10 1ST ST - BUILDING INSPECTION . E�`T'S�QF`��L
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APPLICATION FOR TI� REPAIR RENOVATION. CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
, 1.0 SITE INFORMATION
Location Name: Building:
PropeAy Address: ,O J � � ��/ / � i, ^�
�' 11/�
Property is located in a; ConservaUon Area Y/N Historic D(strict Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner ot Land �
Name: /N l �i /� .—
Address:
i� � S�f � l� � S�f
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXIcT�N�= gUILDING3 ONLY
Additian Existing ,�j
Renovation � Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of ( Area per floor (s� Renovated
construction or renovation
of existing building New
Rriaf Description of Proposed Work: �j / I _/
��yr✓3 a r2.P��AG G l i 00.�2 I h b��%/20/�')
�tr�� � T'�laz�-� �r�� ,�a�,e l� h,��✓,zfl9� �/��
__ _ _ _ _ _
_ _ - - - _ -
_ - - -
Mail Permit to: '
What is the current use of the Building? 5
Material of Building? a?s C� If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name377
G , _
Address and Phone �d
Mechanic's Name
Address and Phone 972
Construction Supervisors License# C S 04125"43 0 HIC Registration#
Estimated Cost of Project$ Z6 . Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
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 Perm' e b ild to the above stated
specifications. Signed under penalty of perjury X dZ-4
Date
4 J
w
a uIZ� n
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
K:Mwcar�'DRLSCOLL
MAYOR 120 WAsHmToN STREET 4 SAt K MAssACM15E rM 01970
TM_978.745-9595 a FAX.978-740.9846
Workers' Compensation Insurance Affidavit: Bullders/Contractors/Electricians/Plumbers
Aaoticant Information � Please Print Lelaibly
Name(BusinessiOrgmiauyqU'
oartndivi&W)! ` l/ W / '•e✓/
Address: :�;Lf Z W aeA1
City/State/Zip: 14t/bD11k-I2 Y/W Phone 9,z;
Are you an employer?Check the appropriate best: Type of project(required):
1.Q I am a employer with 4. (]1 am a general contractor and I Q
_ �ployeea(fba and/or part-time).• have hired the subcontractors 6 N construcdoa
2. I am a sole proprietor or partner- listed on the attached sheet. t '7• [�]teRes ling
ship and have no employees These subcontractors have S. Q Demolition
working for me in any capacity, worlrera'comp, insurance. 9. 0 Building addition
[No workers' comp, insurance S. 0 We am a corporation and its
required] officers have exercised their 10.0 Electrical repairs or additions
3.Q 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. (No workers'comp. c. 152, §1(4),and we have no
insurance required)t employees.[No workers' 12.0 Roof repair
comp.insurance required.] t3.❑Other
-Any spptiam that chocks lax a1 awrd deo a8 inn the swdoe bdow abowiea their waskase'compsnsatioe 00W@ con&ujan IaBcY in�tmetles
Coobsetosa that s hak tlds boxmust�ameb aMdoo,�sh ww8�mantm num��e nee a� swk
md their pnucy taf roudan
I am an employer that Is providing workers'compensadon lnsurancejor say y employees Below b die policy andjob sitemation
Insurance Company Name:
Policy N or Self-ins.Lic.1k Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration PASO(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGG c. 152 can lead to the imposition of criminal penalties of a
fine up to 31,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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.
/do horeby testi an Sism aired
the pe Irks ojper/ary that the injarmadon provided above is and correct
Phone C
-d5 �17_
0,f7eial use only,. Do not write in this area,to be completed by city or town oJ)7ciaL
City or Town: Permit/License p
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.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 employes is defined as"...every person in the service of another under any conned of hire.
It
express or imp ed.oral or written."
individual, •p,association.corporation or other legal entity.or any two or more
as"an Partnaslu or the
defined employer.is f a deceased
An employer and including the legal representatives o
of the foregoing engaged in a joie enterprise. sty,employing employees. However the
receiver or trustee of an individual.partnership.association or other legal
house having not mothan three apartments and who resides therein,or the occupant of the
owns of a dwelling re
dwelling house of another who employs ns to do maintenance.consauction or repair work on such dwelling house
thereto shall not because of such employment be deemed to be an employer."
or on the grounds or building appurtenant
MGL chapter 152,125C(6)also states that"every state or local licensing agency Shan withhold the Issuance or
renewal o[a noose or permit to opente•business or to construct buildings V the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,$25C(7)stamen Neither the commonwealth nor any of its political subdivisions shall
• enter into any contractfor the performance of public work until acceptable evidence of compliance with the insurance
req uiryments of this chapter haps been presented to the contracting authority"
Applicanh
please fill out the workera'compensation affidavit completely.by checking the boxes that apply toyoursituation and,if
sub-conuactor(s)name(s).addresses)and phone numbers)along with their employees
e s other
Of
necessary,supply Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
insurance. Limited Liability mp insurance. If an LLC or LLP does have
members or parmera,ate not required to carry workers' compynsation
is requited. Be advised that this affidavit may be submitted to the Department of Industr
employees.a policy ial
insurance coverage. Also be sutra to sign and date the affidavit. The affidavit should
Accidents for confirmation of
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 can the Department at the number listed below. Self-insured companies should enter their
self-instaanee license number on the a line'
City or Tows Otfidais i
it is complete and printed legibly. The Department has provided a space at the bottom
please be sure that the affidav
Office of investigations has to contact you regarding the applicant.
of the affidavit for you to fill out in the event the
which will be used as a reference number. In addition,as applicant
Please be sure to fill in the permit/license number
applications in any given year,need only submit one affidavit indicating current
that must submit multiple permitllicenee
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 fila for future permits or licenses. A new af ,drvir must be filled out each
year.Where a home owner or titian is obtaining a license or permit not related to any business or commercial venture
is NOT required to complete this affidavit.
(i.e. a dog license or permit to bum leaves etc.)said person
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 can.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Depaunent of lndtlstrjal Accidents
Offlee 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 wwwmass.gov/die
Crry OF SALEM
' PUBLIC PROPERTY
DEPARTMENT
�.�.COMCML
taoa►,wmw,anarsor.s.ta�xwuoawasatsrs
110-!' 746450•PAae M744-S4
Constrnctlom Debris Disposal Affidavit
(Muird AK all detoolidon slid mmvadon wade)
in sceordaoea with do"Widen of lbs stat Buddies Cod16 780 CMI section 111.!
pdb"sod to psovisiam a(IM .a 406 s 54
Building tseeit M is isaod with dw eandWon due du dells reauddes Aon
do wait slut be disposed Otis s psopub,lieaosed waste disposal dkd tl►as defined by lY[M a
1 I1.s 1soA.
The debris wiu be etaoapostd bY.
(rims of b0alatl U
The debris will be disposed of in:
(name of 6eilit»
(address of&Ciuw
),Ve
sidoaaies of prtaut
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FROM :FRIRJk E GI UFFR IDR FRX NO. :6038933316 IJw. 21 216 09:42RI P1
t ,
GRANITE STATE INSURANCE COMPANY 74091-000o WC 439-45-24
13102 ---------------'013-66-0806-00
PENNSYLVANIA
FRANK GIUFFRIDAMember Companies of
��
114 BERRY STREET American International Group
NORTH ANDOVER. MA 01845-0000
EXECUTIVE OFFICES:
70 PINE VIPIG T. NEW YORK, N.V. 10270
SEE NAME AND ADDRESS SCHEDULE - WC990610
NORTH ANDOVER INS ACCY INC
WORKERS COMPENSATION AND EMPLOYERS 9 WAVERLY RD
UASIUTY POLICY INFORMATION PAGE NORTH ANDOVER, MA 01845-2415
qq�SUU fEo qq pREN011a POLICY NiJ16ER --
IINDIRYPDUAL RENEWAL 002 88 04
77-771
0711ER WORKPLACp NOT SHOWN ASOVWSEE NAME AMC ADDRESS X U E - WCM6IO
eters eoucY V[ 122.41& .ws"u'd Haiti at we imu.ed•t
oulass sooner racN 08/27/06 ro 08/27/07
11x,1 A. Worka+e Compensation InsurMec Pail One of the policy applies to the Workers Compensation Law of the mg"listed
hon:
MA
S. E.p"m WOIIMV Inwnnce:part Two of the policy applies to Ma work In each at@%listed in learn 2.A.
The limits of our labillty under Pan Turn,ere: SodiV Injury by Accident E 100.000 Mph accident
Safety injury by D4ease S 500.000 Policy II.R
Healy Iniury by Dlsaaee 5 100.000 each employee
C. Other States Ins angs:Pon Three of the policy Werke*to the atatea, N any, listed here:
SEE ENDORSEMENT - WC200306A
nw• Tha pnmlun,to,this peHey full w dawmined by our Yantis of Rules,Classifications, hates and Noting Plana.
AMI inwtnation required bolo,is subject to verMieetion end claire+by Budd.
[.dmnm tm.1 b`e'ar [.nmrwd
daui}IraYu[
C .Ml b.r tlr'a W'Ol Ilan iter wke R.,niym
IJ Mn WI ]YM. 11111aM1w' YInWI BTMr
SEE EXTENSION OF INFORMATION PAGE - WC7754
TAXES/ASSESSMENTS/SURCHARGES $179
plraMa[uph IT(MI WHERE wnrrvaLs SYSTME) —f2—V4 MA
seeayw"Geou's 5500 KA roTRl®nNaTeo o,swuu $4,569
x m[iu�1r'`I coo-.imeian+elun,ntinn a e( .I..mail ati
1__i corn,-AnnVrlh 13 U .toffy MYnIFIy pfPpyl pl9eUM
[le MEMEm pope NUMl SEE ATTACHED FORM SCHEDULE - WC990612
09/15/06 ASSIGNED RISK 66
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