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0026 CROSS ST - BPA 16-09 --_ ----_----- I he l ommon%%L-allh of % INN.IIIIIbIIIN :It 5 r Iit,arJ ,)I liul!!M� N.rgul:nanu ,uIJ SI InJ uJ, ! f t �� :\1:uNu�hueells `Idtr liu!IJing e', JC, 'SO l MR. edition ! I .•I Buildin ' Pei i it :\ppiie.uilm ru ckmstrurl. R p.Iir. R:nu,.11r t 1r" I)rll„'li,h :I t „ OIt(Null' �— This S etion Fl OHlecd ('se OI1ly i llulldutg Permit Nu her. _- _ .ne Applied: 1!_II.It uIC _ --- - - ---- - - � --�� u .I. l ,nnn!:.auucl: lay+i, 6uJ. !e, )).lie SEC I SITE INFORM LION -- - - ------- — - -- j I.1 Prnperh \ddress: j 1.2 \,sensors \lap r Parcel Numbers I � i.l.l tN thO .In .Ilic'pled Nlu I. \Cn _�_ Ilu j �I.4' �,ulnh•r I'd!.. \unlha ' 1.3 Zoning l riorma[ion: _ - T..4Dimensions: fT -. •n,,: J I 'x• I i_ r t ni. h. nid,� ! 1.5 :° .le r 6 del bat ks ift) - ! Irani card S'de Yards )- Re a y:ud _ ... R•y- n- Pnr...led I Reyuut•d Pnrv!dtd —R ! n d— i 1 L6 !w'utee•Supply: I>'.U i_c. 1U. '+!I 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone.' Puhii ❑ Pneae❑ Municipal ❑ On Nu._c Ju Iwsal_Nt—,lr.!n thrrk )(yes❑ ❑_ _.._.� SECTION ?: PROPERTY OWNERSHIP' 2.1 Owner t of Record: 72 I \.nu• II'nntl AJJrcu li)r Sc!�iic: S:vnrturc-- Telephunr SECTION 3: DESCRIPTION OF PROPOSED WORK"(cheek all that apply) I - - --� "- --- - T- j New i,InNtru;:tiur. ❑ Fxisting Bud lwj ❑ Ouner Occupied I Rep:ursU) ❑ \ile r:J!nnl.) ❑ `:WJ!I_,nn ❑ .� r ----- Deru)Inr Arress,Iry BIJg. ❑ 1 Number u(Units `2_�j Other ❑ Sp .-!r} B t peon .:f P.:)posed W:Irke:_R t__ ! -----_- SECTION l: ESTi` : ONSTRL'C'TION COSTS Item -_----- — ENuntdted Costs: Official Use Only II-ehor and Mmenals! _ ------ 1. Building Pennu 1 ee: 'S 2_6-4:20nd!eate hittt lee n Jetet non,•J. , BuJJute j `---- -- -� ❑ Standard ('ltylro ten :\pp IIcaw nt Fee ?. F.iectnral ) ❑ rotas Pn)lect Cost' (Item G) x mt.:;!plier s t Plunthmg 'S I _'. O!her Fees: 'S Jr-OW"QD ' 4 Mechamc.Il III\':W) S i \Itc hami.I I 'Ire !,dal all Fee, —LL—n i t ( heck No l he,k .Artn"unr ( .nh \n •uuu r, rolal Project Cost ) 0 F'.uJ In f=o11 0 (hu>ta nJ!n, R.d,ul.e Ulw SECTION 5: C'ONSTRUc rION SERVICES 5.1 Licensed Construction Super isor IC'SLI t.`ie PCQ _ YGLLB�'--_._— _._ Lt\i n,i Xuwhir Iapit.tln"u U.tti Lt,l 51. I I,i,.ti hi luK, oi,IcJ �\ 1CJ ,uI,lit ".INllll it 1'1 Re, R r,In. l ' F.utul, 11cnaluti \I \Lt,onrs On \ L �y R( ff:,iJ:ulul It Imc ( .li phnnr �&'/� _�/� � p �` �l\l _iJ.nn.J NInJ . ... J i, 1'ii__ if R.vJ.ntl.J.h lid I 'Icl fl mini`\1L _n Ilnt.l m t� D Ri"d:l' i.,l 55.2 Registered Ilurne Intprovernent Contractor (IIIC) Fill'('�nup.uts Name or IIIC Rc• islfaiu .\.hill' --- Itegi,tralll�Il \IIIIthCI \dda•„ Ey)itauon Date I Slputure frkphunc SECTION 6: WORKERS' COMPENSATION. INSURANCE AFFIDAVIT (NLG:L.-c. 152. § 2506)) Workers Cornpensat ion Insurance affidavit must be completed and submitted Kith this ipplicauon. Failure to pit,\Ide this affidavit will result in the denial of the Issuance of(he building permit. Signed Atfidavit Attached? Yes .......... 1$ 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 au prize _ to act on my behalf, in all ul.niers relative to \voi k authorized by this building permit application. -- _ 1l gilalafl'11t�Klllf Date SECTION 7b: OWNEW OR AUTHORIZED-AGENT DECLARATION 1 , as Owner or Authorized Agent heiehy deckoe (hat the statements and moormetion on the foregoing application are true and accurate, to the best of my knoMedge and behalf. Print .Name - — --- Sienature of OKnvr or Authorized :\gent Date is, mrd undo ibe airs and penalties of ru i —� NOTES: _ I. An Owner who obtains a building permit to du his/her own Kork, or :m owner \\ho hires an umegt,tcicJ c,antra. for .(nut regis(ered in the Home Improvement Contractor (HIC) Program). Kt11 not have ,wceS, u, me .0 hill all. j program or guaran(y fund under M.G.L. c. 112A. Other Important inFtrmation on the I11C Program .Ind I Construction Supervisor Liccming WSI_) can be found in '80('NIR Regulations 1 I0R6 .u)d 1 IU 145, rc,pevu\ch When ,uhNr anal \vork to planned, provide the Inhhmanon below� Fatal Hours area (Sy. Ft i tincluding garage, limshed ha,ement/ait�cs. decks t,r porch, (in t,S hvmg area t Sq. Ft.) Habitable ruon) noun( 1 Number of IticI laces Number of hedroom, Numher „t h.uhnnnns . - - Numhei it --- 1\pe it hc.uoliz ,v,tem Number -I le,k,/ p,i,hc, Iv pie of „ ohng, N ,tern ._ I`.nJ, ,eJ _. __—_____. l)p,n I Project Square F„nt.lge" MAl he ,nbS(Il Liied for f,�,,i Prnleci CITY OF SALEM ' PUBLIC PROP.RERTY DEPARTNIENT \Ll�,�n I': \C �.�I:>:�•:,�\isnlrt • S.�I: �l. �l.��..