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11D-13A2-13B2 FIRST STREET - BUILDING INSPECTION \ Mat is jhro current use of the Building? Material of Building? WO 22 tf dwelling,how many units? - vim the Building conform to Law? Asbestos? ArchheaYs Name Address and Photo Mechanic's Name Address and Phone Construction superviaors Ucens•s< HIC RegistratlOn 0 Estimated Cost Of Project T V, 0 Permit Fee Calculatbn Permit Fee i �� Estimated Cost X$7/$IWC Residential — Es*natsd Cost X$11/411000 Commercial--------- An Addnkww s5m 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 P to uikh to the a stated specifications. Signed under penalty of perjury ate i �i N s a a d `3 x� � a -- 4 EITy-OF PUBLIC PROPERTY DEPARTMENT ^� u•.w*.3v DRWA" S: %"%Va 130 WA*uw w hinesr•SALAft%L%UAas:srrrs 01970 TW M744M•Fez M740.%* APPLICATION FOR TM REPAIR RENOYAnON_ CONSTRUCTION DEMOLITION,OR CHANGE OF USE OR OCCU MNCY FOR ANY EXISTING STRUCTURZ OR BUm ING _ 1.0 SITE INFORMATION Locadon Name: ®(� Buitdlrlg: 11A , f -------- -- - ProPenY Address- - --- -—,. _- ------- - - -- - -- __ .. . ..__ . Properly Y bated W e;Conservation Area M Hietarlc t>Istrld Y 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: l6 / fir �QIZIFs bo W61711;�416 Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISMNa BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use Nay Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation radd sting building New Description of Proposed Work: J, sew OP 5;�XU7-INC- sr�,� pia q 1,144) --- -- ---Mail Permit to: � -- r !� CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT stxmratFr uatst:uu Mt.srd at IY V7n,runG foe STREET *SALEM.M.sssnu lt.It t'Is 0197:, 'fh'l.:978-745.9595 •FAX:9M740.91M Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anriallcant Information Please Print Le ibl � r Name (BusiiwworganiratioNindividuui): Address: City/Stare/zip: Phone M: Are you an employer? Check the appropriate box: 'type of project(required): I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6, ❑ New construction employe"(full and/or part-tine).• have hired the sub-contractors 2-1 I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling hip 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 S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.) officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. (No workers comp. c. 152,§1(4),and we have no 12.0 Ruof repairs insurance required.) r employees. [No workers' 13. thcr­ �f�s comp. insurance required.] •nay apphotnt than cheeks box di must also fill out the aectiarl below sltowiag tlatir wurkmi eumpnnsatiwt policy infurm;uiwa 'liwmstwnms who submit this affidavit indicating they are doing all work and their him outside eontmmon mwt suhmit a new amdavil indicating such. :Comincturs that cheek this box must attached an additional Am showing the name of the WbKomraclora and their wurkma'comp.policy information. l am an employer that Is providing workers'compensation insurance for any employees. Below is the policy and Job site informarion. Insurance Company Name: Policy is or Self-ins. Lie.ti: ._.... .../.'.-_. Expiration Date:- Job �&/ �WIzJ Sire Address: //! City/Statd21p: Vf�nj) Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). /V Failurc to secure coverage as required under Section 25A of�IGL c. 152 can lead to the imposition of criminal penalties of a i fine up to S1,500.00 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 maybe forwarded to the Office of tut e,ngations of the DIA for insurance coverage verification. l do hereby certify under the pains and penalties of pery'ary that the information provided above is true and correct. sunantre: __ ___ Date- Phone is w f Official use only. no not write is drir area,to be coorpleled by city or town afJ/ciaL Cityor'rnwn: Permit/l.icense#____ _ Issuing Authority (circle one): 1. Board of Ilealrh 2. Building Department J.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: _ Phone tt: 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 have 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 M. §25C(6)also states thus"every state or local licensing agency shag 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-contractors)name(s),address(es)and phone number(s)along with their certificatc(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 nut 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 permmitilicense 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 pennit 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. Thu Office ut Investigations would like to thank you in advance for your cooperation and should you have any questions, please du not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents OSit:e of levestlgations - - __ 600 Washington Street Boston, MA 02111 Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised i-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTN4ENT M1 rY i A00-011. A%It R I1C WA91N::JKSMELT•SALP V.%fAtt\t::LL .L1"1]:19IC Tet:9MI45-15" •FAX.M-7469W Construction Debris Disposal Affidavit (required for all demolition aLul renovation work) in accordance with the sixth edition of'the State Building Code, 730 CNIR section 111.5 Debris,and the provisions of MGL c 40. S 54; Building Permit N is issued with the condition that the debris resulting from dis this work shall be posed of in a properly licensed waste disposal facility as defined by .1GL c I11. S 130A. ! The debris will be trap acted by: tna of hauler) Tl1e debris will be disposed of in : 741N? ,%(� hl:unr of acdrtY) G f Z � i o .a fi Oj 3j n 1 N [^ Q ��IJJ/ A np v 1 n n ■■■ ■■■ ■■■ ■■■■■■■■NEE■■■■ ■■■■■■■■■■NEE■■ ■■■ ■■■■■■■■■■■■■■■■■■■E■O■■O■■■■■ENE■■ERM■■■■ ■■N■NONNOONN■■■■■■■■■EEO■■■■OE■■■�ii■■■■■ ■■■■■■■■■■■■ON■■■■■■■■■■NEill!111■■■■■',■■�I■IEEE ■■■■■■■■■■■■■■■■■■■■■■■■ONiEi�■■■■ ■■■�'i ■■■ ONE■■■■■■■■■■■■■■■EN■■■■■■i��O■Oil; N ��■■A� ■■■■■■■■■■■■N■■■■■■■■■■■ON■■r■■■�i�l'S�■��■ONw ■■■■■■■■■■■■■■■■■■■■■i ■ONNN■ii■■E�CI1l�N N■OE■O■■E■NNN■■O■■O■■N■EVEN■■■NEN� i■■ill■�1■■ ■■■■■NEN000NNN■ENO■■©EE monoEE■■■11INN■�ilw��� ONO■�fil iii'7iWi�il ii■■■■■■■■■■■■ill■ME M1101IN �■■■�`jl■■■ ■iiiffigiii'ii'+iii■ I i■IRolla �1 r�1■i�1111■' i EON■O■EN�flii�i'■■ANEWiMAiif{ii■■ iiMMEMOM i.---- ■■■■■■■i■■I�CJ �iii■ii�riril■i■■Ci■■■�i■■■■■■■■■■ E■■■■■■■ii■ud�iMMUN'f�i'ii'I�r�'■■■■i■■■Fil■■■■i■■■■■i■■ ■■■■■■■M �MMOMM■M MONO■■■i■■i■■■■■■■■■■i■i ■■■■■■Ii�(�i��■ii�il�ii(i�ii`il�i■■i■■ii■i■■■■■■■■■■■■■■■■ ■■■iiiiEE�iliiEi� i�i�iili�i �'GW■■■■■■■■■■■■■■■■■■■■■ ■■■■■NNO■■EN■■■NE■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■ loom■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■NON■■■ i■■■■■■NEON ■■■■■ MACS. 082472 MANIC 134520 { t Stephen Prunier Carpentry 61 Poplar St. Danvers, MA 01923 Tel. 978-777.0772 www.StephenPrunierCarpentry.com Pro�vosal ECP Services 400 Highland Ave Date 8/2/2007 Salem, ALA 01970 Location of work to be performed, The Cloister Salem MA d ' e ® IMANAGEMENT EAST CAST PROPERTIES NATIONAL tS IDaN NATIONAL ASSOCIATION OF REACTORS® ILI- August 21 2007 l IIV / U h P Building Department 11 Department of Public Services 120 Washington Street Salem MA 01970 Re: PERMIT NO. 213-08 FIRST STREET, SALEM, MASS Dear Sirs: Enclosed please find original Building Permit#213-08, which I am returning because the name of the owner/applicant is the wrong name and the address is incorrect. The work li that was done on the property is owned and located as follows: OWNER: CLOISTER CONDOMINIUM TRUST APPLICANT: CLOISTER CONDOMINIUM TRUST by East Coast Properties, Manager lif ADDRESS: I IA FIRST STREET and 13A-1 and 1313-2 FIRST STREET Please issue a new Building Permit. If you have any questions, please call me. t Very truly you' EAST COAST PROPERTIES, Manager () �1./& BY: fi yndy elmo Enclosure REAL ESTATE AND PROPERTY MANAGEMENT 400 HIGHLAND AVENUE,SUITE 11 Phone: (978) 741-2003 SALEM,MA 01970-1777 Fax: (978) 745-9684