22 HARDY ST - BUILDING INSPECTION *., 11 PARTNIl:NT
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 F:1111LY D%VELLINGS
1,\I PORFANT: %pplicanis must complete all items on this page
SITE INFORMATION
Location Name 72 OAfDb ? CT Building
Properh, Address
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes 113_Kaet�� ..
Residential (3 or more Units) R2
Type of improvement Residential (hotel/motel) I21
(check one) Assembly (Theaters) Al _
New Building_ Assembly (restaurants 3t clubs) A2r_A2nc_
Addition Assembly (churches) Al _
Alteration \' Business B
Repair/ Replacement,� Educational E_
Demolition _ Factory (moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile M _
Storage SI _Modcrulc Ilasrd
Storage S2 _Low I laz:rd
t)(s'NI.RS1111' INFORMATION(Please type or Print Clearly)
OWNER Name ' P C1 ` rt
Address tAAQhN�,e CT
Telephone 1--)CD 1Z,
Signature •Ry-' �,r�+f
DI:SCRIP'I ION OF %%ORK TO HE PERFORMED - 1 •o�
I-iSI'INI;%I ED CONS'FIIUC'I'ION COST
S� to
Name
Address
Telephone
Construction Supervisor's Lic #
Home Improvement Contractor #
.\ItClll'I'FC'1'/ENGINEER INFORMATION
Name
Address
Telephone
Muss. Registration #
PERMIT FEE CALCULA'rION
Estimated Cost x $1 U$1,goo + $5.00=4 L0t
CONINIIiNTS
The undersigned applicant does hereby attest that all information stater/above is trite to the best of my knowledge
under the penalties of perjury
Signer! (owner) (agent)
APPROVED BY :
DATE APPROVGD: . � -
n. � li�drfl BTR"(��i ti�,a und'SEii�iiar t
- HOME IMPROVEMENT.GONTRACTOR-
Registration: 14472 -.
- Expltation: t 111/2010 Tri1 277360
itype: Pnvab9Cotpotetion,
Z S-CORPORATION- - -"
JEFFREY FERNANDES,. -
225 FOST€R SP'
LIT7LETQN,Mft-09db'@`-'i admiuis(IOCa: '.
✓te'�o?nmamsui�¢� �.J/�{aaoa.�tu6v!L3 ',
Board of Building Regulatioans and Standards
Construction Supervisor License
s,,.. Ugo&p: CS 89300
BirtF"tp',-1_1/13/1970
Trp 6614
' �ioo: 1•G:'
r-. E
JE>=fREY M FERNP1 P'
225 FOSTER ST
LITTLETON.MA 01460 Conunissioner ;i
CITY OF SALEM
Y
r x PUBLIC PROPRERTY
1 DEPARTMENT
4H l!�"
•I l.. q;
III' '/"V-'Ji.7i;IG y: 1),S-'4:-'1.i Jig
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 7S0 C'MR section 11 1.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
ct
(name othauler)
The debris will be disposed ofin
(name ui laolity)
(address A I'acilitv)
+iguamrc of permit applicant
late
CITY OF SALEM
PUBLIC PROPRERTY
,tea DEPARTMENT
'.:I\II::RLt iY:>N IitlU1.1.
�iA)OR I2GWASHINiiI'O.NSTK ELT •SALEM,M.tssAcan s1:'I'IsG197-�
'fl:U 978-745-9595 • fsx:978-740'/84G
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
-\imlicant Information -�-+ Please Print Legibly
N,IMC (nucincvs/OrBaniratiToNln�Jivlclufa�l): G� �d�� '1—� ��� a 1�IV�..�
Address: z7� 1�7I CyC
City/Stateizip: l j t-C Tyty t 401160 Phone ; : 7�� —�ZC) — OS- D Q"1
Arc you an employer? Check the appropriate box: 'Type of project(required):
LW I am a employer with_1 4. ❑ 1 am a general contractor and 1 G. ❑ New construction
employees(full und'or part-time)." have hired the soh-contractors
_.❑ I am a sole proprietor or partner-
listed on the attached sheet. t �• Remodeling
ship and have no employees - These sub-contractors have S. ❑ Demolition
working for me in any capacity. - workers' comp. insurance. 9. ❑ Building addition
iNo workers' comp. insurance 5. ❑ We are it corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 an,a homeowner doing all work right of exemption per MGL I I-❑ Plumbing repairs or additions
myself. INo workers' comp. c. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. LNo workers' 13.❑ Other
comp. insurance required.]
-.Any Igvplicant Ibut checks box in must also till out the wctiou Wow showing their wurk"s compensation policy infurm uion,
'l lumauwm;rs who submit this affidavit indicming they ate doing all work anal Then him outside contrnclom must submit a new affidavit indiwtins such.
-Comm tors that check this box numi atxhted an addition.[sheet howing the name of the subcontractors and Iheir workers'comp.policy information.
l gat an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: .. ---
Policy 4 or Self-ins. Lie. #: _...__._- Expiration Date/: � p� n
Job Site Address: Z-2 �y+-\�_fs� CityiStateiLip: "�-\L�; 'M'il ]���
Attach it 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`IGL 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 S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
I uscstigatinns ul'Lhe DIA for iniur:uxe coverage vcriticalion.
l do here err 'y and the p ins rd penalties of perjury that the iuforinadon provided above is tt1rue and correct.
Sicaatorc A Date I (Z\ GJcsi:
Ojjicial use only. Do not write in this area,to be completed by city or town ojJicial.
City or Town: _._. Permit/License#____
Issuing Aulhority(circle one):
I. Board of Health 2. Building Department 3.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
G. Other -_--- .-
Contact Person: _....... . .- _---_ Phone #:
Information and Instructions
,%Iassachusetts 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 tixegoing 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 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."
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, bIGL chapter 152, 625C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtance 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)name(s),address(es)and phone nunrber(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 cant' 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permidlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple penniu'Iicense 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. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he 011ice of Investigations would like to thank you in advance fur your cooperation and should you have ;my 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
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia