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The Commonweal thPdfM5a; i6hjj,s6t&ES
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Department of Public Safety
MassachusettsStateBuildmaMt a Bt2IRA41: 08
Building Permit Application for any Building of t a a ne-or wo-Family Dwelling
(Phis Section Fur Official Use Onl )
Number. Date Applied: Building Official:
1:LOCATION(Please indicattee Bllock#and Lot#for locations for whi1ch a street address is not available)
City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK.
` Edition of NIA State Code used_ if New Construction check here O or check a8 that apply in the two rows below
[V� Existing Building❑ Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix t)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify: + Y L -(0 51.ee
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No &L
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 13--
Brief Description of Proposed Work:
1'lOiOl..Rc�_ 1M ,'4� ,S ,-e 5 5 cJe-,r Ra -'Cegout S
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here d an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 31) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4 O A-5❑ B: Business ❑ E: Educational ❑
F., Facto F-1❑ F2❑ H: Hi
h Hazard H-1❑. H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional W❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable) -
IA Ill IIA 0 IIB ❑ I(IA ❑ 1118 ❑ 1 IV Cl 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 oreetails on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify,
is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: UAItutgnc C'onuniscion K�rg.r_J4gicas:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ Yes❑ or No❑ Yes❑ No Cl
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: (kcupant Load per Flour:
Uoes the building Cont.un an Sprinkler System?: _ Special Stipulations:
- '' SECTION 9: PROPERTY OWNER AUTHORIZATION .
Name and Address of Pro erty Owner '
FP�Avt � do 3SF�;�
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owners behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control the check here Cl and skip Section 10.1
10.1 Registered Professionall Responsible for�Construction
.�Control S
Name(Re-islmnt) Telephone No I e-mail ac dre s Registration Number
3 1Z/Lev V, .t�C ��J ec]OMvrJ tir i �/{ y
Street Address City/Toi n Slate Zip Discipline Vxpi itlon,,Date
13
10.2 General Contractor
Comp. ` Name �7
V' 0 /o /) /D
Name of Person Responsible fur Co truction License No. and Type if Applicable //\\
S rcet Address City/Town State Zip
�AX 91 i L/7- ) e) 4, (Aei--
Tele hone No. business Telephone No. cell a nail address
SECTION 11:4V0RKERS'COhIPENSAI[ON INSURANCT..AFFIUAVCI M.C.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? - Yes O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ y Building Permit Fee-Total Construction Cost x_(insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check a able to
6.Total Cost $I`L, d(7 d� ("ma.t municipaPlrity)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
,application is true and accurate to the best of any knowledge and understanding.
141 p
41„ '{M Ar �vv L/ / lr 5 0-7
Please print and sign nam Title Telephone No. Date
OTT t T IM0 _e�,w95d
Street Address City/Town State Zip
Municipal inspector to fill out this section upon application approval:
Name Date
The Commonwealth ofMassaehusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
'Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leelbly
Name(Bwinws/Organ ntion/lndividusl): .0 _ 'e
Address: 500 tge s v " IM yt G Q
City/State/Zip: Phone M 7/
Are you an employer?Check the app"Fkate box:
Type of project(regoired):
1.olam a employer wrtk einployees(fWl and/orpart-time). 7. New,construction
2.O I am a sole proprietor or partnership and have no employees working fin me in $. Q Remodeling
any capacity.[No workers'comp.insurance required] - .
3.❑I am a homeowner doing all work myself.[No workers'wrap.insurance required.]t 9. El Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition,
canoe that all contractors either have workers'compensation insurance or are sole I I.0 Electrical repairs or additions
proprietors with an employees.
12.Ej Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the anwhed sheet. --
These sub-contracmrs have employees and Lave workers'comp.insurance./ 13.❑Roofrepairs
6.F1 We are a corporatiw and its officers have exercised their right of exemption per MGL c. 14.❑Other
(4),and we have no employees.[No workers'comp.imarrame regrmed.] -
-Any applicant that checks box%1 must also fill our the section below showing their workers'compensation policy infmmauon.
f Homeowners who subrWt this affidavit indicating they are doing all work and than hire outside contractors must submit a am affidavit indicating such
1Contracmrs that check this box must attached an additional sheet showing the mine of the sub-contractors and state whether or not those entities have
employees. lithe subcontractors have employees,they must provide their-workers'.comp.policy comber.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name`49�JSd"vv - e.� t, n" �d\C%'LA -
Policy#or Self-ins.Lie.M 066 SO[ ' (lam a L9 J ot•Q JS Irl Expiration Date:
Job Site Address:, k::—L r�A City/State/Zip:-�Le-1 1,—L
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up.to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verification.
I do hereby ce ' un er the pains and penalties ofperjury that the information provided abo is true and correct
Si ature: 5
Phone#: 1 T d
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/license#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone M
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 house having not more than three apartrnents 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 152,§25C(6)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,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-contractor(s)mame(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 Departrnent 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 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 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 dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
07TY OF SALEA MASSACHUSEM
I BuLDn,jG DEFArimmr
120 WASFmJGroNS7WT,3RDAWR
TkL(978)745-9593
FAX(978)740.9846
B:IIvIBERLEYDRIS�I.L
MAYOR THCMes STYEXU
DIRECTOR OF FUBucPxoPER7Y/BUIIAII4Gccta SSIomit
Construction Debris Disposal Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit g I t is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
eLyV / tMUd 4 y b T
(name of auler)
The debris will be disposed of in:
Wte&0
(name of facility)
J/L1� 0 1 !2 ire e 1A, Aft
(address of facility)
Si a of applicant
Date
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PERRY MURPHY.INC' �r—I, '
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ARTHUR MURPHY
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300 MERIMAC ST -
Not Lal' wit 'gnature
NEWBURYPORT,MA 01950 Undersecretary -
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Markwood
Management
Incorporated
September 22, 2015
Salem Building Department
Salem MA
To whom it may concern,
Please be advised that the Board of Trustees of the Bowditch Place Condominium Trust, 35 Flint
St, Salem MA, is aware of and has approved the work to be done within Unit 114, Leland Honda
owner. The contractor is Arthur Murphy Construction.
Thank you,
Mark W. Livermore
Markwood Management
Agent for Bowditch Place Condominium Trust
Post Office Box 900 Marblehead, Massachusetts 01945
Telephone (781) 639-4080 Facsimile (781) 639-0228
markwoodmgt@hotmail.com