27 ALBION ST - BPA-08-256 2 ADDITIONS, 2 STORIES, 2 DECKS rUBLIC PROPERTY
DEPARTMENT
MAMO.
130 WASMNGWW!�T•Setae sATM 01970
111L•M745.9S9S•FAX M74&gW
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION Ox ctiiwNG9 OF USE R OCC«, Cy FOR ANY EMI—MG
>�� ORB tnti>,I�
1.0 SITE INFORMATION "
Location Name: F� ACC)
ftw
st
— Property Address ydwv - S
.5
b b boated in a;Corlservatlon Area YM l' Historic OWtrict YM
4.0 OWNERSHIP INFORMATION S,
2.1 Owner aa(Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation I
of existing buitding I New
Mid Description of Proposed Work:
0� 4,1�, ,;-3 hc-t- ck-jr �« y
a Jkq":�,s euo , ,� - mocks
-- - -- - ----Mail Permit to: -- -- _-- - -
What is the curtest use of ths!`uildingT if dwelUng,how many units?--
Material of Building? Asbestos?
we the Building conform to Law?
Architect's Name ( )
Address and phone
Mechanic's Name ✓ s'p/
Address and phone Fee CR Registration e / :L- ,
S 3 � HIC eg (' �.s
Construction superviws license77 rnU akx+lation D co � r" O$
Pe L�
Estimated Cost of Projed S t-- ated Cost X
rn $71$1 esidentlal
permit Fee S 9�
aUated Cost Si11/itOdO
Add s a e
° Administrative charye
Make sure that all fields are properly
legibly written to avoid deleys in Processing'
The undersigned dose hereby apply for a Building Permit to uild to th bove stated
apecftatk)m. signed under penalty of Perjury
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' CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
$I%In RIPY URISUUt1
M.%YoR 12C WASHL\t.f0NSTRrai'r• SALUA.MASSACIIISVI NOl97V
Ttt_978-743-9395 •F:vx:978.74C.9346
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
-1 ) licant Information Please Print Legibly
Name tBu<ilwssiOrganizatiorVindividwl): 444
Address: t/f /410,. Q _S41
City/Srare/zip: C / 3fu "6. Phonek: /7— 7&o)
Arc you an employer?Check the appropriate box: 'rype of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
2.4employees(full and/or part-time).' have hired the sub-contractors
1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employe es These sub-contractors have S. ❑ Demolition
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[heir
10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 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. [ICo workers' 13.0 Other
comp. insurance required.]
'Ally applicant that chucks box 01 must also till our the section Ixauw showing their workers'compensation pulley information.
'homeowners who submit this affidavit indicating they arc doing all work and turn hue outside contractors must aubmir a new afrdavil indicating such.
�C.mtraunms that chuck this box must attached nn additional Asset showing the name of the sub-contracuxs and their workers'comp.policy information.
fain can employer that Lv providing workers'compensation insurance fur ury employees. Below is the pu/icy and job site
infatvnution.
Insurance Company Vane: -------- . _-- --
Policy#car SelGins. Lic. #: ------ _. _______ Expiration Date:
Job Site Address: City/Stateizip:
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),IGL c. 152 can lead to the imposition of criminal penalties of a
Fire up to SI.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. lie advised that a copy of this statement may be forwarded to the Office of
luvesngations ul'thc DIA for insurance coverag: verification.
:i
l do hereby err stud r tide tins d p u! 'es ujprrjury that the informalfon provided above i true and correct.
7� U
I Si�•aaolre: Dad r N/
Phan:c si: 0,2`
OJjiciul use ally. no not write in this area.to be completed by city or town officiaz
City or'ro%vn: _. PermitlLiccnse#____, __
Issuing Authority (circle one):
1. Board of health 2. Building Department 3.Cityirown Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: -- _ ---— _ . _-- Phone #:
4
Information and Instructions
Massachusetts 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,
express 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 a joint 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."
v state or local licensing agency shall withhold the issuance or
' ( )also states that"every
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 orcompliunce 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 am required to obtain u 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 and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till nut 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 permitllicease 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 bur leaves etc.)said person is NOT required to complete this affidavit.
I'hc Ottix of lnvestigations 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
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised i-26-05 www.mass.gov/dia
BOARD OF,BUROIND REQUP ATIONS
cLlelpMt COWTRLCT)OIISUQkRVlSiC1R,Y .
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r,-NumWr: CS '0539Fj'f y r ,>.'.,�"�
„ BkMAiI�• 1�? 11963 R
�Explres�l0/2612007 �*aTr.tro:,,17619 _
.•+. ;ANTHONY A DANDREA..tf,
.E BOSTON, MA.
'Commkslonar "f y Z
p
r
r Board of Building Regulatio and Standards `fir
F HOMEIMPROVEMENTCONTRACTOR
j �. ,Reglstratlorl 149867'-
' '• ExplraHon: 10 ;r....
T!peIridividual
ANTHONY D'ANDREA� �- - v •�',
ANTHONY D'ANDRFA .-
111:MOOREST
" EASTZOSTON;.
CITY OF SALEM /
PUBLIC PROPRERTY
_ DEPARTMENT
Mmolt 12C 5.\tl°N. MAS&%C>tt
Tr..I:9M7454599 •F.%X:97i•74Cr9"
Construction Debris Disposal .Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CNIR section 111.5 -
Debris, and the provisions of M. GL a 40, S 54;
Building Permit 0 _ _ is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
ICI 111. S 150A.
The debris will be transported by:
(name of hauler)
i
Fhe debris will be disposed of in :
(a=v of fa'Alty)
ixldCC5a Nf I��tIdY1 .
.. ♦i_ .:fYr. .a :i:Il'.:I al:h),IC 1At__ ___
•.ate
JM Builders
_ 119 Lafayette St.:PMB#1225
Salem,MA 01970
(61.7) 315-5710
Proposal
Project Name: Ca/ �_ GN,c �r. CA e C I7i✓i✓
Customer:
Address: A R;oo,) S SA r'M-f9A.0/S D
Contact Information: Co� v s - 4 7 9- 2 6 V- :7- 9-
The contractor proposes to furnish all fisted labor necessary for the completion of the
following job lspecification: Framing 4 decks (porches), 16 windows, siding, roofing,
electrical work(for new construction only, and sheetrock (for new construction
only), 2 canopies in front on residence.
a_ -AU- � -
The contractor proposes hereby to furnish all labor with above specifications for the
sum of Thirt -seven Thousand'Five'Hundred dollars 37:500 .
Y ($ )
Payment schedule as follows: $9 395 to begin ro'ect
Ym gi D l
$9,375 at the end of 2°d week
$9,375 when p`ro'ect is completed
� n -
$10 375 includes 1 000 finance char O to be financed over one year and made in 11
( $ . g ) v
payments of$865 and last pavirientof$860.00
All labor is guaranteed to be as specified and the work will be completed in a
workman-like manner in accordance to s ecifications. -Any and all alterations or
deviations from the stated specifieatioris4involving extra costs and labor will be
executed only upon written orders Thgse char s t �n into ext charg over an
above the estimate. r'
Submitted by: C�eo ✓ ! i z - P'
- f
Tb s proposal may be withdrawn if not accepted withinjy ays.,
SoD.o� 6 2,_ R (J) - !}S, t s' (.L�.y �10`v�1rl
.ems �,�� /y9y�lnL etio�s1L 7 > �t� ZS,
Acceptance of proposal as stated in the'above spe ' c ions. The labor, costs and
specifications are hereby accepted. I uthorize JM Builders to
perform the work as specified and payments wit be made.as summarized.above.
Customer Signatur Date: - Gf' a 7
Print Name: i2A-YIoS ::5— 2 'r_D 41