26 ARBELLA STREET - BUILDING JACKET 26 Arbella St. —����
CITY OF SALEM, MASSACHUSETTS
Y BUILDING DEPARTMENT
120 WASHINGTON STREET,3" FLOOR
TEL. (978) 745-9595
F
HIMBERLEY DRISCOLL FAx(978) 740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
May 3,2016
Raul and Maria Herrera
15 Cherry Street
Salem ma.01970
Re: 26 Arbella-zoning complaint
Dear Owners,
This Department has received complaints regarding a tenant of your property running a business from the
property. Specifically Event Planning Company.. The complaint is that trucks are picking up and delivering
tables and other items on the weekends. This property is clearly a residential property and no business that
involves the storage or manufacturing of goods is allowed.
Please contact me directly to discuss this matter.
Sincerely,
G
Thomas St.Pierre
Building Commissioner/Zoning Officer
CITY OF SALEM, MASSACHUSETTS
a s BUILDING DEPARTMENT
120 WASHINGTON STREET,312'FLOOR
TEL. (978) 745-9595
Fax(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
February 4, 2016
Raul and Maria Herrera
15 Cherry Street
Salem Ma.01970
Re:26 Arbella Street
Dear Owners,
This Department has received a complaint that a third unit was created at 26 Arbella. Looking from the
exterior,three mailboxes are obvious and a third floor deck appears to have been added.Therefore a"Required
Inspection" is required and has been scheduled for Thursday February i 1ffi at 1:30. (Mass State Bid Code 780
CMR section 104.6) All areas must be accessible for the Inspection. If you feel you are aggrieved by this order,
your Appeal is to the Board of Buildings, and Standards in Boston. If you have any questions, please contact
me directly.
Thomas StTierre
cl,� 4
Building Commissioner
CITY OF SALEM, MASSACHUSETTS
" BUILDING DEPARTMENT
120 WASHINGTON STREET,3""FLOOR
TEL. (978)745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
March 28, 2012
Tache Real Estate
208 Derby Street
Salem Ma. 01970
R.E. 26 Arabella Street
To whom it may concern,
The property at 26 Arabella had contained a third unit that was determined not to be legal. A building
permit was secured to remove an un permitted stairway and to remove the kitchen. This satisfies the
City's concern removing the unit. However,the access door and stair to the third floor are only
suitable for the third floor to be used as attic space. If a future owner wants to utilize the third floor for
additional living space connected to the second floor, a plan showing proper construction details and a
building permit must be obtained. After the work is complete and inspected, an Occupancy permit will
be issued for the third floor to be used as part of the second unit.
Sincerely,
rAW
Thomas St.Pierre
Building Commissioner/Zoning Officer
cc. file, Fire Prevention
/o- CITY OF SALEM
q` PUBLIC PROPERTY
DEPARTMENT
KIMBFJU.GY DIUSGOL1.
Mnvac 120\\/As-11 NITON S�ire'r SrvLFdi,(\4 nssna iu6 01970
PeL978-745--9595 IIns:97S-740-934
Notice of Violation
PROPERTY ADDRESS
26 ARBELLA STREET
October 8, 2008
Mr. John Vitale
26 Arbella Street
Salem, Ma. 02170
As a result of the inspection conducted by this office on September 30, 2008
it has been determined that an illegal dwelling unit exists on the third floor of
26 Arbella Street in violation of the City of Salem Zoning Ordinance chapter
6-1 for a 3 unit building in a location zoned for 2 family dwellings, and also
in violation of the State Building Code 780 CMR section 1010 for a non-
conforming front entry stair.
Said violations must begin to be corrected, repaired, and/or brought into
compliance within 7 days of your receipt of this notice, Failure to do so may
result in further actions being brought against you, up to and including the
filing of complaints at District Court.
Sincerely,
Thomas McGrath
Assistant Building Inspector/Local Inspector
CC: file,Health Dept.,Fire Prevention, Mayor's Office, Councilor Veno
1
Y w
CITY OF SALEM, MASSACHUSETTS
$ 1� BUILDING DEPARTMENT
a " 120 WASHINGTON STREET,31'FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERL EY DRISCOLL
NIAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
October 13, 2009
John Vitale
26 Arabella Street
Salem Ma. 01970
R.E: 26 Arabella
Mr. Vitale,
This Department has received a complaint regarding the third floor unit of your property. As you
are aware, This Department cited you last September for an illegal third unit. It would appear
that you have ignored the violation and have continued to rent the third floor. Included is a 21-D
citation . You are again directed to cease the use of the third floor. You are further directed to
secure proper Building,Electrical and Plumbing permits to remove the third unit within 30 days
of receipt of this notice. Failure to comply with this order will result in additional tickets as well
as further enforcement actions. If you have any questions, please contact me directly.
