13B-1 1ST ST - BUILDING INSPECTION awe /S:
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: ;%pplicants must complete all items on this page
SITE INF0RAIA'1'I0N
Location Name dGG'X* Building G�ISZaI'� �Q�O
Property Address
Located in: Conservation Area Y4V Historic district 10V
APPLICATION DATE 3/31/09
Use Groups
(check one)
Group Homes R3_124_
Residential (3 or more Units) R2 ,
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) At —
New Building_ Assembly (restaurants & clubs) A2r_A2nc_
Addition Assembly (churches) Al _
Alteralion Business B_
Repair/ Replacement_ Educational E_
Demolition_ Factory (moderate hazard) F1 _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile N1 _
Storage S1 _Model ale 1-I:zard
Storage S2_Low I lazard
O%%NERS11111 IN ORMA"1'1UN(Please hype or Print Clearly) Y_ Vpo i .raGfiJ'-Ti/✓I
OWNER Name CLOISTER CONDOMINIUM TRUST
Address c /o EAST COAST PROPERTIES
Telephone 0 Highland lf! . , Sa em MA 01970 41r
Sig natur IF
DESCRIPTION OF 1i'ORK l'O RE PERFO NIF.D
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ES I INIA"FED CONS'I'll L'C'I'll ON COST'
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cuNrttnCrOltlNrcIRN1AruIN
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Name f
,address � �ytctt2 /do,zov q/1 /� G✓kr/�d+�l �
Telephone R 7- 3o$-Slote�
Construction Supervisor's Lic #
Home Improvement Contractor #
ARC111TECT/IiNOINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
1'1?Ki\II'1' F'IiE CALCULA"PION *52d0,
Estimated Cost x $1151,000 + $5.00=
CONIb1ENTS
k2m4x-e >` 6uwl ran-, avr
The undersigned applicant does hereby attest that all information stated above is true to the best of my knoivledge
under the penalties-of perjury
Signed (owner) (agent)
APPROVED BY : C` L%?�`%''
01,
DATE APPROVED:
U
�=y CITY OF SALEM
PUBLIC PROPRERTY
DEPART'NIENT
Iii- v'8.-4;.)v); of NX. ':rS.V_'64�.
Construction Debris Disposal .affidavit
(required tier all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 CNIR section I 1 1.5
Dcbiis, and the provisions of MGL c 40, S 54;
Building Permit N 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
111. S 150A.
The debris will be transported by:
�i�a�au2 /,vus I�2
I name of hauler)
I he debris will be disposed of in
(name of lacility)
IadJres.u(In ilitvl
,��ual c rf p.•nnu .y,phcant
lair
CITY OF SALEM
„ , PUBLIC PROPRERTY
DEPARTMENT
w'1 Y.Inte(.-I 1
%I r,44 W,sstu.sst:I,^S181-Ii1' 0 5nt l]1, M W% It it Its 3PJ7^
fra. P3.71343'+3 a 1:lx 97a.74C'IM46
Workers' Cumpensation hlsurance lifftdaxit: Builders/Contractors/Electricians/Plumbers
Am incant Information Please Print Leeihly
�I:11T1C l8usnssv t�r;;anlratiaNlndn uluull: l �' /tl
l
Nddress: LAZ 1/12IiIy- GxA /✓( n y tits4
City,Stara Zip: G1/R �>`� 4 f� 0-2 11hune '!: 6,1-7 54,8—SLv 6 2-
Are)%ou all employer:' Check the appropriate but: 1,)pe of project (required):
1.❑ I am a employer with 4. ❑ I am a gcncral contractor and t g. ❑ new construction
nplo)ccs(full andur pert-lione).• have hired the soli-convectors 7. ❑ Remodeling
2 I ,un a sole proprietor or partner- sod on the attached sheet. r
Sleep and have no employees These subcontractors have 8. ❑ Demolition
working tier me in any capacity. workers' comp. Insurance. 9, ❑ Building addition
'No workers cum . insurance 5. ❑ We are a corporation and its
I P 10.❑ Electrical repairs or additions
1 required.) ofticerx have amrciseJ their
ri lit ofexem neon r MGL 1 I.❑ Plumbing repairs or additions
3.❑ 1 :on a homeowner doing all work g P Pc
myself. LKo workers' rump. c. 152, ¢1(4),and we have no 12.0 RRuuf repairs
insurance required.) employees. LKo workers' 13.L�I altar �P�1/ox2�3Cl J2arN
comp. insurance required.j
•tm .,,qu6cwa thwe checks box III must also fill utu the sec0ou wow ahuwmy Ihea w'urkui cumpansuliwl Iw6cy udi,rttueiun.
