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1 FORRESTER ST - BUILDING INSPECTION � CIT�C O� SAI.E:�T, �'��SS.��--it�'SE�"I'S :. , .�o scu.n�c��ar�c�.rr , y 1'_'0 W.iSHRVGT9 `D�OOR � �" = -- �� ---�'�y 97 7�5-9595 — Fnab(97� 7�(S-9fi�6 Kl�ffi�RLEII DRISCOI.L i�i1.iYOlt T�tO�ta�SY. DI�ECYOA OF PI:Bi.2C PROPER2Y/Sl'IIDQ�G CO�LIIISSYO�iEA ' dp�.l�el6��'��TF9E 6'.�N ��@�. ��. . �'��4lO�s�'..�6�°.s�.�� 7$�.�� J��eB�d�Y. OR� Lr6@ON O��{e91f��D1i.D89dti OR 3YRtJC'Ai! " oei fot .: B��'OB°hl__ �� eaildie�6'�i[�jea�- � � � �� t�'.�. l �� B ,_ .. �.,_ � , �, : �,. . n � �, , ' Btai�ir�;! ,. ; . . _- � ,, . . �t�:�.x> ; ._ ' � ,�" �t�: S4�et Eeed: . 9�: 9.0 Sl71�9Ad�RFA91'61�T1 # Buiklirvg: ' �dr�: � �� rp� ,2 � - .. � A�A ' LAPd6�aeL�6: , ,. ..arra�.mrv!+..W.�. :kKn . �t � .. . . �!1 �S.n _. .�[.,.i:� �Et�� .._ Y Y�� . , � � M�'VR��W Y� . . .. . . . . . . - P9�er�: �ov C�'i,2�2.^� A�� 22 '-" Addre�_ � '��.�s�� s� � �a1Q..� M�, a Ia�o T�t� . wrv:e �1\ (n��-331 - (oSS � .� �eA �a ��- `Ilo1 - � S 3� 2.��os�e�P�s��bee08�lee�� Pd : �v.n� lts �:Zo.� Addre�: Tei�pB�eie: 3.A /BGEAlCY OR.�@JT6�90R@"dY AU7HOR9ZIRl8�C�A1S'T'Rt1CT1OM Agencle tdaene: --.__ e Adde�s�: Agency Praject Number. Praject AAana er IVam�: TeL• 9 ` �� .5. �� ►Sfi��;�,�_ _. �;�,� � � � �-,� �� 4.0 PR�i=ESSD® DESIGN SERVICES: `:.. . 4 9 Regist Archi f Marne: Seal and Signa Address: T Fa-k,. . Y 4 �� 1 ai 'glrreer�e tum* It- k. to i 4 - Seal wW S - _- S .... . Addresw,:. Telephone. Fay Are sibility . �._ �af and Sigat 1 Address Telephone. Fad Area of Responsibility: Name: Seal and Signature Address: Telephone: Fax-- ax:Area Areaof responsibility: Matte`RIF.Y URKWOLL M. Ay It CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT 12C 9fastew'ratc Snot • Si um. Massnc l n.xra is 0197; Ts1: 978.743-9595 • FAX: 9M740.9816 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlclrns/Ptumben Address. �ZS' `� City/StawZi1r VJC i tM P�Z- o [ & fl hone p: 6e Z c( l�-- 1 Are you on employer? Check the appropriate box: 1. 024'am a employor with�Cd 4. 0 1 am a general eomractor and [ 'rype of project (required): employees (full atultur part -tine).• have hired the sub -contractors 6' � �� construction 2.0 1 am a sole proprietor or partner. listed on the attached sheet 7. Remodeling ship and have no employcal These sub -contractors have 11. 0 Demolition working for me in any capacity. f No workers' comp. insurance workers' comp. insurance 5.0 We arc a corporation and its 9 ❑Building addition required.] officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. (No workeri comp. C. 152, 01(4), and we have no 12.0 Ruof repairs insurance tequired.j t employees. [NO workers' 13.0 Other. comp. insurance required.) •••s -YY•—......».... w. n....w a........ vw u.a .,&,=www, Ytow.as .carr wwams- elm.panuakm policy in6armbti'm ' Iluma.wnen whm submit this aflldsvie indicating it" ant doing an wart and thea hies omsids eomroeton mus .utmnit a naw amJ.vit inJiaaina wick. C.ruracton; that chick this baa mut anaelmd m aeditio W abet J owing the name orate su?comratim, and their wurkers' comp. policy inrortna tim. I am an employer that Is providing workers' compensation insurance for my employees. Below is the puBry and Job sire information Insurance Company Name: �l -ev�a. SSs32:eQ., _ Policy korSelf-ins.Lic.0: CJ7 !h!!' -Expiration l Expiration Nate: e> Z'1 Job SiteAddress: -- N✓ef�-C�-c cS� �/�"+-�-. u -^P— City/SlatVzip:.C�1"", `-s.4 A« ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure tU secure coverage as required undo Section 25A us.' YIGL c. 152 can lead to the imposition of criminal penalties of