This SLPi e
Building Commissioner/Director of Inspectional Services
cc.Jason Silva,Fire Prevention ,Councillor Sosnowski
CITY OF SALEM
(� s'� PUBLIC PROPERTY
��—:� , DEPARTMENT
KIMUEIII.EY DRISCOLL
MAYOR 120 WASHINGTON STREET ♦ SALEM,MASSACI-IUSEI'I'S 01970
TEL.:978-745-9595 ♦ FAX:978-740-9846
REQUIRED INSPECTION
PROPERTY ADDRESS 26 ARBELLA ST
September 25, 2008
Mr. John Vitale
26 Arbella Street
Salem, Ma. 02170
The above referenced property has come to the attention of this department for the
following reason(s):
A report has been made to this office that there is an illegal attic apartment unit
in the building. For this reason an inspection must be conducted by our inspection team
to assure compliance with the code and city ordinance.
Under the provisions of 780 CMR, Section 115.6, the State Building Code, access
to this property must be granted for the purposes of this inspection. Please call this office
upon receipt of this letter to schedule this required inspection. If this property has rental
units, these tenants must be notified in advance of this inspection, so that access to these
spaces may also be accomplished.
This inspection must be completed on or before October 7, 2008; failure to respond
to this notification will be construed as non- compliance, and as such an Administrative
Search Warrant will be sought, so as to allow the lawful inspection of this property.
If you have any further questions regarding this letter, please call this office at (978) 745-
9595, extension 5643.
Sincerely,
Thomas McGrath
Assistant Building Inspector/Local Inspector
C : fil ealth Dept., Fire Prevention, Mayor's Office, Councilor Veno
&03 8osnoI
/.,owig4p
s
CtU of �$Aem, fflttssar4usetts fuer
� c�P�' emaerx.s�,irH. Hes
nttra of ral
DECISION ON THE PETITION OF JULIE & MATTHEW CAR_RICK/CATHY &
THOMAS TARDIFF FOR A SPECIAL PERMIT F0R_26YARBELLA ST. (:R-2)
A hearing on this petition was held November 9, 1988 with the following Board
Members present: James Fleming, Chairman; Messrs. , Nutting, Strout and Associates
Dore and LaBrecque. Notice of the hearing was sent to abutters and others and
notices of the hearing were properly published in the Salem Evening News in
accordance with Massachusetts General Laws Chapter 40A.
Petitioners, owners of the property, are requesting a Special Permit to allow
an existing deck in the rear of 26 Arbella St. which is located in an R-2 zone.
The provision of the Salem Zoning Ordinance which is applicable to this request
for a Special Permit is Section V B 10, which provides as follows:
Notwithstanding anything to the contrary appearing in this Ordinance, the Board
of Appeal may, in accordance with the procedure and codnitions set forth in
Section VIII F and IX D, grante Special Permits for alterations and reconstruction
of nonconforming structures, ane for changes, enlargement, extension or expansion
of nonconforming lots, land, structures, and uses, provided, however, that such
change, extension, enlargement or expansion shall not be substantially more
detrimental than the existing nonconforming use to the neighborhood.
In more general terms, this Board is, when reviewing Special Permit requests,
guided by the rule that a Special Permit request may be granted upon a finding
by the Board that the grant of the Special Permit will promote the public health,
safety, convenience and welfare of the City's inhabitants.
The Board of Appeal, after careful consideration of the evidence presented, and
after viewing the plan of the property, makes the following findings of fact:
1 . There was no opposition;
2. The deck is used only in conjunction with its use as a two family;
3. Councillor O'Leary spoke in favor;
4. The deck was not constructed by the petitioners.
On the basis of the above findings of fact, and on the evidence presented, the
Board of Appeal concludes as follows:
1 . The granting of the Special Permit will promote the public health,
safety, convenience and welfare of the City's inhabitants;
2. The relief requested can be granted without substantial detriment to the
public good and without nullifying or substantially derogating from the
intent of the district or the purpose of the Ordinance.