' I h,maaw lion whu tubmil This affidavit milis,oneg they Ore duina 411 work owl duct hire uuhlde cavraelon muse.uhmit 4 new Atfdavil indi"Ina sash.
-(,•ramuM that check this box muul.uexhcd.In Adddiun4l nlwen.hawing the mole of the subtontrwl,srz and their aurkan'Bump.Imlicy mfslrm anon
luny an employer that is providing workers'rmnpenearion in.tarance/br my employees. Behnv is the pu/icy and fob xiter
iajurntutiun.
Insurance Cumpaoy Vame: --- - -- - --------- -
I'olicv a or Scif-ins. Lie R: __.. .. . .. -_ Eapiraton Date:_
Job Site Address: 7 /�.5 S�• (� '�l Cuy;Slate1Zlp. -,tAA-
.hnache It copy of Ilia workers' conpcnyatlun pnlic) declaration pug*(showing the policy number and expiration date).
Failure to secure coserege as required under Sediun 25A uf>IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to.51.5110.00 and/ur one-year imprisonment, as well as cisd penulllcs in the I"orm of a STUD WORK ORDER and a fine
ref till Ill S250.00 a Jay agalegl lite Violator. Iic advi.: d that a copy of this Yiate'ment Inay be forwarded to the Oilicc of
1,1s ;a u,n1,ul ale UTA :or msos.uxc e,ncragu scrilieaimn.
/Jo hero by(.rriw urrdcr the lm is and penrrhicv u perjury that the infunnarlon provided above is true aad correct.
H41,
t)/firiul axe only. Do ant rvrife in Mix urea, to be completed by airy,or town al)h iu/. I
(-ily or 1'mia: __. _—_ Pcrmit/Liccnse0.
Issuing; .ilulhuriiv (circle noc):
I. 1{a,arJ of IIe.JIhDcpanufrut 1. ti. luau Clerk 4, L•'IvOrical Inspector i, PI ... in, Inspector
6. Oilier _
Gauacl 11cr un: - .. _ Phone t/:
- a
Information and Instructions
N I.u;.)chuscus Gcneral Laws chapter I52 rcquires all cmplo)ers to provide workers' compensation for their employees.
Purou.mt w (:us ,rawte, an empluree is defined as ' e)er), (ntson in the service of another tinder Ally contract of hire,
evpre» or unpltcd. oral or +vntten."
An .•inplup-r Is defincd as"in individual, partnership, .issocianou, corporation or tither legal entity, or any two or more
,q the torcgomg engaged m aprtnt cnterpr,se, and including the legal representatives of a deceased cmplu)cr,or the
receiver or trustee of.ui mdtvtdual, pwtnunhup, assoctation or other legal cnnty, employing employees. However the
owner of'a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelluhg house of another who employs persons to do maintenance, ;unstruction or repair work on such dwelling house
Jr on the grounds or budding appurtenant thereto shall not because of such employment be deemed to be an cmplo)er."
\IGL chapter 152, §25C(6)also stares that "every state or local licensing agency shall withhold the issuance or
renewal of IN license fir permit to operate a business or to construct-buildings'in the commonwealth for any
applicaot who has flat produced acceptable evidence of compliance with the insurance coverage required."
Additionally, `iGL chapter 152, §25C(7)stales"Neither the commonwealth nor any of its political subdivisions shall
enter into any;untrue( for the performance ufpuhlic work until acceptable cvidence ufcumpliance with the insurance
requirements of this chapter have been presented to the contracting authority." -
applicants
Please rill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if
necessary, supply sub-contracior(s)name(s), address(es)and phone number(s)along with their cortlficale(s)of
insurancc. 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 insurancc coverage. Also be sure to sign and date the affidavit. The affidavit should
he retuned to rile city or town that the application for the permit or license is being requested, not the Department of
Indu trial Accidents. Should you have any questions regarding the law or if you are required to obtain is workers'
compensation policy, please call the Department at the nunnber listed below. Self-insurcd companies should enter their
.elf-insurance license number on the appropriutc 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 affidavit for you to fill 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,license applications in any given year,need only submit one affidavit indicating current
policy int'ormation(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 f'or 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
t i.e. a dug license or permit to burn leaves cte.)said person is NOT required to complete this affidavit.
I he I)I Ike of Intest)gat)an) would like to dhank )l)u in advance fur your cooperation and should you havo Any questions,
please du not hesitate to give us a call.
fhc Uep.unncnt's address,telephone and fax number
The Commonwealth of Massachusetts
Department of industrial Accidents
- ---_ OffIce of Investigations. --- -- --------- --_-_ -- _-_ - -
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia