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ALMEDA ST - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) ` \ Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) SEE A-TAc_Ne0 No.and Street City/Town Zip Code - Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Fleppim,❑ 1 Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) .., Change of Use ❑ Change of Occupancy ❑ Other Q'Specify: ANitt-NA.- jkA—MmiAT%O'✓ Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: I MS TAL- GeMhuvtGATuw_f AtNTEN►*S A7 59T:r- jN SALGM X *,Qi-e9 oN ATTAGHe9 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ - Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable). A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F:Factory F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I--1❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ . S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: - Special'Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ HB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ . Indicate municipal❑ A trench will not be P Private❑ or hrdentify Zone: ar on site system❑ required❑ or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: 1A i listoric Cunnn4ssion,Review.Proc"s: Not Applicable❑ Is Structure within airport approach area? - Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code:- Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: i SECTION 9: PROPERTY OWNER AUTHORIZATION , Name and Address of Property Owner (SEE A1TA-CA CO) 4I ly OF SALEM rt'T WASHiW&T*N S-s• SAL-tH o1�r�o Name(Print) No.and Street City/Town Zip Property Owner Contact Information: crry +=N�tN� 478 - )4 - G7o ��_$ _ gb2 �know� �KGsa4unt•Caw Title - Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes MAVM Kf%btjLT09J ILo WA3Hjx-4rTyAj ST• SALIEM MA 0197o Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft of enclosed s ace and/or not under Construction Control then check here O and skip Section 10.1 10.1 Re 'stered Professional Responsible for Construction Control - - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiation Date 10.2 General Contractor - - - �—rS -royvirk I- AMfooVA SE(ZVt4= Company Name _ S7t-Vtav CHILL) c5 9310s'a GnIJTTV0Cr1Q0 SvpeRVISa2 Name of Person Responsible for Construction License No. and Type if Applicable 2-32- EAsy %yiLEEt' CAST 7y%D&r-u^4rTE4z AA 07-373 Street Address City/Town State Zip S09 30- 5464 SS+ot aCr eAMbt� Gaut Telephone No. (business) Telephone No. cell a-mall address SECTION 11:W'ORKF..RS'COMPENSATION:WSURANCE AF EMVFF M.G.L.c.152§ 25C(6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of they'ssuance of the building permit. Is a signed Affidavit submitted with this application? Yes L�f No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE - - Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical. $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ - - Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I he attest under the pains and penalties of perjury that all of the information contained in this appl' true and ac a he best of my knowledge and understanding. isRL AlZE �},< -�-j SALt'S JJ&, SAS!ehS . AAf-IAGf.7Q 50 `d,Lj t(/oit 7 ii Please print and sign name Title Telephone No. Date {jIJ'>S56r� 1?.aAD SODSUOW 4A 017` & Street Address City/To State Zip Municipal Inspector to fill out this section upon application app oval: - Name Date Antenna Site Locations: 1) Gallows Hill Water Tank,Almeda Street, Salem MA 01970 2) Salem Housing Authority, 27 Charter Street, Salem MA 01970 3) Loring Towers, 1000 Loring Avenue, Salem MA 01970 4) Loring Avenue Firehouse, 64 Loring Avenue, Salem MA 01970 5) Winter Island Hanger, 50 Winter Island Road, Salem MA 01970 6) Mack Park, 29 Grove Street, Salem MA 01970 The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street" Boston,'MA 02111E P www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busiriess/Organization/Individual): S+ S I.y✓eM _+ A r�1Tt tJ"A SE:7-vtC Address: Z-32— EAST- �IZi tM &ST l Rtn�wA ,5 hone TC MA `P City/State/Zip: Phone#: S08 - d 7—S `r Are you an employer?Check the appropriate box: , I Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.[4 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y P ty 9. ❑Building addition [No workers' comp.insurance comp.insurance.' required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions [No workers myself. 'co right of exemption per MGL Y 152 1(4d e have no 12.0 Roof repairs t c. , § ),an w insurance required.] 13.aOthor employees. [No workers' comp.insurance required.] *Any applicant that checks box Nl must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must pmvide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /t M En-I C A-N Z O K t C FI 1 IJS . CO - Policy#or Self-ins. Lic.#: D.�,2_2 t,3 B¢<i� Expiration Date: Job Site Address: SCt A-MAGNEV U5 r I N6t City/Statc/Zip: „:r,_,. _,.,,,,• 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage v rification. I do hereby cern under the pains d n es of perjury that the information provided above is true and correct. Signature: Date: Phone#: 'S G Ofcial use only. Do not write in this area,}o be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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." t 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." 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,§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 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-contractor(s)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. 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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense 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 pemnit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office 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 Office of Investigations 600 Washington Street Boston,MA 02.111 Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass_gov/dia �=�* IiZ.ItY�Ff •r �.7.1Q.�It![ r � 07/07/2011 15:55 5086975909 ESTABROOK PAGE 02/02 o VDAC ZU©H WORKERS COMPENSATION AND � //� EMPLOYERS LIABILITY POLICY ()V� X S0 (--!L7 3-�� TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6ZZU8-o522N84-8-I 1 ) RENEWAL OF (6ZZU8-0522N84-8-10) INSURER: AMERICAN ZURICH INSURANCE COMPANY NCCI CO CODE: 80012 1 INSURED: PRODUCER: CHILD, STEVEN DBA ESTABROOK & CHAMBERLAIN 5 a S TOWER & ANTENNAE - P D BOX 277 P 0 BOX 152 BRIDGEWATER_MA 02324 EAST BRIDGEWATER MA 02333-0152 Insured Is AN INDIVIDUAL Otherwork places and Identification numbers are shown In the schedule(a) attached. r 2. The policy period Is from 05-20-11 to 05-20-12 1201 A.M. at the Insured's making address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state($)listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed in Rem 3.A. The limits of our liability under Part Two are: Bodily Injury byAccldent; $ 10Oo000 Each Accident, Bodily Injury by Disease: S 1000000 Policy Limn Bodily Injury by Disease: $ 1000000 Each Employee C. OTHER STATES INSURANCE: Pan Three of the policy applies lathe states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT.WC 20 03 06A D. This policy Includes these endorsements and schedules: .off ' SEE LISTING Or ENDORSEMENTS .- EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All required Information la.subject to verilicatlon and change by audit to be made ANNUALLY. E� DATE OFISSUE; 05-25-11 DS ST ASSIGN: MA OFFICE: ZURICH-ORLAN 809 PRODUCER: ESTABROOK & CHAMBERLAIN 28FBB . so►1M