DECISION ON THE PETITION OF JULIE & MATTHEW CARRICK/THOMAS &
CATHY TARDIFF FOR A SPECIAL PERMIT AT 26 ARBELLA ST. , SALEM
page two
Therefore, the Zoning Board of Appeal voted unanimously, 5-0, to grant the
Special Permit requested allowing the existing deck to remain as shown on the
plot plan submitted to the Board of Appeal.
SPECIAL PERMIT GRANTED
� L
John R. Nut-ti g, See etary
A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK
„I'I .L Fi,:i::i THIS DECIaI i" d.''!Y
SHALL BE D° P'JPSCANi TO, SECTn ! 17 ^r 11. .'
_R5L li 5 G '� - � PF 20 DAYS 51'�� idc ''4 c OF
11iE OFFICE
' in Cii} GLEN. i,.
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Ti E n.,. PE:'
Of R �ORJ OR IS RECOROEO AIIJ N EL O1J TH, Ov -cR S GERTiF ICS . OF TITLE.
BOARD OF APPEAL
UNITED STATES PaSfiRL�.S�RWa -% -? FjrSFCla93"AQad °"..y,
"' Paskg�'A 8 Fees Paul .
w, Perynit
• Sender: Please print your name, address, and ZIP+4 in this box
Id eM-
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete a S`gnature
hem 4 if Restricted Delivery is desired. gem
■ Prim your name and address on the reverse X ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C. Dat of e
■ Attach this card to the back of the mailpiece, i7 l� /t
or on the front if space permits. �'o� t O (/
D. Is delivery address
1. Article Addressed to: different fmm item 17 Ye
If YES,enter delivery address below: �No
Service Type
3. OCertified ail El Express Mall
❑Registered O.Return Recelpt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(Transfer from service label)
Ps Form 3811,February 2004 Domestic Return Recelpt 102595-02-M4546
--- I'lie C'onunonweal(h of Massachusens
hoard of Building Regulations and Standards Cl IN OF
Massachusetts Stine Building Code. M 0,111 SALEM
O`/v�] n,:.. Ndri.tc�l.Ilur_III/
Building Permit Application To Construct: Repair. Renovate Or Demolish u
One-or Tu u-kanoly Du dlhi r
This Section For 0111clal Use 0
Building Permit Number: Date Ap)' d:
�KBuilding 011116 l(print Name) h Sign I)to /
SECTION I:SITE ORNIATION /
I.I Properly Address � /)� J 0 d1 I.1 Assessors MAia S: Parcel Numbers
1.1 a Is this an accepted street? 'es Fnjop// flap Number Parcel Number
I.] Zoning Information: 1.4 Property Dimensions:
Loning District I'n+posed ilia Lot Area(sy 11) Fronlage ill)
1.5 Building Setbacks(R)
From Yard Side Yards Rcar Yard
Rcyuimd Pruvidud Required Pr,,idcd Required Provided
1.6 Water Supply:(M.G.1.c.JU.§!J) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Ihtblic❑ Private❑ Zone: _ Outside Flood Zone.)Check iY csO MuniMunicipal❑ On site disposal s)xrem ❑
ecord 1.1 Owners :
SECTIONS: PROPERTY OWNERSHIP'
of
2(, Q 1 P-�I,re t SAC " h
Munc(Print) C' state,zip
2� l� Ybell � s+ } 8,1-676- 2y-/T,
No.and Street relephune Email Address
SECTION.): DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number f Units_ I Other Cl Spccily:
Brief Oescri tion o Proposed \York': Lit '.'L J 1 /L / p r y
S'J e /
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Iwm Estimated Costs: Official Use Only
(Labor and .Materials)
I. Building S I. Building Permit Fee: S Indicate how fee is detennined:
'. Electrical S 0 Standard City+Tossn Application Fee
O Total Project C-ostt Illetn 6),1 multiplier
I ?. I'IumMng S ]. Olher Fees: S_
J. \tech.mieal ill\ \('I S LisC.— -'—__ _ .
CutgcssiUnl rolal .\Il Fees: S_.
