2- 4 BROAD STREET - BPA-09-56 16 - —----- --- fhe ('oninionwcallh of NEa>,achu,en,
I uk
11t),uJ of I3wIJiug RCQulalitm., .uld SLtnJ.IrJ, Nit `I( II' \I I I 1
Slate Building Code. 'So( NIR. )::: rJlum 111
O\ 13uildin'-, Pern)II Appli I uil. Re pat I, Heno% I(e l)r I)cIII" i, I a I R: .......
I Ihte , r (II„-fnrrlr l)n rlh,t(' l -,u,y
I
�— I' is Secnrm :or Official t',e Only
Building Permit Nw (her ` Dale Applied:
IIiwlJ�up ('ninnu..lnu:u n il :I HudJw e, U.nr
SF('IION 1: SI I'E INFORNIA I ION
I.1 PruperN Nddress: 1.2 \,sessors Map c& Parcel Numbers
h,- NP iP fi N ber
-_-_. I -
J.
ZoningoUingrinfurmutPrnfx ,•J I'.c— — I Lr�,\caR4 it)
r9y Drrneneiun;:
L5 Building Setbacks (ft) _ 1
i10%
Runt Yard tilde Yards Rear Ywd eJ PnnIJeJ I(eunired Pnir iJeJ Kryuu rJr Supply: IN1 G L e. 40. §Sir 1-7 Flood Zone Infermt{urn: 1.8 Sewage DisposalSystem:
Zinc _ OulslJe FLwJ Irn:e:' Slumn ul O On ,ur die w,el ,a,lrm CI Private❑ P ICheck .I ye,❑ _j
SECTION 3: PROPERTY OWNERSHIP'Xerl of Record: l
\.arc Pnnu -Wee ) WIf'o 1 :1Jdre,a IirQ'!i`�91asl+ �>o f- J ♦ -__—._
CJV �Us�—��
Slgrowre Telephune
SECTION 3: DFSCRIPTION OF PROPOSED WORK'(check all that apply)
x New Construction ❑ 1 Esisling Building Ouner-Ocwpied Rrp:uni sl Alter:uium,) ❑ \Jdlllnn ❑
r� —i--------�
(3rmol Rion ❑ Accessory Bldg. ❑ Number of Units_ t� (�Otth{er• ❑ Sppear}
F r3..e(Descnpuon of Pnlposcd 1Vurk2: � ---
L.
SECTION 4: ESTIMATED CONSTRUCTION COSTS _—
Vern Estimated Cots: Official Use Only
I Labor and N1a(enalsI
�I. Building Penult Fee: 5 _ InJicatr hr�w fee �, Jrlei mocd:
X � I BmIJuIg � I g
f
❑ Standard Cif dE'uwn .\ppheatu rn Fee
'_. Flectrical S ❑ folal Project Co,l� t Item 6) c multiplier ___- t
3 Plumbing S 1 Other Pees:
4 .Ntechamcal iMAC) 5
Ala hamral IPire -------
5
1i111Elrl'„htni �_ ----
('heck Nn ChC,k .\ittnuni _ _ l'.I,h \In:,unl
F n Fatal Project Cult I ) 0 Paid in Fall 0 Ou(>Ianding B.II—.In.r Uue__
SECTION ION 5: CONSTRUCTION SER% R ES —
5.1 Licensed C•unslruction Supervisor (C'SL)
�-C3Y03- -- - !a ��a
L,.:n,r Vumhir I.,Ini.u,nu l),II: !
j \.0 tic I ("Sl. I1„ it I.,,I ('SI. 1\pc ,•ri hots t,I
w.tri, ( - - - -- ----
1 t wc,u i,lid �np to �,.INNI(L I`I
Ri,tl io led I.\_' ).uwf, Dwo•ILne .. _ _A
Rl It:aJ.wui It
fclrphnnc•
i �SI FR.aJ:mL,IS IiJ li.i lS lulu`\ill n linil .i_. •u
!I r5.2 Rogistered I I e I!An rucrmrn Contractor (IIICI P
If IC C nn I ink Nome or MC R"istrinl N.mtr _—_— Rel.l,ll duos Nu ihir -
Q �� _
\darn„ )
f:,pit al tin ae -
i Slgnulutr — frlepinmr
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (NI.G.L. c. 152. 9 2506))
Workers Compensation Insurance affidavit must be completed and ,ubmitted with this application. FaJure t„-pr,,,ide
this affidavit will result in the denial of the Issuance of the.hullding permit. -
Signed Affidavit Attached'' Yes .......... ❑ No ... ❑ . .
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 - as Owner of the subject property hereby
authorize - it) act on my behalf. in all In-turn
relative to won k authorized by this budding permit application.
i �
Stgnatuic•of Owner Dale
SECTION 7h: OWNER) OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby der.late
that the statements and information on the foregoing application are true and accurate. to the best of my knowledge .Ind -
behalf. - - -
k,S�',"n,edundet
Name -
ure of Owner or Authorized Agent Date
Ilte air aria enalUrs of (u )
NOTES:n OWrier who obtains a building permit n) Jo his/her own work, or an owner who hires .tit unregnteled c,anra, aria
(nut registered in the Home Improvement Contractor I1110 Pr(,gram), will niH have acccs, it, me mhiltaw at j
program or guaran(y find under M.G.L. c. 142A. O(her important int,amannn nn the MC Pn,grain .Ind
C,)nstrucnun Supervisor Licensing ICSL) c.ln he found In 780('SIR Regularlons 1 I0.R6 and III) 145. tr,pri n,cic j
' When ,uhmannal work Is planned. pro,Ide the information helow: -
T,,(al floors area,Sq. Ft,) unOud)ng garage. f'int,hed hasemenUdnlc s. decks ,a p,v.h,
Gr,),s Irving area ISq. Ft.) Habnahle nnnn c,turn _ ------_-- -. .
