203 ESSEX ST - BPA-2008- HARLE DAVIDSON SUITE 113 g 7y
KaniHrgfTk'!}Ri9r?.;�4L
4t 1}ON 52CiAT'nv'i i'h4'r{),3 y"i'�ilr '1 ..I,A 1 i�iUJ1[:JPI - f I'.rit
'i'In=47a-'9°,-i;395 O 1'-dA:4'&7�t?.9it=6
APPLICATION FOR PLAN FXAMINATION AND RUIC IIING PFI3NIT'f —
ALL STRUCTURES EXCEPT I AND 2FAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page -^-
--_ SITE INP'QRA7ATlt�N r
Locationt rrr; /Y1 UI�f'^�1 /�GE l.t Building��✓J2LE�,Ofnh)
Property Address 2.r!?�7 rr'te/ST-
Map#
Located in: Conservation Area YI Historic district YIN
Use Groups
(chuck one)
Residential(3 or more Units) R2
Type of improvement Residential(hotellmutel RI
(check one) Assembly(churches) Ai
Now Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants,recreation) A3
Alteration Business a. _
Rcpuirl Replacement_,_,_ Educational F
Demolition Factory(moderate hazard) P _
movefRelocate r, Factory(low hu4rrd) P2_
Foundation Only__„______ High.Hazard H
Accessory Building ins'tkutional(residential care) 11
Other(describe) Institutional(incapacitated) 12_
Institutional(restrained) 13
Mercantile M
Storage(modente hocani) S 1—
Storage(low ha«rd) S2—
t
OWNERSHIP INFORMATION(Please type or Print Clearly)
OWNER Name
___.....w Address a n V g (�lii7L�/gn /veR 02y�J
Telephone
DESC:R[PT[ON OF WORK TO BE PERFORNIFI)
�nTin✓/> �YDuI&� AJZf✓G �yJwf A A—, 44' &Fk "1 _
FSTI]1ATED CONSTRIJM014 COST i l, 4J t7 t1• d'o _____
CONTRACTOR MiORMATICN
Name Cho yW6a D
Address /, 9 ( n.n�„� S r _ < f �r-�furr./YI� 01507
Telephone 1 OV/ -?Y 2 . 3 St/
Construction Supervisor's Lic # C-,S 06 / 06 I
Home Improvement Contractor # Y 9 9
,ARCWT'ECT/ENGINEER INI,'t}RMATION
Name
Address
Telephone
-Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1;000 + $5.00
Commercial est. cost 11/$1,000 + $5.00= 3,6 - nD
COMME NITS
The undersigned does hereby attest that all information stated above is true to the best
`' of my knowledge under,• the penalties of perju
Signed'
T3rrto G - g- 08-
CITY OF SALEM
\ PUBLIC PROPRERTY
DEPARTNTENT
tl
I \S: 778 74:'NA,
Construction Debris Disposal Affidavit
(required [or all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it 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
l 11, S 150A.
The debris will be transported by:
(name of hauler) U
hhe debris will be disposed of in
L ��r ���
(came of facility)
(adder of Facility)
---- _ agnature of permit applicant
/b xyj
LhI ,.J,
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
;d; • 1 %\. I-Y-'1:.'I.S 4,,
N% orkers' Conipensation Insurance .%nida%it: Builders/Contrac torsi Electricians/
PlPrint rube s
IIIi f i ant Information
\,11I1C ilfl:.iue.. thp.uuinu,�n lncln:,Iu.IIC�TI p., ny� �
Address:
l�r�{//a'W1/7�GG Phoile #:
Are %ou an emplo%er•.' Check the appropriate box: Type of project(required):
I all, a emp toyer is ilh 4. ❑
❑ 1 ;till a general contractor and 1 h. New construction
I p[1
euglluyers(full and'ur port-tine).' have hired rite sub-contractors 7. f�Ic t�-,,�
emuJrling
'.❑ I and a sole proprietor or partner- listed on the attache) sheet. • T\
- .hip and have no employers these cab-contracture have 8. ❑ Demolition
workers' comp. Insurance. y. ❑ Building addition
iiorking for me in any capacity. 5. ❑ We are a corporation and its
No workers' camp. insurance 10.❑ Electrical repairs or additions
required.) atficers have exercised their
ri ht of exem tion per fv1GL 11.0 Plumbing repairs or additions
1.❑ I am a homeowner doing all work g P P
myself. (No workers' camp. C. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.) f employers. (No workers' 13.0 Other
comp. insurance required.)
•:wny,fl,licant that checks box nI muet also till out the section below showing their workers'compensation policy information.
' I Iunxuwners who submit this affidavit indicating they are doing all work and then hire outside contraours must submit a new affidavit indicating such.