('heck No. ( Iteck.\mtuunt: ('.uh \m.umt:
n i'utui Prnject CwL S / vv�� ❑ I'Ad in Full ❑Outsrmdiog Bal.utce Due:
SEC1'ION 5: ('ONSI•RUCf10NSERVI('F.S
S.I C istructiun Supervisor License(C SI.) -- 1 S l
— --
--- -�
p P I Iccnx Norther �,{nrnli it Date
Nallic ott'SI II loolldcr 1 nt CAI. I\pc her/ V^
er1 ^ ol
— 'llpr Dcicripliun
No. .u1J Alrect ki l In I iin s li to 15IU2 cu Il.l
R ICr,trivird h1 Fanl Dilrllin
l'ityil'own..Cla1r.L11`"-- /1G ._—_.__. .\I \luilm
RC' H,allin Onerin
'A'S 14111d11w dlld`Id111
2 SF Solid Fuel Iluming Appliances
I Insulation
Talc hunt Pmail❑JJrrss D Demolition
LS. Registered Ilumprovenwn ntractor(HIC)
rfih,�l`f' Jy� /I/l/�l(/I LAi'///J— IIIC' Regiiu;niun Nmnhrr livp ration Uutc
1IIC I it in¢ 1911
' I rgistrunr Name I �
. and Street J' 7 Email address
City/Town,State ZIP rein hone
SECTION III WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L.e. I52.1 25CM)
Workers Compensation Insurance affidavit 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.
Signed ARldavitAttached? Yes..........0 No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE C0111PLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
i? AU1,. 0 evV-q-V C', 1 ��-
Pnn ON01ef s Nallle(ElrrlN111e$lgnaturvi - le
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below.
I 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.
I'riol U,1ncr's or AuthurinJ Agent's Nunw(Flectnnlie Sign;lulre) Dale
,NOTES:
I. An Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered cunuactur,
Not registered in the Hume Improvement Contractor I HIC) Program),will nu have access to the arbitration
Program or guaranty fund under M.G.L.c. 1�2A. Other important infurmation on the HIC Program can be lilund at
kM OIJ" '�„ 0% I Inrormadun on the Construction Supers isor License can be found at „m„ Ill
2 \\hen substantial wurk is pl;ulncd,provide the intornalion below:
total (lour area Isy. 111 . 1 including gauge, lmished basement attics,decks Or porch)
Cin,ii lis ing urea t iy. tl.t -__. habitable roost count _ -
\mubcr of Iirrplaccs Number of hedruOms
\luuhcr ol'hathrooms \unlher Ol'halFhalhs
I'.pe of hcaring s)stem \wmhcr tlt de"ir p„rchcs
o I'1 J,v CooIIIIg i\Swill
1'1161,cJ l)1,cn
1 "I'oial Proicel Square l',hnagr IICI\ he ,Ilh,titutcd tIV"l mal l)rujr Ct(•,INC
A
Y
Lemus Home Improvement
Commercial & Residential Lic,& Ins
186 Breeden Ln Revere Ma 02151
617-438-3653
Homeowner Info:
Raul Herrera
26 Arbella st
Salem Ma 01970
781-696-2417
The following contract is for the alterations. This paragraph describes the work to be
performed. With this price it includes labor materials.
Scope of work:
• Replace and repair all rotted facial boards
• Install aluminum trim on the facial boards
• Install vinyl soffit underneath the facial boards
• Install new gutters around the house
• Install new architectural shingles around the walls of the roof
• Contractor will dispose of all trash collected at the job site.
Note: you may cancel this agreement provided you notify the contractor in writing at
the address above by ordinary mail posted, by telegram sent or by delivery, not later
than midnight of the third business day following the signing of this-agreement.
Notes: (*) Any special equipment or custom made material which must be special
ordered in advance to meet the completion schedule. (**) Any alteration or deviation
from above specifications involving extra costs will be executed only upon written
order, and will become an extra charge over and above the estimate. All agreements
contingent upon strikes, accidents, or delays beyond our control.
Date to commence work /_/ Date of completion of work_/ /_
Total amount: $12,000.00
Payments will be mAde as follow: A down payment of 1/2 of the contract at the start of
the job. $ 6 U�
$ by_/ / or upon completion of
Coop .
The balance due of$ upon completion of the contract.
The above price, specifications and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payments will be made as outline
above. Upon singing, this document it becomes a binding contract under law.
Lemus Home Improvement Raul Herrera
Date Date
• -k d -,O o J, , 7�
�, 1'ha C'ununonsae;dth of Massachuscus
yl 1� Board of Building Regulations and Standards CI IN OF
'r Ntassachusetts State Building Code. 780 C NIR SALLAI
Building Permit Application 'ro C'onstnrct, Repair, Renovate Or a
One-or Tivo4`a nilr Uurlliugr
This Section For Official Us nl
Building Permit Number: In App ed:
)�
IhiilJing Official(Print N;unc) Signatu / Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Slap di Parcel Numbers
�;<Irbc,t 1W5t
1.1a Is this an acce ted stree0yes no Map Number Purcel Nunther
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq III Frontage(11)
1.1 Building Setbacks(R)
From Yard Side Yards
Rear Yard
Required I'ruvided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Prk ate❑ Zone: — outside Flood Zone?
Chock ir' es❑ Municipal Von site disposal s)'stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.IV42 UO��n; rtof egor ^ n
� P S���'
/V l
N;wte(I' utl) City.State.ZIP
��� l;(� C-� e(� J*
To.and Greett Telephone iftail Address
SECTION]: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed \York': e M t C 1 ( Cu t Ol
F► l loot1212 4,dove- /W
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Rent Estimated Costs:
I labor hod.\lateriels) Ofliciol Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard CityrTosvn Application Fee
❑Total Projeet Cost'(Item 6)x multiplier _ _x
i. I'lumhing S , _
_. other Fees: S
a. \Icdtanieal ill\.\(') S List:
5. \Icch:mic:d (Fire I — --- --- -
Cugynessian) S Total \II Fees: S — — --_._
n Tutul Project Cost: 5 ('heck No. _..._ eck Annount: . _-. — Ca5h \mrnmt:
�U ('h❑ J in Full ❑Outsumding Balance Due:
P
SECTION S: CONSTRUCTION SFRVICTS q
5,1 Cunstru Ion S
• upen''cor Li-ens e(CSL)
I icensc Norther I:y,irahion Dale
Nanhe ul'CSI. I lulder
I is l'ti I. I)Pe I see hduo 1 —
' l's Description
Na. d 1&2l Ih
-t J 5reyt\ ----- -- - ---'-- Pc
�,(��`_ /, �ryr(�j� l Innsrieled I Ihlildin's u w 15,11110 eu. lt.l
R¢.+triciciunil +ellin
l•il+(I'own•%uc,/ I' M Alasuo
R Newlin l'occrin
µ'gC \4'inJu+r:Ind tiiJin
tiF solid fu¢I Horning.\pplianecs
�7`�f�� /ea I Insulation
1'cle bona I[mail address D Demolition
5.2 Registered flume Improvement Cmrtractor(HIC) _
IIIC'Reptratiun Nunther li111 ration Date
IIIC'C'ompan) Nome or I IIC'It¢gistrunt Name
No.mid Street Email address
City/Town,State,ZIP tale hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I32.1 25C(6))
Worker Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes ..........cdf No...........O
CTION 7a: OWNER AUTHORIZATION TO BE COI►IPLETED WHEN
SE
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print 0+mcr's Name(Electronic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,I 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.
Print 0++nct s or:\ulhoriicd -,—
it's Name Ilflecuonie.tiign;uurol D c
NOTES:
I. :\n Owner tsho obtains a building permit to do his.her own work,or an owner who hires an unregistered cuntmctur
(nut registered in the Hume Improvement Contractor(HIC) Program),will nrr have access to the arbitration
program or guaranty fund under\I.G.L.c. I42A.Other important information on the HIC Program can be found at
111.11+ , .x l Information on the Construction Supervisor License can be found at
?. \Then substantial work is planned, preside the inl'unnatiun below:
rota) flour area I sq. ti.l - ____.._I including garage, finished basement attics.decks or porch I
Gross lising.reaI sq. ll.) _--.. Habitable room count
Number of fireplaces_-.. __ Number of bedrooms
Nunlhcr of tiathrooms Number of half hallo
I')lie ail'heating s)Stem 'sumher ul'decks, porches
I\ l)pcn
I pe„I iJUlnlg s\Slelll 1'11cased
1. "I'.dal I'n jed tiyuarc Puot,lyc"m;q h¢suhstitutcd Ilr"I'olal Project Cost"
L
R
CITY OF SAL.EM, Akss,1Caf USETTS
1 BUILDING DEPART-,LV—\T
130 \Y/.1SHL�IGTON STREET, 1-FLOOR
"�• ' TEL (978) 745-9595
F,4-X(978) 7-M-9846
G�IBEAIEY DRISCOLL
NUYOR. T"oNW ST.PIEMH
DIRECTOR OF PUBLIC PROPERTY/SUR.DING CONL]IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A i t Illeant Information Please Print Wiltl
.V;1111C Inurlillt. Orpnuarioti lnllividu \
Address: �u yu ktnr h l City/State/Zip:_1 N5w �c�k M, Phone N: 6,0 —9
9--I — l o s
Are you an employer?Cheek the appropriate box: 'type of project(required):
f.O 1 am a cmployer with 4. ❑ I am a general contractor and 1 6. ❑New construction
ram-employees(full and/or part-time).• have hired the subcantractars
2.r[1 1 am a sole proprietor or partner- listed on the attached.rhect t 7. ❑Remodeling
.hip and have no employees These subcontractors have V. &f5emolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition ]
INo workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
J.❑ 1 am a homcownor doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers'comp, C. 152,11(4),and we have no 12.❑ Roof repairs
insurance required.)t cmpluyees. (No workers' I5.❑Other
camp.insurance required.)