a rine up us. 51.500.00 and/or one-year imprisonment, as well act civil pcnallics in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. lie advised that a copy of this slawment may be forwarded to the Office of Invesngatiutu of dtc DIA for irsurarcc coverage verification. I do hereby pains information provided abive is ytee and correct U/Jts ia/ au urely. /ka not write In tbii area, to be completed by cIy or town ofJleial City or'rnvvn: Permit/License M Issuing Autburity (circle otic): I. I. Isnard of liealth 2. Building Department 3. Citylrotwn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: .. _ Phone Information and Instructions Massachusetts General Laws chaplet 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an eamp/oyee is defined as ".-every person in the service of another under any contract of him express or implied. oral or written." An employer is defined as "an individual. Partnership, association, Corporation or other legal entity. err 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 utdividual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not mme than three apartments and who resides therein, err 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." AtGL chapter 152. $25C(6) also states that "every state or local licensing agency shag withhold the Issuance or renewal of a license or Permit to operate a business or to construct buildings In the commonwealth for any appllenot wbe bas not produced acceptable evidence of ComPllaate with the insurance coverage required." ubdivisions shall .additionally, MGL chapter 152, f25�C(7)) a of ublic work until acceptable evider the commonwealth nor nce of co pl ante wiy of its Political th h the insurance enter into any contract for the per P requirements of this chapter have been presented to the contracting authority." :applicants Please fill out the workers' compensation affidavit Completely, by checking the boxes that apply to your situation and, if necessary. supply sub conmactor(s) name($), addteas(es) and Phone nwnber(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, ate 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. Ilia affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Deportment 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 applicanL Please be sure to fill in the pemtitJlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permitilicense applications in any given year, need only subunit 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. Anew 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 dug license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. Che OCticc of Investigatiuns 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 Ofike of Investlaatlotaa 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-977-MASSAFE Fax N 617-727-7749 Revised S-26-05 www.mass.gov/dia .;d below) Contractor Name: Address: Area of responsibility: " Ltbense Number-" " Date of F�epiratto�: - Telephone: Iayc, Contractor Address: Area of responsibility: License Number: Date of Expiration: -Telephone: Contractor Name: Fax Address: Area of responsibility: License Number Date of Expiration: Telephone: Fax Note: For portions of work utilizing exemptions of MGL a 112 s. 81R complete the section above. Use additional sheets it necessary and attach to appiicatlon. 61 General Contractor sc5 �—��Ft,� Address: s 2S we' -.0 vt 1 � 123 3 CSL (P -4 Telephone: 81 S�9 - Cn 24 s Fax: l 5��c • Co z 5 'Co Responsible In Charge of Construction: WON � 9 � -Ccs � - �IZS- C-33 b. 7.0 CONSTRUCTION DOCUMENTS - to be prepared by applicant Item as Applicable' 7.1 Plans (Note 1 this page) Submitted Incomplete NqLRMuired 7.1.1 Architectural ;. 