6C HALSEY WAY - BUILDING INSPECTION (2) 1
What is the current use of the Building?
Material a Buiildirg? if dwelling.how many units?
Asbestos?
Wit am Building Conform to Law?
W
Architect's Name ( '
Address and Phone
Mechanles Name
Address and Phone S. O� ���HIC Registration N
Construction Supsrvaats�^��
Estimated Cost a Project i
' iG� Pon*Fee Calculation
Permit Fee i Estimated Cost X$71S1WO Residential
�� -1=Y�-
Estimated Cost X S11/011000 Comrmercial -- ..-- -
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
I
specifications. Signed under penally of perjury
Date
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PUBLIC PROPERTY
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APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION,
DEMOLITION,OR CHANGE OF USE OR OCCITp NMv FOR ANY EXISTINCs
STRUCTURE OR BUILDING
1.0 SITE INFORMATION I.
Location Name: 9uikting:
opt
Pi ops ly Is located
In a:Conservation Ares YM Hlstalc Dhaka YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name: P(^ �A r/v�
Addreae 4/`%
Telephone: 6 ,
3.0 COMPLETE THIS SECTION FOR WORK IN i'=IFM3 BUILDINGS ONLY
Addition 4(sf) Renovated
g
Renovation f f Number ofated
Change in Use
Demolition g
Approximate year of Area per flo
construction or renovation
of existing building New
9riet Description of Proposed Work:
-- —- ---Mail Permit to: �c�t6• d`7i� ��1
From: Robin Fairbanks At: WPM Insurance Agency FaxID To:Vladimir Prokupets T- ,..�- •�"•"+' 'J� Date:4/31?007 11:59 Afv1�.Paae',2 of 2
• � Y+ 0 .
_ �_ '('� sr a€9CA�G flF LIR�6L@T'y ENSt3�fifJC� DATE 14.VDDWIVY)
AGO�1,D �.+ "OPID R
\ PRODUCER y - y=., - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORiAAMN
�". t�'/ 'i ry: ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA r E
i:jm Insurance Agency, :nC. HOLDER. THIS CERTIFI=ATE DOES NOT AMEND,-E%TEhrn OR
327 Union Avenue - 1'` ,,t� ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. -
r Framingham 19n 01 702 . j t ° -- s' ♦ I '":
Phone:-508-872-0662 Fax :5y8-8Z9-5295 r.p'.SURERS AFFORDING COVERAGE NAIC'=
IPISURED r - lyn. Fenn-cT+mexica �I.nsurance CO.- I
. _ V & F Ccn:' r.actors,
12 ,1`aL6ln 'I,ane. ,qy
- I Newton 1I- 02459
COVERAGES - -- - _
T.1E=ULLIE;-.t'!.'I. 1 .__IiTEJE '/V FaYc I %•rD� r l!_1 !J.YS'VE ._7Qt,'YFGIgL'. 'JLr STF_ Nb71- rY_>•.rr
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?tn 2ECf IIFE':°p'T 7c3M•:"r'CJ!"=�°L,;PrF..=1IT CV vji _ _.f.J+_f.t Y+l ii F._Sr=�i� �M1',�-,.-.-1-.JEST F.i--=r.4/".-E'�5: i("
`• _et:_;f_IE° n,�.•.o:�_ L 9T:_ p:T,f =- � Illcv Y to .L,n � -
11F5F.ADGU ... .,+ :� .� . .,.I_... _ 1 CP ESFE:7IVE TPILf 6tPIR 1 'I?.l__..