•,hny appliaam Jut durokt hoe sl must alvu fill caw Ihv lectioo bcWw ahewiny their waken'compenudun puling inlimmation.
'1 Lvnvov)nun who ruhnalt this arifidavil indicating they in doing all mark and then him twlride centmctora most mhmit a new a0ldavil indioliny ruck
c',ietmctm Thal chvck this but must muhud an additime"J.hurt ahuwing the nwno of the mbaomoctors and their wurken'mmp.policy infotanotion.
fain can eurpluyer shut Jr providing workers'compensation htsarance jar my employees. Below Is the policy and fob site
injornrariun. _
I nsurmtce Company Name:__....
Policy 4 or Sel Gins. Lic. d: Expiration Dote:
Job Sift: be- 6 Address: �/i� �1 Cityistatetzip:
AHach a copy of the workers' compensation pulley declaration page(showing the policy number and expiration date).
F.tiluru to secure coverage as required under.Suction 25A of S(GL c. 152 can lead to the imposition of criminal penalties of a
rinc up to S1,500.00 und/ur one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and s line
of up ro S_M-00 a day against the violarnr. Ile advi.<ed that a copy of this statement may be forwarded to Ute Office of
Investigations ufthe 01A for insurance coverage verification.
1,10 hereby certify ruder the pains mod penuides ojperjury that the imjurmudor provided above is true and correct
ii •• t - I aad.
Zl—
iO/ficiai use mdy, nu not write hr drir area, td he completed by city or town )fjiriai I
City 'I'uwn:
or — PcrmiuT.lccnse.i_
lnsoing Aulhurify (circle one):
I. L'uord of Ilealth 2. fluildln., Deparfmcal .1.Cityifmtn Clerk 4. F.leetric,ll Inglector S. Plumbing fuspector 'i
b. Other
—Cnut:mt l'cnun
i
i
Information and Instruc ion3,
.,tassuchuscus 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,
cypress 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 ajuint 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
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, MGL chapter 152, 325C(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 rill 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 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. Sclf-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Offlelsis
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 filled 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Off ice 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
OMce of Iavestigadons
600 Washington Street
Boston, MA 021 l 1
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
5-?6-OS Fax# 617-727-7749
Rtvi;cd
,www.mass.gov/dia
CITY OF SALEM, AkSS.ICHL'SETTS
BLMDLNG DEP.jATtE,VT
I o W.kiHLVGTON STjMM0 JW FLOOR
TLL (978) 743-9599
KIAMEAL EY DIUSCOLL FAx(978) 740.9&M
MAYOR , Ikomu St PMX"
is E)"ECTcltOPPLSUCPKOPE;t y/BL:ppLNGCOIOASSIONEIt
Construction Debrlr��65 OS31 A
(required for all deri olidOn and renovation work) Vjt
In accordance with the sixth edition of the State Building Code, 780 CMR section I I I.J
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
111, S IJOA. licensed waste disposal facility as defined by MGL c
The debris wilbbe transported b
(name orhauler)
The debris will be disposed of in :
—62 ` Y be&
(name of 6
( diva orrac,hty
+ignamre r "m,tippl,c4nt
lit
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