7.1.2 Foundation 7.1.3 Structural 7.1.4 Fire Suppression 7.1.5 Fire Alarm 7.1.6 WAC 7.1.7 Electrical 7.2 Specifications 7.3 Structural Peer Review 7.4 Structural Tests & Inspections Program 7.5 Fire Protection Narrative Report 7.6 Existing Building Surrey 7.7 Workers Compensation Insurance 7.8 Other Documents (Specify) (Energy Narratives, etc.) Note 1 Areas of Design or Construction for which Plans are not complete at the time of this application must be identified herein. Work so identified must not be commenced until this application has been amended and proposed construction has been approved by the Department -of Public Safety District Building Inspector having Jurisdiction. 2 Plumber of Stories above " ; IS16niber of Stories Below_ - Gude Gradri x Story Height - Ftoar Area Per.. Floor z Total Building Height Total, ftilding. Area Abov® above Grade Grade Total Building depth below. - Tool Building Area Below - Grade. ^•. , Grada... s .. Brief Description of Proposed Work: 82, USE GROUP AND CONS'TRUCTION.0 eoa (New ConstruledoOnlY):. �. USE Gii�®t�W �jt pIFIC6!•�Ot4, 5 USE GROUP SId AT V® « 6eON� as appllr bip}i� (� aa'appi lite CSS wiCAnON ,i� A Assembly 4 A 1a X-2'. •Y A 3`"' A=� 1A 13, s Business 1 E' Educational 2A F Factory F-1 F-2 2B H Hight Hazari H-1 H-2 H-3 H-4 2G I Institutional' 1-1 1-2 I-3 3A M . Mercantile 3B R Residentlai R-1 R-2 R-3 4 S Storage S-1 S-2 5A U Utility 58 Specify: Mx Mixed Use, Specify: Sp Special Use Addition. , � - as . k =isung Irt USE Group(s) .� Use. Hazard _ CLASSIFICATION azard Renovated ; Renovation Number of Stories G%up , Index New Change in Use 0 -4.,F Demolition Existing 1<-n Approximate year Of x (40 Area per floor (sf) Renovated' S Business. construction or, ren ovation . New of existing building E Educational. 9def Description of Proposed Work: (,O ;� k> ,.i VV 6 iW �ti +' ` ka.� 4,,, 2A- t 2 CJ '(4-z—e d ..ir 2C" - H High Hazard 4 k a ,.. EXISTING` PROPOSED change. w ,.x CONSTRUCTION Irt USE Group(s) .� Use. Hazard _ CLASSIFICATION azard t}s®» Hazard, (note sum-ceteg") , _Group - Index G%up , Index ' 4 IJ � i�l�p A Assembly 1f3" S Business. E Educational. 2A- 2 -F Factory ..ir 2C" - H High Hazard I lnstitutional, 3A- 38 M Mercantile 4 . R Residential 5A S Storage 53 U utility Mx Mixed Use Hazard index Sp Special Use 0 Note: Include Hazard Index Modifier for Construction Type as applicable 6?,�encv or Auftft, hereby authorize. - —to appal Signature 12. Certificate of Occupancy required on completion of project? _ Yes No Inspector's [dotes: Vendor Notes Notes for Vendor Waste Management Inc. Company: Waste Management Inc. Phone: 781-933-2113 11/1/07: Called and spoke to Mandy. Q. Where does the trash from the SXR shop dumpster go? A. Trash: Dedham Transfer Station (straight trash) or Somerville Transfer Station (mixed waste). Ak1-td 3v0 �orreST �' 1�• Page I 11/1/2007 10:10 AM ✓ae vomcnwow�e¢cerc a` ✓vcaooacrttueuo Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registratign 123313 Expiration 1/27/2009 Trlt 127888 Type Pri4ate Corporation ESSEX RESTORATION/DEVEREAUX ENTERP. ENT WALTER BEEBE CER 325 NEW BOSTON STREET 44 Q{,wGLeo...` WOBURN, MA 01801 Administrator License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Ran 1301 Boston, Me. 02108 Not valid without signature. sand[..dards-- Acense, 7 Tr# 8750 __. imimioner 00 - 35,000 cf enclosed space IA - Masonry only 1G - 11 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. a Application /for Permit to: i�l�r'tr UCQ�Jtii`h� Location Peet Granted l) d 01