'cu1VCICtors that ihe,k this box mutt attached an additional.Iheet showing the name of the sub-contractors and their workers'Comp.policy Information.
l airs an employer that is providing workers'r^ampensalion iin�.surunce for/)troy employeie�.s./Below is the policy and job site
information. 3 / Y ! //�Lv // �'1.�7�1•P.1,,.�-CJ
Insurance(bmpany Name:_— J�W�f a U Lid-
Expiration
Policy Jt or Self-ins. Lic. p: � C ��� ✓v Data:J �✓�U��
Job Site Address: City,State/Zip:
.%oach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to sector co%crage as required under Section 25A of%i(;L c. 152 can lead to the imposition of criminal penalties of a
line up h) SI,jU11.o1) and'or one-year Imprisonment, Is %cell as civil penalties in the ti,rm of a STOP WORK ORDER and a fine
III till to \_2511011.1 dav 'warlst the wlolalor. Ile ad%ked that a Copy of Ill's statement stay he torso arded to the Otflce of
In%a.0 c.uums of illc DIA for ituur,tncc cu%erage %cnticmlon.
l J, hereby.'erii/1'under the pains turd penaines of per/ury that the rn/orrnanon prn%Ideal aha u a is true and s orrec t.
D,t /b C�
�iyn_tlnr �
ollicial u,e mlly- no flat n'rite in this area. to be emopleted by city or town gJil.iat
( it% or fawn: - _ . Ilermivl.iceme b -
I%suing \uthorith (circle line):
1. Iloard of Ilealth 2. Illlilding Department J. Ill'it%1 I"mIs Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other _ _ __- .'- -_ .-_-- ----'
Contact11cr%on: -- __- ---------- Phone 4:_.__ _—._--
Information and Instructions
\I.I,,,in hu,cn, liencrA I aI„:haptcr I icyuu c, .ill CngtloS er, wprot ice workcrs' coinpcn,awm for tocir emplu,ces.
I'nl,u.uL n, this ,t.uutc. .111 rrnphwee i, dcGr.cd .I, ctin person it the %vi icc of .ul,ahcr under suns :ontrict of hue.
yv c" •,r ill p!ic& oral or wlwen
ter I, ,Iciincd .is ".ul :11,11% dual. p.uu.cr.hip. .l,,ocialion. :oip,,rauon or other cgal ctintx. or .in nso or more
• I the finccoui,! cm�aged In a niun cnlclprl,c. .md in:IwlLle the Ie_dl represclnan,c, of a Jccc.t,cd emploscr, or file
e,cn cr or no,ice of in utdn iJual. p.unicrShip. .l„oiianor1 or other Icgal enws, cutplos ing cmplo�ce. IloweSer the
„,,ncr of .l dwcIIIll6 house ha%Ing not :fuse ih.m three aparnncnt, and who rc,tJc, therein. or he occupant of the
dwci:ull,! hou,e of.mothcr who anipin„ per:on, to Jo maintenance. con,trucuon or rep.ur work on such ,Iw elhng house
,.1 Ill file _n,ulyds or budding .Ippwrc:t.mt 111ctclo ,hall nol hc:au,e of 'Lich cogtloS meni be decided to he an cnlploSer."
V/ impicr I S2. 2.15C(11) also ,late, that -'c%ery state or local licensing agency .hall 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 cs idence of compliance with the insurance cos erage required."
Wditionally, .MOL chapter I", S25('I-) ,rate, Neither the unnniomvealth nor any of its political Suhdry i,tons ,hall
enter Into any contract for the periminance of public work Lund acceptable eS i,lence of compliance w uh the insurance
regllocitlelits of this chapter ha%e been presented IU the contracting authority."
Applicants
Please fill out the workers' compensation atfidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) nanm(s), addresses)and phone number(s) along with their certificates) 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 atfidavit 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
;elf-insurance license number on the appropriate line.
City or 'Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the atfidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please he Sure to till in the permlL 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 atfidavit indicating current
policy intormation (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
n)w n).•' A copy of the affidavit that has been officially ,tamped or marked by the city or town may be provided to the
.Ipplicant as proot that a valid affidavit is on lilt for future permits or licenses. A new atfidavit must be filled out each
year. Where a home owner or cilven is obtaining a license or permit not related to any business or commercial venture
(I e. a Jog license or permit to burn leases cic.),;lid person is NOT required to complete this atfidavlt.
the t Mice of Imestigations would like ill thank ,wu in athance tor ,'ottr coopel'alion aitd Should you tease any questions.
Idca,c do nor he,nate to QI%e uS a call.
I he 1)cp,uimcin'S iddre,s. telephone .md tax nuuther: -
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of InvestigatIons
600 Washington Street
Boston, MA 021 1 1
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax H 617-727-7749
www.mass.gov/dia