LTRVIICSC_—_ TYPE 06IIISUR.LIICc j _Y POLICY IIUF.IBER D••='rE;MtiL•U,Wt 16ATE 041.110 fi. I UNITS
>r rEgai LLslmr i Y- - '- ( . z, r c cx -h' 500000 ^
FAC6625535 ,j 11i 09/Oo` i i.1/U1/07 in i00000 r-
tecc W14-L A I i. 1000000
1000000 '
� 1' n1 -t r rR.I;.F � _. � �� L,.,�n _�....__ i_100G000��•_ -
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DESCRIPTIOJ Pr OPERATI_NS LOCATI NS 'EHIC_ES1 EkCLUSIDHS=0DE0 BY Ef1DORSEMENT 1 SFEr1=L PRCNIS1011S y
CITY OF SALEM
4,D PUBLIC PROPRERTY
DEPARTMENT
I2C W.%.it uu::JN$MUT 0 SAU%1. *I-I S:.9/C
T¢r:vn745-95es •F-%X:9M?4G99K
Construction Debris Disposat affidavit
(required for all demolition aml renovation work)
in accordance with the sixth edition of the State Building Code, 780 CNIR section 111.3
Debris,and the provisions of M. GL c 40, S 54;
Building Permit 0 _ 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 .1GL c
111. s 150A.
The debris will be transported
��by:
®® �
�e7�� 2SlI Lit-L_
— — (name of hauler)
rho debris will be disposed of in
t ame of&illty))
�dd�cxe of t�ciLly) /A'
��� aw —
CITY OF SALEM
PUBLIC PROPRERTY
�~+a_ DEPARTMENT
ltstnratXy uatst:uu
M.tvtat l=WA%'HlxGfox STRM_T a SALEM,MASSACiftll:'t'l%0I=
Th 978-743.9595 •FAX:979-740a9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Agolicant Information Please Print Le ibl
Name tBucinculOrganizatiorVlndivtdual):
Address: IJ/ A—
City/Stare/Zip: /�� Phone lk
Arc you an employer?Check the appropriate box: 'type of project(required):
1.❑ 1 anta employer with 4. ❑ 1 am a general coutraetor and 1 6. Q New construction
,,}}{{ employees(full and/or part-time).• have hired the sub-contractors
2.lY1 I am a sole proprietor or partner- listed on the attached sheet. t 7. ® Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. Q Building addition
f No workers'comp. insurance S. ❑ We are a corporation and its
required.] officers have exercised their 10.El Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12,Q Roof repairs
insurance required.] t employees. [No workers'
13.❑ Other
comp. insurance required.]
-Any applicant tIW cheeks box al most afro HIS out the unction below awwing their workui cumponaaiun policy iofurmtaiun
' t twnojw;v;M who submit This affidavit indiruing they are doing all vatle and then him outside canrntetoes must aultmtl a new affidavit inaictting such.
ZC'untincturs that chock this box must attached an additional sheet showing thin name of Cho indi eomraeCoes and their wurkata'comp.policy information.
fain on employer that Is providing workers'compensadon Insurance fur Sty empluyees. Below is the policy and fob site
information.
Imurance Company Name: /..`._.>0.j..__ 51..
Policy#ur Snlf ins. Lie./#: P 1,(��+e— I/'V / r� /._ Expiration Date:�f r�f
Job Site,Address: 1,/7l r/7 /�c� v/% I�w y City/State/Zip: al/
Attach a copy of the workers'compensation policy des aration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
nne 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 S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the 011ice of
Iavcangatiuns of dtu DIA for insurance cm crage verification.
l da hereby certify under the pains{and penis ins of pery/u//ryry that the information provided above is true and correct
Si.•:tatuure: ..//s �4' �7 Datc'
Male d3 Z3
UJrcial use only. Do not write in Mir area,to be completed by city or town oJ]h-Ad
City or Town: Permit/License
Issuing Auhhurily(circle one):
1. Iloard of Ilculth 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: ..- _ _ _ ___ Phone AS:
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 uustce of as 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 shad not because of such employment be deemed to be an employer."
MGL chapter 152. §25C(6)also states thut"every state or local licensing agency shad 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 w ith 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-contractors)name(s),addresses)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
he 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 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 permitilicense 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 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 tilled 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 bum leaves etc.)said person is NOT required to complete this affidavit.
1'hc Oi fix 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
Of lee of Investiptlons
600 Washington Street
Boston, MA 02111
Tel, # 617-727-49M ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
BOARD OF BUD�t'4 REGULATtON6
p License: CONSTRUCTION SUPERVISOR
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�i Numhei CS+ 0768M ,
j Birtfgl -0:1/19/953 �'..
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r 4/49/2008 Tr.no: 13014 "
12 MARVIN LANE.
.NEWTON, MA 0245 Commissloner
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