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34 AMERICA WAY - BPA-05-201 U1 REMODEL BATHS What is the current use of the Building? a if dwelling. many unas?-- Material of Budding? W—r D Q Asbestos? d "a the Building Conform to Law? Amhiteds Name ffD ( 1 Address and Phone MechanWs Name �— Address and Phone HIC Registretbn fr ��on gupervisors License N p Estimated Cost of ro'ad S permit Fee Calcuistion Estimated Cost X i71311000 Residential Permit Fee i Eatirnated Cost X:111S1000Commwciat---- -- - L0 An Additionei $5.00 is added as an Administrative charge. Male sure that all fields are properly and legibly written to avoid delays in processing- The undersigned does hereby apply for a Building Permit build to the above stated specations. Signed under penalty of perjury /� ific4 Date_70 7 UAII N y 1 r 6N � . 1 - GIT�tOF�A�ti PUBLIC PROPERTY DEPARTNI&NT �rAYa 130 W&%um w b�*&'MAK y.MACMS6TR 01970 MM.M74S.% 6•FAX M740.9848 APPLICATION FOR THE REPAIR. RENOVATI N CONSTRUCTION DEMOLITION OR CHANG9 OFflUszlbR5B = y FOR ANY 1.0 SITE INFORMATION " Location Name l` t; V 11n tit— e Building- Prop" 3 �•� w" mow, + Property is located in a:Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 1.1 Owner of Land C r o c Name: t. ) Address: 3L� �} -�^t�Cfa_ IJQky ll►ti1 J`'2.( DlR7p Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EYISIING BUILDINGS ONLY Addition Existing , Renovation Nu er of Stories Renovated V Change in Use L 1r\e+#1 unP C,e,rde� New t Demolition Existing Approximate year of ! l� 3 Area per floor (sf) Renovated construction or renovation Of existing building 16 DD New Brief Description of Proposed Work: �- r�ep/ca-cam ., Mail Permit to: w,w -314 um o^t`c t, t It u� .��"B07�tf5fS�U1L171N�1����� . License: CONSTRIJCT.IOflSOPWVISORe�, I NumberW' S 084417 -, It Birt h 965 ire}�t 4 OPfp Tr.no: 3"1.0: 'Air T_ JONATHAN N B 7 ( 17 NICHOLSON S. MARBLEHEAD MA - 3C,ommlaabMr - ��Qda f----.-, •- -- i BbaiH oY Mmg eguTati7nv A. W. R.TaFas J' License or registration valid for individul use only" HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registr' n: 139953 Board of Building Regulations and Standards ' One Ashburton Place Rat1301 Expira on;. /6/2007 Boston,Ma.02105 Type I r- tlividual ti � `' JONATHAN N. BRIcw�S�TER 1b 17NICH L BREWSfEf � 17 NICHOLSON ,.y star MARBLEHEAD,MA'019e' i/ .... �'"✓ — — " Administrator Not valid without signature — • CITY OF SALEM PUBLIC PROPRERTY 1'.as- DEPARTMENT 1.71iR Iic 1t1.79QNt::JrSCREET •S.itc'V, St.\u.\l::a .w a:19/C TEt:971.74i9595 •F vt:9MAC-98416 Construction Debris Disposal Affidavit (required for all demolition alul renovation work) In accordance with the sixth edition of the State Building Code, 780 Cb1R section 111.5 Debris,and the provisions of vtGL c 40. S 54; Building Permit # - _ is issued with the condition that the debris resulting from this worst shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111• S 1.50A. The debris will be transported by: 1U y -7✓ u.LIL. &name of hauler) 7'17c debris will be disposed of in bloom of L;illty) --_._ o CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT YI\tn RITW Uar9Cut1 MAYOR I20 WASHING:ION SrataT • SALEvI,MASSACI It IAFTIY 01970 'rri:979-743.9393 0 FAX:978-74C-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information 7�y/,,�J'�,/ Please Print Leeibly Name lf;usincss/OrganizatioNlnJiviJuul): h" Address:_1 7 kite,1w - City/State/Zip bW Phone tf: ['Z B�� 63 l 14 0 -9 Are you an employer?Check the appropriate box: -rype of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and[ 6. [3 New construction �ployces(Full and/or port-time).• have hired the sub-contractors 2 1 am a sole proprietor or partner- listed on the attached sheet. 7- ❑ Remodeling ship and have no employees These subcontractors have S. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its rdquircd.] officers have exercised their 10.❑ Electrical repairs or additions 3.El 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.❑ Roof repairs insurance required.) t employees- [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box 01 must also rill oil the.waion 1,clow showing their work= compensation pulley infunrwtiwr. ' I omcnwmn who submil this affidavit indicating Ilccy are doing all work and then hire ouWde cunlrntton must submit a new affdavil indicaaing etch. �C,mimtu s that check this box must anached an additional sheet showing the nattto of the sub-contractors and their woken'comp.policy information. l an;(in employer that&providing workers'compensation insurance for lily employees. Below is the policy and job site information. Insurance Company Name: --.-_. . ...-. __-. ......._.__-- Policy#or Scif-ins. Lic.#: _-- --- _...___ Expiration Date: Job Site Address: City/State/zlp: 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 tine up w S1.500.00 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. He advised that a copy of this statement may be forwarded to the Office of hwtc ugauons ul'thc DIA for insurance coverage vcritication. l da hereby ccrt f under th pains uad penulries ujperjury that the injorinaf/on provided above is true and correct, Dater P tt: .7 1 - / Ofcial tine only. Do not write in this area,to be coarplered by city or town oj/iciaz City or Town: Permit/License p Issuing Authority (circle one): 1. Board of ifealth 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." 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 uustce 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 02.§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 perfortnance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority" Arpticants 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 certificatc(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 yuest. its 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 the affidavit for you to till 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 permitilicense 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 tilled 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 burn leaves etc.)said person is NOT required to complete this affidavit. 'I he 01,1-1 c ut luvestigations would like to thank you in advance fur your cooperation and should you have any questions, please do not itesi(ate to give us a call. The Deparnnent's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Otllee of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 Revised 5-26-05 www.mass.gov/dia.