37 VALIANT WAY - BUILDING INSPECTION 4 5 �
fLr. rr Pl'13JAC PM )111 'RTY
DEPARTNIFNT
I'u AC v�I I I., I,'. ::I(I I I • T 41 tl, AI b>Ai III .I !'I"I I�"-i l
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
7
IMPORTANT: Applicants must complete all itemson this page
SITE INFORDIATIO
Location Name VAiA *X wA'y Building -fid —39
Property Address -
37 VZilkAiC u/Ya�� ,Shu twt, wt�
Lucaled in: Conservation Area /N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes R3 Ra
Residential Q or more Units) R2_
Type of improvement Residential (hotel/motel) Rl _
(check one) Assembly(Theaters) At _
New Building_ Assembly (restaurants& clubs) A2r_A2ne_
Addition Assembly(churches) Al
Alteration Business B_
Repair/Replacement ✓a Educational E_
Demolition Factory(moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care)
Institutional (incapacitated) 12_ S
Institutional (restrained) 13_
a(# Mercantile M
r.,Storage � S1 _Moderate Ilaz:ud
Storage S2_Low I lizard _\
01\'NERS11111 INFORMA PION(Please type or Print Clearly)
OWNER Name
Address p
Telephone S
Signature �I-
- a
n
DESCRIPTION OF%%ORK'I'O BE PER -OICNIED 1 /�
,S�o -Wto, L IQtc�3. I�Loat aF DfdGS /4�GiAhP. /�u5fb[G reC ;
UwtcK SI.IIb S0 Y4FAoca A-Cr5141hrt-"5
ES l'INIA FEU CONST RUCTION COSI'
CON I'RAC IOR INFON>IA'1'ION
NameF-
Address- St Q v-1A uii±rF
Telephone f! I!li/- /b"I
Construction Supervisor's Lic # 10/4/9
Home Improvement Contractor# 001V
\14(111-IICC'T/IiNGINEER I.N'FUINIATION
Name
Address
Telephone
Mass. Registration # -- ---- --_._
5 L'
1%
PERDI I'1'FRE CALCULATION 50 0
Estimated Cost x $11/$1,000 + $5.00=
CONINIENTS
The undersigned applicant does hereby attest that all ittforntation stated above is trite to the best gflny knolvletlge
ander the penalties o perjury
Signed (owner) (agent)
i
APPROVED BY :
DATE APPROVED:_ gl 09
j��= CITY OF SALEM
� PUBLIC PROPRERTY
�` DEPARTMENT
LO'M Vs'
111.4-8-V;.'1;;1; ♦ 1 \C: 'i'8.'J:v 4,,
Construction Debris Disposal Al•tidavit
(required litr all demolition and rcnovatiun work)
In accordance \\itll the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resultin- from
this work shall be disposed of in it pruperly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
tJt lm�T�uGIL
Iname of hauler)
f he debris will be disposed of in
(name of facility)
Add!Q% MA
t ddres<of lacilitvi
A4. M kf�_':i
,iguatule of p:nn .1111 i ant
ff/0
Male
CITY OF SALEM
„ p ( PUBLIC PROPRERTY
DEPARTMENT
,1111'.w'll Ixh(„Ii
\II�1NI 1/-. WMtII.\(.1U\5G(ll1' a SAII'\t. Ibl.\l1.\( III III INJ1977
I'1 1. 97t-.'13.93'15 • F(x 97111-74, 1.46
Workers' Cumpensation Insurance ,lifftdaxit: builders/Contracturs/Electricians/Plumbers
%ouncant Inturmulion / Please Print LeCihly
NIil lnrJ lllu.uKvyl)r�amlalinNlndnulual): < � e (G(( S
City,Stare.Zip irEEA &14 smile, C 116 Thune ;': 9��-S3I 16�j
:%re „so at%employer?Check the appropriate box: Type of project(required): <i
4 I ala a general c'ollractor and I
1. 96 :un a employer with�_ ❑ b. ❑ New construction
enylloyccs(full ind,tor part-ume). have hired the sub-cuntriours
?. C] I stat u sole pmprietiK or partner- listed on rhe attach it sheet. �• ❑ Remodeling
,hip and have no employee. These sub-contractors have 8. ❑ Demolition
(wrkin tier me in an capacity. workers' comp. Insurance. q.
g Y ❑ E3wWing addition
I No workers'comp. insurance 5. ❑ We are a cotporation and its
I
required] onicers have exercised their 10.0 Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work tight ofexcniption per MOL 11.C3 Plumbing repairs or additions
myself. (Ko workers'comp. c. 152, ¢l(4),and we have no 12.0Rout'rcpairi
insurance required.j r cmployccs. [Ko workers' 13.❑Other
comp. insurance rcquired.l
• nv y+plicmd lwt checks boa of must alba lilt out the vnmu Iwiuw.huwina Iheo workeri eumpentaition(whey nailrmatiun.
