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11 CHURCH ST - BUILDING INSPECTION (5) PUBLIC PROPERTY b� /�✓`=0� DEPARTMENT �\ KI.NWERLEY ORISCOLL MAYOR 120 WASHINGTON STREET* 'bM1iM,\1A1SACH1:56'TR 01970 v TEL.978-745-9595 *FAx:978.740-9&16 APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: , S T . Building: (kef SS e Property Address: S o-m,e Property is located in a; Conservation Area Y/N tJ Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land ` Name: -qs,eX Coodo Address: _I h vvc,� S Telephone: 7 g- 7 c(S_ 3 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING B*U'LDINIGSONLY Addition Renovation Number of Stories Change in Use Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building I New Brief Description of Proposed Work: p Mail Permit to: - 3 4-" ©�9 0 i Qe�. ti What is the current use of the Building? Material of Building? r! '^� '�0�P If dwelling, how me�nun�its �� 1 Will the Building Conform to Law? u Asbestos? Architect's Name 0-160 Address and Phone Mechanic's Name H -e-1 Cq 1 Address and Phone I q7 -svm H iT ST / Construction Supervisors License# HIC Registration# / Estimated Cost of Project$/ o00 Permit Fee Calculation Permit Fee$ ('5q, Estimated Cost X$7/$1000 Residential Estimated Cost X$111$1000 Commercial *431 An Additional $5.00 is added as an )a 31Y Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury X Date //'/3 O 6 i L l�t' l G G, CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KMBERLEY DRISCOLL MAYOR 120 WASHINGTON STREET*SALEM,MASSACHUSETTS 01970 TEL:978-745-9595 *FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _�1 \ Please Print Leeibly Name (Business/Organization/Individual): QA 1 y r Address: q_7 SuJ N^'tT_ :S;I /3tii fc4 314 , '!'� City/State/Zip: P2c_\'600! I /�1A 0/960 Phone #: `P 70e' S 3 I—ssy�f� Are you an employer? Check the appropriate box: Type of project(required): 1.VI am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/ part-time * have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' M"6ther f P comp. insurance required.] 13. I ��g 'Any applicant that checks box#1 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. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �1 Insurance Company Name: a MAvl 'n c L�_a r RR 1yV-)Ct] ynG 14C P LO• Policy#or Self-ins.Lic.#: W G V 06Sl "02— Expiration Date: 75-10 7 Job Site Address: I I r G yYJ\ 1 City/State/Zip: 3442r 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 verification. I do hereby certify under the pains and penalties of erjury that the information provided above is true and correct. Si nature: '/'` Date: v Phone#: ��0('—n l— �`t /1-13 -o 6 Official use only. Do not write in this area, to 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." 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 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 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 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 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia I�G2 LICENSE copy This agreement is made this day between the City of Salem, a municipal corporation located in Essex County, Massachusetts with a mailing address of 93 Washington Street, in said Salem ("Salem") and The Essex, a condominium development, located at 11 Church Street, Salem, Massachusetts ("Licensee"). WHEREAS, Licensee owns real estate located at 11 Church Street, Salem, Massachusetts, WHEREAS, Salem owns a municipal parking facility,the Museum Place Parking Garage; WHEREAS, the Licensee current maintains access to its condominium development via a set of stairs upon the municipal parking facility to condominium development; and WHEREAS, the Licensee wishes to establish a wheelchair accessible entrance to replace its existing stairway to the condominium development. NOW THEREFORE, in consideration of an annual charge equal to the cost of two parking spaces, which will be recalculated annually by the city, and other good and valuable consideration paid to each other, the receipt and sufficiency of which is hereby severally acknowledged, IT IS AGREED THAT: 1. Salem hereby licenses and authorizes Licensee to construct at its expense a wheelchair ramp upon the roof of said above described Museum Place Parking Garage. 2. The Wheelchair Ramp shall adhere to all plans submitted to the Parking Director. 3. As a condition of this License, the Licensee must apply and receive all required permits and comply with all ordinances, relations and laws of Salem, the Commonwealth and the United States. 4. The Wheelchair Ramp shall not occupy more than three parking spaces. 5. The Wheelchair Ramp shall be located in the three parking spaces to the right of current stairs that allow access to The Essex. 6. Licensee shall be responsible for purchasing materials to build, install and regularly maintain the Wheelchair Ramp and any other costs associated therewith. Maintenance includes: snow and ice removal, ensuring the structure stability, repairing of damages and routine inspection of the structure. 7. Licensee shall not construct or erect any permanent structures on said Museum Place Parking Garage, besides the aforementioned Wheelchair Ramp which must be approved by the City Building Inspector. >. 8. Thi"i license is to be considered for renewal by the Licensee and Salem no earlier than ninety days prior to its expiration, but no later than thirty days prior to its expiration. 9. If the licensed property is damaged resulting from any act or negligence of Licensee or any of licensee's agents, employees or invitees, Licensee shall be responsible for the costs of repair and shall hold the city of Salem harmless to any liability personal or otherwise. 10. Licensee shall evidence to Salem in writing from Licensee's insurance broker that the Licensee's property insurance policy includes coverage to said wheelchair ramp. 11. Licensee shall at all times relieve, indemnify,protect and save hamnless Salem and each of its boards, officers and employees from any and all claims and liability of death of and injury to persons or damage to property that may arise from or be caused by the operation, maintenance or occupation of the aforesaid premises by the Licensee under the provisions of this License or by the negligence of the Licensee, its - agents, officers or employees. 12, Licensee shall pay the equivalent of two full priced parking spaces on July I'starting on July 1, 2006 for the term of the License. 13. The initial length of this License shall be three years, expiring on June 30,2009. Upon the expiration of this License,the Licensee shall have the right, with the agreement of the City,to renew for an additional number of years to be determined by the parties. 14. The Licensee agrees that the Licensor may, at its election, terminate this agreement by giving written notice thereof to the Licensee and specifying the effective date of such notice, if at any time during the term of the license the Parking Director determines: (a)that the Licensee is creating a safety hazard through its negligent maintenance of the Wheelchair Ramp, (b)that the Licensee is unable to comply with any city regulations (c) that the Licensee is otherwise not performing the agreement in accordance with its terms and conditions, (d) or for other just cause. 15. At revocation,the Licensor shall provide thirty (30) days notice to Licensee,before use of the Wheelchair Ramp shall be terminated. Signed and sealed this_of 2006. CITY OF SALEM The Essex Condominium Association Licensor Licensee 7zPsJ Kimberley Driscoll, Mayor Richard L , Trustee Albert C. Hill,Jr.,Purchasing Agent James Hacker,Parking Director As to form, Elizabeth Rennard,Esq., City Solicitor COMMONWEALTH OF MASSACHUSETTS ESSEX, SS 12006 On this_day of ,2006,before me,the undersigned notary public, personally appeared Kimberley Driscoll,Mayor of the City of Salem,proved to me through satisfactory evidence of identification,which were to be the person whose name is signed on the attached document in my presence. Notary My commission expires: COMMONWEALTH OF MASSACHUSETTS ESSEX, SS , 2006 On this_day of 2006,before me, the undersigned notary public, personally appeared proved to me through satisfactory evidence of identification, which were to be the person whose name is signed on the attached document in my presence. Notary My commission expires: - I �; ry i-1 %/lF'' \ 1 15AFT MIJU U111 P)I' KAR. }e ' -1 ;:r 9 J° ti_UM. ;r-AP ',JNhEi. Wi i 114" S:H� 4�' �1.61i OD % U.1 IL- •A. "� ' is P!I j A!UM. FIFE IIA14DRAIL 1YP. Y-3/4` X U' SO. ALUM. IIIRF PICKEIS 9 ; VhX. -)PACE BETWEEN la ; �li ill 12, =,_, �.;�;�,• cTlF -WMG CHI-IT,iE_ 16"„ I A Spa I I 1 1/:' X V le' R SISTlldT I•I CRTRUUTA Al UrflWM, LIPM ll?.-z I ` -- S7ANUARD RAMP � ?u LEC ASSEMBLY I' SECTION: __I PJIINU L)! i- . ^7" IPlI_ �,t.Fa!iYd. PK'i!!=i >JAF�::i�!u '..:S,n -�•.. e Side View: 29" RISE / 30' RAMP Job Name: 0.97" RISE/ 'RAMP Esesex rP A' A Condo B C D E P Association BTP Salem, MA 516 L-10 L-10TOTAL = 10 10RISE Location: AmRamp ton �-- 8' --�►— B' —�k 4' 'tom- 5' 5' 8' —�I 2' Boston . Requested: Top View: FULL RAILS Myron P. BOTH SIDES Phone: 800-649-5215 5'-6' Fax: 617-268-3701 N 5x5 Date: w ° A B C D 9-21-05 w ziP: LEVEL 02127 5x5 10'-a" NOTES . Drawn By: E 1. Pat 48" F Checked By: LEVEL Sean ELEV. = 0 15'-4" Job Number: 1 0280/.R E D BuyLine 9834 RESEARCH, ENGINEERING, DESIGN, AND DEVELOPMENT +S �� 2hSl}ssb u2� •�. n - �r , 1 r� - v� vaaid ^•� tom' IA,I,.. 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