8 CHASE ST - BUILDING PERMIT APP PC'13L1C Plto 1)1,RTY
DEPARTNIEN'1'
„n
I'uU >ruri.r . S1i.r.•,i.\1 ill >r.ns ulo-11
APPLICATION FOR PLAN EXANIINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: Applicants must complete all items on this page
SITE INFORMATION
Location Name Building ..
Property Address
Bc qAS C S
Located in: Conservation Area Y� Historic district
APPLICATION DATE A
Use Groups
_ (check one)
Group Homes R3_Ij;J_
Residential Q or more Units) R2
Type of improvement Residential (hotel/motel) RI
(check one) Assembly(Theaters) At _
New Building_ - Assembly (iestaur:mus & clubs) A2r_A2nc
Addition Assembly (churches) At —
Alteration Business B_
Rcpair/Replacement_ Educational E_ �--
Demolition_ Factory(moderate hazard) F1
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile M_
Storage .St _Moderate Hazard
Storage S2_Low 1-lazard
OWNI•:RSI111'INFORMATION(Please type or Print Clearly)
OWNER Name So E 13 oqT4:�ol
Address
Telephone - ZY 9 — 52-X5 13
Signature _...--- - -- --- - - 3
UI•:SCILIP'1'ION OF WORK"1'O BE PERFORMED
ES'I'IM,%*I'ED CONSTRUCTION COS'r / y rUU( C,0
13 ou A/L
L2
CU:\TIt:\C'l Olt INMICNIATION
Name j�AuC C 1�24V0.r� 4hlan
Address 2- 7 V It'- 1'h e-At=v hvr9
Telephone 6 /?- `12 0- 52-1 f-
Construction Supervisor's Lic # C S /
Home Improvement Contractor# 1 y O Z d
:\ItClll'1'I?C'1'/I-AGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FIiE CALCULATION [
Estimated Cost x $11/$1,000 + $5.00= 3 cio
CONINIENI'S
The undersigned applicant does hereby attest that all information stated above is trite to the best of my knowledge
ruiner the penalties of per'urye
Signed (/�/ - (owner) (agent)
APPROVED BY :
DATE APPROVED:
ao� i�� Rsi�
HOMEIMPROVEMENT CONTRACTOR
Registration: 140204
Expiration: 9/22/2009 Trli 274494
Type: DBA
DIVERSIFIED BUILDERS y i
PAUL DERVARTANIAN'
27 MAGOUN AVE --�
` MEDFORD,MA 02155 - ,\d.mistraior
.r v
. x
BosGifItRE�91��4d3�aKfiS4�
Consmiction Supervisor License
.: License: CS 84815
Expire'f�on 312009 TrA 8856
PAUL'_ DERVARTANIAN -
27 MAGOUN AVE,
MEDFORD,MA dl!53' Commissioner '4
. 4
CITY OF SALEM
A Y.!�nu�4-; PUBLIC PROPRERTY
DEPARTMENT
d 12C IN'I IRIA TO "A I IM,
Construction Debris Disposal Affidavit
(required lbrall demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CNIR section 111.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit It . - is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
( Ff(.--D 4
(name of hauler)
f fie debris will be disposed of in
(name of tacility)
IRTI S4q& � S
V signatulcof permit applicant
/0
date
CITY OF SALEM
a �, ,, PUBLIC PROPRERTY
-;Ma DEPARTMENT
'nl\le N!.Ifl'1)NI1CULl.
l2cWASHING IONS IX ELT • SALI; I.M.\i5ncnrxl%lIS01970
978-74.5-9595 • 1':\x. 978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeihly
N,lMe(nnVlICS$io rganizatioNlndivulual); 1/ I✓Pk 1
Address: Z? MA (r-G l,�/-/ 14 y
Cityistalci%ip:A &SV Fob ('') A14 Phone i': ��7—
:%re you an employer? Check the appropriate box: 'Type of project(required):
4. ❑ 1 am a general contractor and
I.El 1 am a employer with G. New construction
- om\ployces(full and/or part-tinic).• have hired the sub-contractors
2. I ant a sole proprietor or partner- listed on the attached sheet. : 7• ❑ Remodeling
ship and have no employues 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 lo.❑ Electrical repairs or additions
required.) o8icers have exercised their
3.❑ 1 ant a homeowner doing all work right of exemption per NIGL 1 l.[3 Plumbing repairs or additions
myself. INo workers' comp. c. 152, §1(4),and we have no 12.❑ R(wf repairs
insurance required.) t employees. LNo workers' f3.❑ Other
comp. insurance required.)
-Any:applicant that chucks box 81 must also till out the section W.ow showing their wurkas'eumpensatimo pulley infortrutium
'1 fomeuwnr:rs who submit this affidavit indicating they are doing all work and then hire outside coin titers must autenii a new affidavit indicating uah.
-Commctors that check this box most utached.t addilimaLchcet sho.iou the name of the sub-contractors and their workers'comp.policy information.
l our can employer that is providing workers'compensation insurauce fur my employees. Below is the pulicy and job site
infornation.
Insurance Company Name:----.._.. .. . . . .. -.--
Policy 8 or Self-its. Lic. ?%: __._.._... .._. .. ... _.__..__ Expiration Date:
Job Site Address: CitylStale/Zip:
Attach it copy of the workers' compensation policy declaration page (showing the policy nutubcr and expiration date).
Failure to secure coverage as required under Section 25A of JIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 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. Be advmd that a copy of this slutement may be forwarded to the Office of
111\'CStlgalrotrs of the FAA (or insurance coverage verification.
l do hereby certify and• the pain' nd pen t/tics of perjury that the infornalion provided above is true and correct.
Date:
ADA
Phw:c 4: CA 1 1-2 J—
official use only. Do not write in this area,to be completed by city or town official.
City or Town:--__-. _ Permit/License q .
Issuing Authority(circle one):
1. Board of llcalth 2. Building Department 3.City/fit"n Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.01her ---.__
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 emplgree 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 emplover,or the
receiver or trustee ol':n 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, fv1GL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtance of public work until acceptable evidence of coupliance w ith 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-contractors)name(s), address(es)and phone nnnber(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 pennit 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 pennitflicense 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
towny" 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 hone 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.
The ot)iw of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do no 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 5-26-05
www.mass.gov/dia