16 FOREST AVE - BUILDING INSPECTION i
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLI-
MAYOR 120 WASHINGTON SIREEr• SALEM,MASSACHLSETIS 01970
TEL:978-745-9595 ♦ FAX:978-740-9846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
160 SITE INFORMATION
Location Name:
Pro p✓ Building:
erty Address:
P /
✓ C. iA 1, JcLr a
o✓e _� c rsf
Property is located in a; Conservatio Area YIN Historic District YIN
I - _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land S
Name:
Address: J _
/� �d✓PSt �V-er4/C�
Telephone: 5-�7k- y4-
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition t,��l( Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation ZG p t'
of existing building New
Brief Description of Proposed Work: p ® 1170164 S- 0UP0,
�d �fa ce l � Ei�pprrx 3P �'. ever �. d }tea✓� (1 c �(
ttt cA r Ov✓ d wc11I I ferns, f✓c� p✓tu,o s0 /d t4�an,
Mail Permit to: (�U4fAlz`(7,
t
What is the current use of the Building? 6OW d ea1 l i V L�
Material of Building?Zkre, c� If dwelling, how many units? 3
Will the Building Conform to Law?_4 OS Asbestos? no
Architect's Name V
Address and Phone /6 For¢s/- Q✓PNv t ( )
Mechanic's Name 711 ,cS G �
Address and Phone /S ai+✓ rely L r�ss algiS
Construction Supervisors License# 01/k 67V HIC Registration # /z3 2.z3
Estimated Cost of Project$ T`" Permit Fee Calculation
Permit Fee $ 2,5. crO Estimated Cost X$7/$1000 Residential
p/ 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 Permit to build to the above stated
specifications. Signed under penalty of perjury ld�
Date Z�K
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CITY OF SALEM ?do- ,i 8 t{G
' PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOIl
MAYOR 120 WASHINGTON STREEr♦ SAI.EM,MASSACHt1SE_M 01970
TEL 978-745-9595 ♦ FAx:978-740-9846
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers
Applicant Information // Please Print Legibly
N. (Business/OrganizatioNlndividuap: -Z40.L�Jsi_r �A)
Address: /,<-- . a i am -tom
City/state/Zip: J2,aLf, 40 A s Phone #: 4?7,F— fZ7
:tire you an employer?Check the appropriate box: Type of project(required):
I.JK I am a employer with 4. 0 I am a general contractor and 1 6. New construction
employees(full and/or part-time).' have hired the sub-contractors � Remodeling
2.0 I am a sole proprietor or partner-
listed on the attached sheet.t KY
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. (] We are a corporation and its 10.0 Electrical repairs or additions
required.] o right
have exercised their
gb exemption t of per MGL 11.0 Plumbing repairs or additions
3.❑ I am a homeowner doing all work P P
Myself.[No workers comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any applicant that checks box*I must also fill out the section bduw slowing their work=*compensation policy infutmalion.
l lomeowncn whu submit this affidavit indicating they are doing all work and then h'uc outside conamcron must submit a new affidavit indicaing such.
=Contractors that check this box most attached an additional sheet showing ahc name of the salrcontracton and their workers'comp.policy information.
I art can enspluyer that is providing workers'compensation insuranee for nay employees. Below is the policy and job site
infonrution.
Insurance Company Name:
Policy#or Self ins.Lie.tr: Expiration Date:
Job Site Address; _1W City/State/Zip: �C-�fN Bna)o
.kttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
I-'ailurc w secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 5250.00 it day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
lavcstigatiuns ul'thc DIAL for insurance coverage verilicatiun.
I da hereby certify under the pains and pen-ult-ics coif perjury that the information provided
above is true and correct.
SiL t nut / idt1 t� L�CAn t^ Date'
Phure ti:
Official rise only. Do not write in this area, to be completed by city or town ofjiciak
City or Town: _---.-- Permit/License --
Issuing Authority(circle one):
1. Board of Ilealth 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other —
Contact Person: Phone#:
Information and Instructions
bfassachusetts 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."
,kn 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 uustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house 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."
h1GL 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,Iv1GL 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 rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(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 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 till 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 pennit/license applications um 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 dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
1'hc Of,ice 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 call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax#617-727-7749
www.mass.gov/dia
CITY OF SALEM
j' PUBLIC PROPERTY
j DEPARTMENT
KIMHERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET ♦ SALLiM,MA.SSACHUSETFS 01970
TEI_978-745-9595 ♦ FAX:978-740-9846
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 c 40, S 54;
Building Permit# _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(riamo6f hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
v�ly -/b zG�a
date
drhiisatrJuc
May 8. 2006
16 Forest Ave. Condo Association
16 Forest Ave.
Salem, MA 01970
We, the undersigned trustees of the 16 Forest Avenue Condo Association, approve the
proposed remodel of unit 3, which includes a change in the size and shape of the kitchen,
eating area and one bedroom. The construction will take place during the summer of 2006.
Unit 1: Z
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Unit 3: 5us pA
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