of in
Cc' is
(name ut facility)
t uddres<ul I�cllitvl .
vgnatu If pe rout.yiphcant
date