' 16rmeuwnen whu,uhmit this afildavir indicating Ihey am doing all work and Olen hire autstde cwurxwn must submit anew atfdavil indi",nj;.mh.
d\mtnwl(uv Ihut thcck Iho box mint a0.xhcdn addniunal ahivi%hawing Ilse came arthe sub:ontrxtors and their wurken'comp.pulley mfurmannn
/
,,or we eorpluyer that le prueiding Ivrrrtters'c•otnpensruion in.surnrtee fur troy eniplayecs. Below is rite policy and fob rile
nfurnwrion. M
Inburancc Company -Name: -- - ------
1'ulicv a ur Self-ins. Lic. re: 03 kq(Q�l . . .. ___ Expiration Daie:_f61
Job Site -\ddre'ss; VANLIA&K WIhM( Cay,StataZlp. 5k4M f r*E4 Lit q76
.\trach n copy of the workers'compensation pollc) Jeclaralion page(showing the policy nusuber and expiration date).
Faders to secure cuserage as required under Sieben 25A ul':•IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 inlbur one-year imprisonment, as well ax Lied penul(Ics in the Ibrm of a STOP WORK ORDER and a fine
nfnp to 5250.00 it Jay•Igainsl the vo)lmor. He advised that i copy of the matcmcm may be lurwirded to the 011ice of
1:1% ,1 _,j3. it-'.he DIA :or w,ta ircc c„ca.Ige sez itb.almn.
Ido hereby terrify orI r/11//00 it in 7l teed penm7icx of perinry that the iofunnullen provided
above is true and correct.
6rf
or
17f/ic'iul nae only. Do not write m this arra,m be co iphved by(tiy ur toren alltrial.
( ire or fawn: PcrmialAvisse 0
Isvuin}( .\uthurity (circle one):
I. Il,,ird of IIvAill Z. Molding ncpartiucul .1. CihA to%u Clerk J. Electrical lu;pecror ;. Plumbing losilwor
G. Other _
CmllaclProwl: ., Phone 4:
l_
Information and Instructions
Liss.n I,u.eeils General Laws chapter I i2 rcqu irrs all co qh lo)crs to provide workers' coin pens aon for their employees.
f1Ur,aalt N 1:16 ,natuuc,an empluree is defined-is " escry person in tie service ufanoiher under any contract of hire,
e%press or implied. oral or carmen.'•
\n employer is defined as"an individual, partnership, ,issociatiou,corporation or other legal entiry, or any two or more
,.r the f„rogoo;g engaged it apnnt enterprise, and including the!cgal representatives of a deceased cmplulcr, or the
reenvcr or trustee of.un uidrvidual,pannenhlp,assoewton or other legal cnnty,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
jvvvlluhg Iwuse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on; the rounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer.”
.%vtGL chapter 152. ;25C(6)also states that "every state or local licensing agency shall withhold the issuance or
renewul of u license or permit to Operate a business or to construct buildings in the commonwcultb for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
\ddiuonally, %,IGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ufpuhlic work until acceprable evidence ofcunnpliance with the insurance
f requirements of this chapter have been presented to the contracting authority."
Applicants
Piv:asc rill out the workcrs' 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 certificale(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees whet than the
members or partners, are not required to carry workers' conipensation insurance. If an LLC or LLP docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
\ccidents for continuation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he rcmrned w the city or town that the application for the permit or license is being requested, not the Llepartment 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of tie affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
1 • to fill in the ennit/license number which will be used as a reference number. In addition,an applicant
I I_.nae be sus p
that must suborn p p
t multiple ennio'licmue applications in any given year,need only suborn one affidavit indicating
current
policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town).' \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 filled out each
year. Where a hone owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I h.: ,)mice of Invesrigaliuns would bke to bank you in adv;uuc for your cooperation and should you has° .my questions,
please du not hesirarc to give us a call.
fhc Dcp,ironent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
0MCe of Investigatlons
600 Washington Street
Boston, MA 02111
Tel. 4 617-7274900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
'u.ui
www.mass.gov/dia