Number of litrplacrs Numher of hearo,nn, --
Nunlhel or h.uhlnnns Number „I h.,P+xh,
k lle -,thea(ine ,,,tem -
jf.y)e „t ,,,ohng ,,,tern__ --
"T,a.d Priyect Square Footage" may he ,uh,ululrJ for r,aal Project C,,,C -- _--- f
L
Y
ry
Salem Historical Commission
120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT. 311 FAX (978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
Reconstruction ❑ Alteration
Demolition W— Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 2 and a Broe Street
Name of Record Owner: William Harlen Welsh Cynthia Doyle-Welsh Brian & Barbara Shaughnessy
Description of Work Proposed:
Repair/replace wood siding where needed to replicate existing. Repainting house in existing colors. No
changes in color, material, design or outward appearance. Non-applicable due to being in kind
maintenance/replacement.
Dated: July 8, 2008 SALEM IS C COMMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
_
violation). All work commenced must be completed within one year fro this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals)prior to commencing work.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I_- A\,i SIHII10S.\I \I, �1.\s�.\� !❑ �i l :s .I'/
-I I.I: • F\\: 0"8-_4:-'I841,
N\'orkers' Compensation Insurance Af idacit: Builders/Contractors/Electricians/Plumbers
1plicant Information �l OK-4
/��y/e Please Print Leeibly
Nallle tliu;mc"(h.g.uucuwn. InJntduul l: /i�rM) �� - 1// /.— _62�&u tf
ddre,s . d c
('ily,stateiZip: Phone : l���� M'S
IL • you an employer:' C heck the appropriate box: Type of project (required):
I. I am a employer with '1QL.f1'f ❑ I ❑m a general contractor and I 6 ❑ New construction
employees(full and/or pan-time).' _ have hired the sub-contractors 7. ❑ Remodeling
_'.❑ I ant a sole proprietor or partner-
listed on the attached sheet. *-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. y. ❑ Building addition
\o workers' cum insurance 5. ❑ We are a corporation and its
l�� ` p� 10.0 Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I 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.)
':\uy applicant that checks box 41 must also till out the section below showing their workers'compensation policy information.
t Ilunieuwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:c,miructurs that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.
Policy # or Self-ins.
`�Lic. d: �j cp Expiration Date:
.1 Job Site Address: —LI �L'�f17 J /F `'✓1«'�� City/State/Zip: S-,+("r+ 0
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 to S 1,500.00 and/or one-year imprisonment, as \%ell as civil penalties in the firm of a STOP WORK ORDER and a tine
iif up to S250.00 a Jay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
I r,\e+titalions of the DIA fur insurance covcrige verification.
l do hereby cerriJy under Nre pains and penalties of perjury that the information pruvided i v is tr e wrd rrect
1�icn;nurc:
Date:
H one =
t lQicial toe only. Do not write in this area, to be completed by Lily ur taivn ufficciait
City or l o\sn: _--
Issuing Authority (circle one):
1. hoard of health 2. Building Department 3. 0"It town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:_-- _- -- __-- Phone q:
Information and Instructions
,,I,,ssac hu,eus General Laws chapter 15' requires all employers to pros ide workers' compensation for their employees. ..
Pursuant to this statute. in etnplgree is debated as ".. ON Cry person in the set ice of another under any contract of hire.
ccpres.s or implied, oral Or written."
\n rmp6arer is defined as "an indis idual, parntership, association. corporation or other legal entity, or:uay two or more
of the foregoing engaged in a joult enterprise, and including the legal representatis es of a deceased employer. Or the
receiver or trustee of an individual, partnership, association Or other Icgal entity, employing employees. However the
,,w ner of a dwelling house having not more than three apartments :and who resides therein, or the Occupant of the
dwelling house of.mother who employs persons to do maintenance, construction or repair work on such dwelling house
,a On the grounds or building appurtenant thereto Shall not beealale of such employment be deemed art be an employer."
\IGL chapter 152, 25C'Ih) 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, SIGL chapter 152, §25Cf%I states`'Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the pertoinlance of public work until acceptable cs idence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary. supply sub-contractor(s) nmme(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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permindicense number which will be used as a reference number. In addition, an applicant
that most 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 tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
6'e. a dog license Or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
I he Ot ice of Investigations would like to thank you in ads:mce for your cooperation and should you have any questions,
Please do not hesitate to give us a call.
I he Dcliarnnent's address, telephone and tax 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
www.mass.gov/dia
,,' ,;:,. CITY OF SALEM
SL
PUBLIC PROPRERTY
DEPARTMENT
P17�IN_t V�-'
Y;.
.� + .. -I'+ -
Construction Debris Disposal Affidavit
(rc(luired lirr all demolition utd renovation work)
In accordance \%ith the sixth edition of the State Building Code, 780 CMR section I 11 5
Dcbris, and the provisions of NIGL c 40, S 54;
Building Permit rk is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I It, S 150A.
The debris will tic transported by:
(uame of hauler)
fhc debris will be disposed of in
(name ul 1-7 iIity)
IaJdresa ul tac+lilV1 j
-- 1+guature of permit applicant
Jatc