23 WALTER ST - BUILDING INSPECTION Crn' Ota
f Ir= Irl 131.IC I'R( )PI :RA 1
DEPARTMIAT
(AAS^1 — I'll\\ \•I11\l.l '\ "Ifo I I � T'I. '.I, \I\••\, til •I '- ul'I it
APPLICATION FOR PLAN EXAJIINA"PION :SND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAIINULY DWELLING,
IMPORTANT: Applir:mts must rum Irlr all items nn this ra'r
SITE INFORMATION
Location Name 23 ttg(tzp.ST Building (�/
Properly Address 23 lat/'►tTQ2 �, SLI6,IM�45S .
Luxated iic Cervation Arra Y/N d/'d His
onstoric district d
APPLICATION DATE
Use Groups
(check one)
Group Humes 113 R4 {J
Type of improvement Residential (3 or more Units) R2
(cheResidential (hotel/inutel) RI _
New B one) Assembly (Theaters) Al
New Building_ Assembly --
Addition (restaurants& clubs) A2r A2ne
Assembly(Churches) AI
Alteiatiun . // Business B
Repaid Replacement V EBtnmibnul y •-
Demolition_
Factory(moderate hazard) Fl
Mand"if(inoelRelocale Factory(loCv'haiard)' . . —! `.:. . .
Found:niun Only F2_ . .. . , .
High Hazard II
Accessory building_ Institutional(residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile - 14I
.. Storage - `_SI—_Moderate Ilarinl
—'---- Storage
0%%NI':R.SI111'INFOR31A I ION(Please h pe or Print Clearly)
OWNER Name i "&l,C4 AN6f4ei> �clRi�ELEh/G PCgv12
Address -�P f�dr�i/fvvl le i9e lei r�fn � D/f3
Telephone 24t2jf� f7
Signature
DESCRIPTION OF IRK"1'0 RE PERFORMED �•-E
F � g
t ln,cuxis -ag Tn nor., n �nCel!�r
"I'I:M%IIA)CON:STRUCI[ON COS[' � n O00
•
' r
luN'I'ILAI`r111t IN,owl FIUN
Name �n F� �ui�CII,QS
A/�
Address t_.
Telephone (9�PT 1 S 0—YO(O.L
Construction Supervisor's Lic # 4w/0 0 / L?
Home Improvement Contractor # �d711 rATm l=l L
YI/GHYIf-�/
.\HCilil'I[C'I'/ENGINEEItINFY)PMAr1UN
Name
Address
Telephone
Mass. Registration #
1'I{IL\II'I'FEE CALCULATION
Estimated Cost x $Il/$1,000 + $5.00= i� yZ3 oe
CaNlnu N'rS . 1 tell w Jt Q TO 17StS70eo S �_
cti A 2�InICiJ( poQ2('"O F C 1�em
The undersigned applicant does hereby attest that all inforu+alion staled above is trite to the beet of my knowledge
ander the penalties of perjury
(owner) (agenl)
Signed
APPROVED 13Y : lr`
DA'L'E ,\PPROVED:
' CITY OF SALEM
r•.,'a �r�I PUBLIC PROPRERTY
DEPARTMENT
.i I., M 11 inl,l.'1l
\I t•.•el I,^
ItA. 171.713-v345 • f vx 979.. <.1346
loYurkers' Compensation Insurance '%ffrdo.it: Builders/Cuntracturs/Electriciiins/Plumbers
ilunlicant Information Mate Print Leeihly
V:IITIC IIIu.IIa,i I)rparnaaioNlnJt,�.luall: t.�TL7 ime� LLC
City'slarc.%ip �FTl�tyl.� . Thune r': � a agae
Arcyou an employer:'Cheek the approprime bus: '1'y p:nod
jecl (required):
I.❑ I ,un a employer wish 4. ❑ I am a general contractor and I
anployccs(lull antL'ur part-ante).• hove hind the soh-contractors f construction
2.❑ 1 .tat a tole prnprietttr or partner- listed un rhe anached.nc�et. 7. deling
,hip ad have no employees These sub-contractors have g. [ lirion
working ti,r me in any capacity. vorkers' comp. Insurance. q. ng additioninn wnrkcn'comp. insurance S. Weare a crnportinn and itsrequired.] officers have ccercixcd Ih-r 10.[Ieal repair or additions
J.❑ 1 anta homeowner doing all work right ofcxanption per MCL I I. ing repairs or additionsmyself.(Ko %vnrkcrs'comp. c. 152, §1(4),and we have nn 12. pairsinsurance required.) r employees. (Ko worker' 1 J,QtA (all•IgR liD[K F
comp. in..urnce requirc 1.j
•\u. .yy,hcad that cheeks boa nl must alsu Jill wn the•eauun I,cluw.huwuta Ihea wurkui cumpunvuiwr Iwhey ndiamulion.
, I m..hu nubnlll this aorldavir indicating Ihuy ate auiny all wurk aid Ihcn hire uurude cwurxtan mull.uhmil new alQJav:l indi"'nu uJ,h.
-f•minwu.n that aJuck Ihn box mtrl machcd.m addlliunal.Auolt,huwiug ow nmrw of Ih sub•aonrracion and their wurkan•rump.policy mrurmanun
/unr un employer I/ml it pruriding Jvorkca'r•urnpenratimr iu.ranulcr/br ttry tarp/u)•er•.r. Behnv is rhe pat/iry un11/ub aile
injunnution.
In,uranccContpany Valne: _.__
I'ulicv aur Sclf-ins. Lic. it: _-_ . . .. Expiration Date:
Job Srtc 4ddnss: _,_. City,State/Zip:
.\tlach it napy of the workers' cumpensallon policy declaralion pal;a(sh0wlnu the policy uuntber and expiration date).
failure to,ccurc wlerage as required under Section 25:\ul'\xOL c. 152 can lead to the imposition of criminal penalties o(2
line up m 51.500.00 inti/or UIJe-)Yar imprismuncnt• an well as 6it pellallics in the login of STOP WORK ORDER and a fine
of till cc, i2541 60 a Jay .ogairot lire violator. Oe ad% .wd that a copy of thls,laicmi:rl miry be lurw arded to the OI)ice.1'
I mi% gauuro ul :hl: OL\ :or unlro.wcc tcrlliul;un.
Ido herrhy t rrli[v loader floe pain%and pen 'ev of perjury that the infarinallon provided above is/rue(11111 correrf.
I ffik ill sue only. Oct nor -rite in frit arra• to be ramp/elect by wily or/dwn ra/til is/. j
I„uinll ." I "Ity (circle noe): i
I. Ih,ard of Ilv.dth !. Iluddin;; IIvp.IrlmclU I Cih.'f own Clerk J. Electrical Inspccror 5. Plumbing Inlpeetor
6. Other
l'"Illacl Phone M:
Information and Instructions
1•,udla.xns C,;ncral Laws chapter 1 i2 legwres all employers to provide workers' compensation tor their employees.
t. .
I'unu.mt to taus .l atwe, an rmpfuree is JclineJ as" every pcason in the service of another colder any,untract of hire,
;.press or implied. ural or written."
\n e1"pluyrr Is defined as"an Individual, partnership,assoclatlou, corporation or other legal entity,or any two or more
.11 the I,Irceomg engaged in a Joint enterprise. and Illeluding the legal representatives of a deceased cmpluyer, of the
re,ci%vr or trustee ul A) ludlvldual, palmerihtp,assoelauon or ether legal cnnly,employing employees. However the
owner ora 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 maintenunce,cunstruction or repair work on uch dwelling house
or ol; the groun&nr luuliling.,appur?enanr.r�,ereto shall riot becauseofsuch;employment be deemed to be an employer"
;.
NIGL 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 communwealth for any
applicant who has not produced acceptable evidence of cumptlance with the insurance coverage required."
Additionally, NIGL chapter 152, J25C(7)slates"Neither the commonwealth not any of its political subdivisions shall
;mer into any cuntract for the perfomlance 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-contracror(s)name(s), address(es)and phone nuntjer(s)along with their certificate(s)of
Insurance. Limited Liability4:ompantes(LLC)or Limited Liability Partners hips(LLP)with no employees whet Than the
members or partners, are not)required to carry workers' compensation insurance. ff an LLC or LLP docs have
employees.•a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Nccidents for confirmation dt insurance coverage. Also be sure to sign and dale the affidavit. The al)itlavit should
'NI` inrivdP)dNi6`'iry or town that the application for the permit or license is being requested, not the Department of
ri
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain it 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 Oflldals
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of du affidavit fur you to fill out in the event the Ofi ice of Investigations has to contact you regarding the applicant.
Pl.ubu be sure to till in she pennit/license number which will be used :Is a reference number. In addition,an applicant
that must submit multiple permit licetlse applications in any given yeah,need only submit one affidavit indicating current
policy information('if necessary)and under"lob Site Address"the applicant should write"Al 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 nut each
year. where a hone owner or citizen is obtaining a license or permit not related to any business or commercial venture
I i.e. a dug license or permit to bun leaves etc.)said person is NOT required ro complete this affidavit.
I he I)Ii1Ce UI Illve\thationb wuuld line to dlallk y'Ilu Ill adv9111ce lir your euoperat on and should yull bav'e .Iny queblions,
please du nil hesitate 10 gave us a call.
fhe Ucpanmcnt's address, telephone and fax number'
? % " The Commonwealth of Massachusetts..
Department of Industrial Accidents.
Office of Investiptlans _
600 Washington Street
Boston, MA 02111
Tal. 4 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.mass.gov/dia
t
CITY OF SALEM
,•.�,y PUBLIC PROPRERTY
1
DEPAR"I•'.IVIENT
•rr -a;.r-J; ♦ I \o •j-.4.•4_ •1;1„
Construction Debris Disposal .-affidavit
(reyuiicd li)r all dei ItoI11it)11 and renovation work)
In accordance t%ith the sixth edition of the State Building Code, 780 CAIR section 1 1 I.5
Debris, and the provisions of VlGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal I'acility as defined by MGL c
111, S 150A.
The debris will be transported by: f
Ganes- I-eor�- bS�1_ CO23
(name of hauler)
I lie debris will be disposed of in
(name tit lacilrty)
e5f - PeA
1adJrrx ur laa lirol
apuatwc pit pan et p i ant
3� 30--oc?
i