ARTISTS ROW - BUILDING INSPECTION C.rn, of
}I1 APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY MVELLINGS
1\IPORTANT: Applicants must complete all items on this page
SITE aMA
Location on N Namm T10Ne W Building
PrupertyAddress
Loc:ued in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes R3 RJ_
Residential Q or more Units) R2_
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) Al _
New Building_ Assembly (restaurants & clubs) A2r�A2nc_
Addition Assembly (churches) Al "
Alteration _ Business B
Repair/ Replacement_ Educational E_
Demolition_ Factory(moderate hared) f 1 _
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13 'i
Mercantile NI
Storage S1 _Moderate H:zaal
Storage S2 _Ltw I lazard
0\\'NERS11111 INFORMATION(Please type or Print Clearly)
OWNER Name 6(IbL1�7
Address
Telephone
Signature
DESCRIPTION OF WORK TO BE PERFORMED
/LFi/�G,AGE 2 �t17�r�^di2,G.f � S
h:Nfl\I:\'I'ICD CONS'1'RUCTION CUS"1'
1
CON I'RAC1'Olt INFOR>1.1TION -�—
Name " � t Tvfasek
,address �j_�er}.r.e✓�1,
Telephone 791 631 o7XC
Construction Supervisor's Lic # CS $� 1
Home Improvement Contractor #
:\RCIII'1'I-VIVENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration # .____
PERNIIT FE'E CALCULATION
Estimated Cost x $1151,000 + $5.00=
CONINIENTS
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the penalties of perjury
Signed (o).%,ner) (agent)
APPROVED BY :
DATE APPROVED:
t rt
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I\P'. N'1 Y ru hl•'11
�I\•.•sl 1 is W,\,ta\G J,^5l xLhl' a 5nu'vl, Af.1 vv.va III it I I,J197-_
ICI. )7/.7Ii931i5 a 1:,x 9711-74,-1446
Workers' Compensation Insurance %irldusit: Builders/Contractors/Electricians/Plumbers
\ )l)jjcdnt Information Please Print Leeihly
N it nta: l llu.utc,v l�r;t]n17.uirnV lndn'duul l7.r 1�
Vldress: a b �r VU ►1
City,slafC,/iP-
rbJelK� Mist o I J YJ Phone;!: 7 Y ) 63 LO7a,
.\re yuu an employer? Check the appropriate bus: 'f)PC orproject(required):
1.❑ I an a employer with 4. ❑ I um a gcncral couuactor and t G. ❑ new construction
annploycc%(full JnIL'ur part-unto).' have hired the soh-contractors 7. Remodeling
I Jm a sole pmpricux or partner- limed on the coached sheet.
hip a ul have no cmploycts These sub-contractors hove g. ❑ Demolition
working for Ine in any capacity. workers' comp. Insurance. g. ❑ pudding addition
5. ❑ We are a evil ration and its
required.]
ired.]rs' comp. insurance P° 10.❑ Electrical repairs or additions
1 reyuireJ.] oftietrx have esereiseJ their
ri ht of per MMOIL11.0 Plumbing repairs or additions
).El I am a homeowner doing all work exemption 5 Pon P'
myself. (Ko w'orkers' colors. c. 152, g 1(4), and we have no 12.❑ Ruul repairs
insurance reyuireJ.J t :comp. insurance n:quircd.J 11
•1... ....phcant that chccke boa its nlusi Aba till unl the wd-au i.iow showing IIRtr workoo cumpent aivo 1,uhty udinmaliurt
' I lomuowrcn who eunoo Ohio affidavit indicuiny Ihuy am doing us work and awn hire uutslde cuouracrora must auttmis a new JlQdavil indi"ini1.nch.
-C-. .rxtur,shut shuck Thus box mwt joikiNd.m adslasonal nlwaf,hawing the--Jule of 1110%sub- onlrxt.xs and their wurkaro'cutup.puhry mfurmannn
OF utn tin 11 employer thus is pruviding tvurkers'cumpeueutinn hisarnnce jar wry employees. Below is the policy and fob silt
injurututinn.