�� �r .li :. :l')"� Workers' Compensation Insurance AffidaNit: Builders/Contractors/Electricians/Plumbers > f tlicant Information Please Print Legibly `:Illy mustncs Ur�.uu�anun.In.ln ideal l:� ✓� G7..3s�[®1�-�f��C 4eE�j�d ALI&CSS: u'x" :� 2 / �� �u ✓1/i �F S �J�� City.State'Zip: e — Phone 4: ''�/-2 \re you an employer? Check the appropriate box: "rope of project(required): 1.❑ I am a enlployerwith 4. © I mn a,gencraliconlractor and 1 ....,6.. El New construction employees(full and/or art-time).' have hired tile sub-contractors part-time) '.� I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling These sub-contractors (lave 3. El Demolition ship :old have no employees working for me in any capacity. workers' comp. insurance. y. ❑ Building addition [No workers' cool insurance 5. ❑ We are a corporation and its [ p officers have exercised their 10.❑ Electrical repairs or additions required.] 1 1. Plumbing re airs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL ❑ g P' myself. [No workers' comp. C. 152, §I(4), and we have no 12.0 Roof repairs insurance required.) f employees. [No workers 13.❑ Other�a comp. insurance required.) •Any applicanrthat checks box al must also till out the section below showing their workers'compensation policy information. t I homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this hox must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. l am its employer that is providing workers'compensation insurance fir my employees. Below is the policy and job.site information. / Insurancaiice('ompany Name:. Policy b or Self-ins. L�i 2. 00_f(a: Expiration Date:4 ZAXI �_ ,e — Job Site Address:�f2���� City, 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 penaltiesof a line up to S 1.5110.00 and/or one-year imprisonment, as cee.11 as civil penalties in the form of a STOP WORK ORDER and a tine Ot up to S250MI) a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of lul cai¢ations Lit the DIA for inSur:ulcc cOvcrige verilieatioll. l do hereby cerul.t, under the pains and penalties of perjury that the infirrtttatioti provided above is true mid correct 1�icnanna: Dale: — Phone = — ll/fic'ial use only. Do not write in this area, to he congdeted by city or rown official ('it% or Town: . -- _.—_ Permilil.icense tl_ ___—_ issuing .\uthorily (circle one): I. Board of Health 2. Building Department 3. Cil.w Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. 0lher -----_.---- Contact Person: _--__-- Phone #:_-- — —. Information and Instructions \IaIs achuscus Oc tie ral Laws chapter I i' tagmres all cntplosers to pro\ide workers' compensation Ior i lie ir enilflo%ees.- Put%Uant to this ,tatute, an entploree is dctu:cd as ".. c%en person in the sen ice of another under airy contract of hire. e\ptcC s or ImI,hed. Ural or NI'It l en.- .\n rntplgrer is &Ilited as "an indl%ideal. 11artnership, a lc,gal corporation or other Ical emir, or any two or more ,.I the lixegoing cng:Iged in a joint enterprise, and Including the legal representaises of a deceased employer, or the tcccis er or trustee of an individual. patnienhip, association or other legal entity, eniploy ing employees. However the o%s tier of a dwelling house ha%ing not more than three apartments and tvho resides therein, or the occupant of the dw cuing house of another who employs persons to do maintenance, construction or repair \%ork on such dwelling house or on the grounds or building appunenam thereto shall not because Ofsuch employment be deemed to be an employer." M L chapter IS?, >2j00) 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. %I(;L chapter 152, 2507) states"Neither the conunomvealth nor any of its political subdivisions shall cntar into any contract for the perionnance 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 permidlicense 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 t)dice 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. I he Dcparnnent's address, telephone and f:Ix number: The Commonwealth of Massachusetts Department of industrial Accidents Ofllce of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-877-MASSAFE ItcIised �-'6-0i Fax # 617-727-7749 www.mass.gov/dia CITY OF SALEM y r PUBLIC PROPRERTY DEPARTMENT . �:$i rr r � �.�i i \I, \L�"u :. .: i .. =I•r -_ I I I V'S V; );+J; t\Y: 91X.'4}_ 9S4 Construction Debris Disposal Affidavit (rcxluired 1'ur all demolition and renovation work) In accordance pith the sixth edition ofihe State Building Code, 7S0 CNIR section 111.5 Debris, and the provisions of'v1GL c 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposed of in it 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 (name of raolity) laddrcss ut ISrJity) NLIIa IUI I' of pcnuit applicant — � O date