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113 GRAND TURK - BUILDING INSPECTION crl.,y (.)I, S U_1-"",vf RTY PUBLTC JDROPI DEPAR T.N I ENT dlnvuiz W.%.i I M; Syria T APPLICATION FOR PLAN EXAMINATION AND BUILDING PIERNIFF LL STRUCTURES EXCEPT I AND 2 FAMILY D WE IMPORTANT:A licants must complete all items on this page SITE INFORMATION Location Name .5"i� &(MBuilding_WV0_,e Property Address- /$5 ai&" "D Map Located in: Conservation Area Y/N Historic district YiN Use Groups (check one) Residential(3 or more knits) R2 Type of improvement Residential(hotel/motel RI (check one) Assembly(churches) Al New Building Assembly(nightclubs etc) A2_ Addition Assembly(restaurants, icvrcaLiun) A3_ Alteration Business B Repair/Replacement Educational E Demolition Factory(moderate hazard) FI — Move/Relocate Factory (low hazard) F2— Foundation Only High Hazard If— Accessory Building Institutional (residential care) 11 — Other(describe) Institutional (incapacitated) 12 Institutional (restrained) 13 Mercantile M Storage(moderate hazard) Sl Storage(low hazard) S2 OWNERSIIIP INFORNIA HON(Please type or Print Clearly) OWNER Name 5r Address�TMal,61i&v&Atl 11101faf-Al /014k Telephone 0 W X Q DOCRIPI-IONCIFNVORK-10 El-ll:RFORNIEI) UQTJ�5;t�'W/ ,x all,�V& 511i l7 30 eA-? ESTIMATED CONSTRUCTION COST 4 CONTRACTOR INFORMATION Name Address C ,, , O �D Telephone ,f Construction Supervisor's Lic # G507[7 ' Home Improvement Contractor# //3t/58 ARCHITECT/ENGINEER INFORMATION Name Address Telephone Mass. Registration # PERMIT FEE CALCULATION Residential est. cost x $7/$1,000 + $5.00 Commercial est. cost x $I1/$1,000 + $5.00= COMMENTS The undersigned does hereby attest that all information stated above is true to the best of my knowledge under the penalties of perjury Signe Date CITY OF SALEM PUBLIC PROPRERTY ,t_ DEPARTMENT S,.VIW i:ifltaft isa ��„ �Lv 1 aK I': AA.v,I IINa,f,1\ S t Ill I-I • S V i �,. ALU.�� ❑ •I-I i, I`t'J l l-I: 9'g-J.l;.LJ; • 1'\5i 0"8-'i:-'JSin NNorkers' Compensation Insurance :Nftida-,it: Builders/Contractors/Electricians/Plumbers t th\ant Information Plcase Print Leeib ,plV `;Illy tnu:mc,; t h'LL:uu rttum InJn:Ju:J is lJ��'L/v�f4'i� I City,St:Its/Zip: i ,o i ©�78� Phone .\re s o an employer:' Check the appropriate box: -type of project (required): `� J. ❑ 1 am a general contractor and I 6. New construction I. I :un a employer with ❑ cnymloyees(full andlor part-time).` have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling ❑ I ant a sole proprietor o partner- g_ ❑ Demolition ;hip and have no employees These sub-contractors have working for me in any capacity. workers' comp. insurance. y ❑ Building addition ]No workers' comp. insurance 5. El We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their right ght of exemption per bIGL 11.0 Plumbing repairs or additions },El I ❑m a homeowner doing all work 1(4), and we have no myself [Nu workers' comp. c. 152, § 11.❑✓Ruuf repairs insurance required.] t employees. (No workers 13.0 Other comp. insurance required.) •,\ray,ipplicunt,hat checks bun#1 must also till out the section below showing their workers'compensation policy information. t I Iumeowners who submit this affidavit indicating they are doing all work uud then hire outside contractors must submit a new affidavit indicating such. :C'ontractnrs that check this bon must.attached an additional sheet showing the name of the sub-contractors and their workers'comp policy information. /am an employer that is providing workers'compert.sation insurance jar my,employees. Below is the policy and jab site infarnation. C Insurance Company dame: /' ws //� !y Policy # or Self-ins. Lic. #: �OgamD©l�oe� Expiration Date: 0 D fob Site Address: ��G� G�/g(l(/�1¢ City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of v1GL c. 152 can lead to the imposition of criminal penalties of a tine up In S 1.500.00 and'or one-year imprisonment, as well as civil penalties in the timrm of a STOP WORK ORDER and a tine oI up Io S250 00 a day against the violator. fie advised that a copy of this statement may be forwarded to the Office of Incc,l i_,uions of the DIA ti)r insurance co%cntge wcrification. /du hereby certif' under the pains una!penal 'his of nrrjury that the injirrnation provided above is true and correct. iicnanlre: Date: hoIIc = (official use unit'. Do not lorite in this area, at he completed by city or town ofyiciatt City or Town: _____-- ----—-- ------ Permit/License Issuing .\uthority (circle one): 1. Board of Health 2. Building Department 3. City/l*own Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other —-- -- Contact Person:_---- -- ---- _-- Phone #:__ Information and Instructions N I ase us OCaeral I_a\cs chapter 1 5' icgwres all cmp Io\ers to pro\ide workers' compen.ration for their employees. I'ursu.uu to this ,tmutc, un empluh•ee is defined as ' c. cry person in the scry ice of:unrther wider any contract of hire, r y\ress or inhplied, oral or \\rotten.', \n eruphner is defined as 'im indi\idual, pannership, association, corporation or outer Icu-id entity. or any two or more of (IleGargoing engaged in a joint enterprise, and including the legal representati\cs of a deceased employer, or the iccci\cr or trustee of an individual, pcirtncrship. association or other legal entity, enhplo\in_ cniployces. flow'eccr the inv ncr of a dwelling house having no[ more than three apartments and who resides therein, or die occupant of the d\\clline house of another who emplo\s persons to do maintenance, construe ion or repair work on such dwelling house ot m the _rounds or huildin appurten:mt thereto shall no( because of Such enhplo\ment be decried to be an employer \I(if.. chapter I�'_, 2506) also sates that "caery state or local licensing agencv shall withhold the issuance or I enewal of a license or permit to operate a business or to construct buildings in the commonwealth for anv applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, \I(iL chapter 152, 25C(7) states "Nei titer the comuiomvca I th nor any of its political subdivisions shall enter into any contract for the performance of public \work until acceptable evidence of compliance with tlhe insurance req ui repents of'this chapter ha%e 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 cer ificate(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 tlhe affidavit for you to fill out in tlhe event the Office of Investigations has to contact you regarding the applicant. please be sure to fill in the permiulicense number which will be used its 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 hone owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. it dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Oflice 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. fhe 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 I-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia ° CITY OF SALEM PUBLIC PROPRERTY (Azi);'74 I DEPARTMENT ,_ ):32ET 0 j.v. \f, 11.\\:.0 :r. . � : 1 t..�. .' Construction Debris Disposal Affidavit (required fur all demolition :uid renovation work) In accordance w ith 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 k _ _ is issued with the condition that the debris resulting from ;his work shall be disposed of in a properly Licensed waste disposal facility as defined by IVIGL c L 1, S 150A. The debris will be transported by:y�i, Inumc of haular) II;�i w ill be dis-posed� o�v�l"7 /'�f/(❑0C of I:iChlt' �