Ir..,urancc Comrsaay Vame: _.__ - - -- - ---------
I'oli:v a or Self-ins. Lie. ft:--- .. . _ __ Enpirauon Date:
)uU Site Address: ___. City,stater Zip:
Attach it copy of the workers' compensation policy declaration page (showing the policy nutibur and expiration date).
Failure to+ccury coverage as required uodcr Section 25:\ ul'\IGL c. 152 can lead to the imposition of criminal penalties of a
tine op to S1.500.00 JntVur one-year nlprisonmcrit, as well is civ ll pcnultics in the fain of a STOP WORK ORDER anal o fine
of till at S250.00 a day .1gainst file violator. tic advised that a copy of[his slutcmcnl may be lurwarded to the 011ice of
I II\.',I P_Jlullb ul file I)L\ :or ut,uau:ae c•n.rJ�c \cril ic.tLon.
/du hereby acrtijv under d#t point wid penullicv ujper%ary that the injurrnuslon provided ubu ver is(rut and correct.
IF I
t,igiciul tint only. Do nai Irrift in thix area, to he cumpleted by city or town n/jiciol.
( ilv or town: _... _—. Per mitil.iccnsc 0
1„uing .\uihuriiy (circle one):
I. IloarJ of IIr.Jth Z. Building Oullartatcul 1. Cili.'fuwu Clerk 4. Llectrical In.pcctor 5. Plumbing Invpccior
G. Olher _
Canlxl l'c nun: .. .- IIII one n:
Information and Instructions
:�I.i+sachusctts Gcncril Laws chapter I52 requires all :it lo)ers to provide workers' compensation for their employees.
I'll r"laill to tins ,iatwe, an empluree is defined as" .c%cry person in the service of another under any con(,;act of hire.
c%press or imp Lcd, or it or written."
\n employer is defined as "in individual, partnership, .association, corporation or other legal entity, or any two or more
.a the t rcegou;g engaged in ujomt enterprise, and including the Icgil representatives of a deceased cmpluycr, or the
rcceiser or trustee of an individual, paltiership, association or other legal clarity,employing emplo)ees. However the
owner of dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling huuse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the.rounds or budding appurtenant thereto shall not because of such employment be deemed to be in employer."
MGL chapter 152. �N25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license air permit to operate a business or to construct buildings in the cotnmunwealth for any
applicant "Ito has nat produced acceptable evidence of compliance with the insurance coverage required."
Additionally, `IGL chapter 152, j25C(7) crates"Neither the eoriunonwealilt nor any of its political subdivisions shall
enter into any contract for the perforan inco of public work until acceptable cvidcnce ul compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Plcase rill 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 nuniber(s)along with their certificatc(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employcvv 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 con limitation of insurance coverage. Also be sure to sign and date the alfidavit. The alidavit should
he 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 aeoropriatc line.
(-sty or Town Officials
Please he sure that the affidavit is complete ;and printed legibly. The Department has provided a space at the buttum
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
I'Icase be sure to till in the pennittlicense number which will be used as a reference number. In addition,in applicant
that must submit multiple pcnnitllicemse 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 dug license or permit to burn leaves etc.)said person is NOT required to complete thii affidavit.
I he ,)thee of Imvesti.atiuns wuuld hie to thank you in adv:uice fur your cooperation and should you lia.c any questions,
plcase do not hesitate to give us a call.
ncc Uepaftmetit';address, telephone and fax number
>: ,-The Commonwealth of Massachusetts
Department of Industrial Accidents
- - -- _- Office ofInvestigedOna - -- — - — --------
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
a,•.:..d <-'i, ui www.mass.gov/dis
CITY OF SALEM
Na':70.1
: PUBLIC PROPRERTY
DEPARTMENT
\,l r\r..,rN. 114 l:r r • S.\l i s1. \I.t,;\, .,. ,: I . _I,l _
I I I v'8-'4;');4)j ♦ I'\5: '),N 'a.- 644.
Construction Debris Disposal Affidavit
(required lbr all demolition and renovation work)
In accordance tN ith the sixth edition of the Slate Building Code, 780 C'MR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting front
di this work shall he sposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of'in
`- - (namr ut lacility)
(address of lacilav) 'nI
.Iglr ture aNpenuit applicant
ala.� �og
T— Mate