32 CHURCH ST - BUILDING INSPECTION (3) 1.
t
What is the current use of th Building?
Material of Building?M �� Q-. If dwelling.low many units?
Builds Conform
Law? Asbestos?
Will the r4
Architect's Name
Address and Phone ( )
ic's Name
Meehan
Address and Phone ' ?Q
construction Supervisors Uceen^se�0 �' � HIC Registration#
Estimated Cost/d Project i�2�s�-� Permit Fee CalcuWN n
Permit Fee$ Estimated Cost X$71$1000 Residential
Estimated Cod X$1141000 Commercia'— ---- - - . .. -
An Additional $5.00 is added as an
AdministmOve charge.
Make sure that all fields we property 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 a 67
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PUBLIC PROPERTY
DEPARTNIENT
1q.WWJU"DRISCWl ! Q
MAVM i3owAgmG xw hmEtrr•sALki4 N.%SuaHLstllS O1970
TsL-M745-9595•FN¢M740.9W
APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
IA SITE INFORMATION
Location Nana: Building:
------ Property Address:--
] S k
Property Is located in a;Conswvatlon Area YIN IV Hstode DbMd YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: N4 < FJb�c� eA v C- - cT
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXiSIINQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Beef Description of Proposed Work:
-- ----Mail Permit to: . --
CITY OF SALEM
PUBLIC PROPRERTY
`" r,• DEPARTMENT
IJN111::RI.pY DRISCOLL
MAYOR 12C WASHING I0;`S-rRl.LT• SALEM,MASSACi ash* *ISO 1978
Tia.:978-745-9593 ♦ FAX:978-740.9846
Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibly
Vime(Huciness/OrganizatioNlndividual):
Address: I let
City/Ststci/..ip: C>�LC&I Phoned: D,5 !�77S 11 I
Are you an employer' Check the appropriate box: 'Type of project(required):
4. ❑ I am a general contractor and I 6 New construction
I.Rol am o employer with�y have hired the sub-contractors ❑
employees(full and/or part-time). 7• ternodeling
?❑ I am a sole proprietor or partner- listed on the attached sheet. *-
ship and have no employees These sub-contractors 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
[ p• 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work. P
myself.[No workers' comp. c. 152,§1(4),and we bave no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
-Any:yllla a n that chucks box rtl must also fill out the action iwlow showing their workers'cuntpensation policy informatiun.
t Itomcuwnen who submit this a ffidavit indicating they are doing all work and then him outside contractors mast submit a new affidavit indices ing such.
�Contmctun that check this box most attached on additional sheet showing the name of the sub- crntmeton and their workers'comp.policy information.
I air of employer that is providing workers'compensation insurance f it my employees. Below is the policy and job site
information. t
Insurance Company Name: ?2.._/5--.._._._--__. —.—__
Policy#or Self-ins. Lie. *: �� '2, .t9 �Cj-j C --,.----- L� Expiration Date: 9
Job Site Address: Z C Lm—w Sr City/State/Zip: ,
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 uf.NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 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. lie advised that a copy of this statement may be forwarded to the Office of
luyestigations ul'the DIA for insurance coverage verification.
I do hereby certify uudcr pains and p/e/nal ies/o/Af pr ary that the lnfonnatior provided/abo is true and correct.
Sienautrc: / V SLC Datc- G Z / 7
Pi, I l7k SIB ( � 1
Official rise only. Do not write its this area, to be completed by city or town offivial.
City or Town: _ Permit/License
Issuing Authority(circle one):
1. Board of Ilealth 2. Building Department 3.Cilyffown 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 emphtvee is defined as"...every person in the service of another tinder 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 grotmds 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,b1GL 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 nwnber(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 aff idavit 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 till in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/licemse 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. it dog license or permit to bum 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
Offtee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MAIL% 120 W.t91INl�:JN S�RE£T .S.tLF\t.�t.Ki.\C;CI iL Cl i]191^.
Ter:978-745-4595 978.74G9946
Construction Debris Disposal At'tidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 C141R section t 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
— — Inaine at hauler)
I'lie debris will be disposed of in
(G)ame of facility)
11llU[Cl] Jt (al:( IyJ
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' RE: Cork Flooring Page 1 of 1
From: World Floors Direct LLC <wfdllc@yahoo.com>
To: leolson1 @aol.com
Subject: RE: Cork Flooring
Date: Tue, 26 Jun 2007 3:04 pm
Eric,
Wow, my supplier already called me back:
Fire Rating (ASTM E-648), Class II
Smoke Density (ASTM E-662), Flaming: 148 Non Flaming: 272
Hope this helps.
WFD
http://webmail.aol.com/27618/aol/en-us/Mail/PiintN4essage.aspx 6/26/2007
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REV. DESCRIPTION DATE BY TITLE: PROPOSED WINE CELLAR CLIENT:
SALEM WINE �- VIGILANT—�
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REV. DESCRIPTION DATE BY TITLE: PROPOSED WINE CELLAR CLIENT: SALEM WINE
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