22 HAWTHORNE BLVD - BPA-2009-271 7
PLT
PROPFRTY
D[71)ARTNIEN 1
„M M1
APPLICATION FOR PLAN EXAMINATION AND BUILDING PERNIrr
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS l
IMPORTANT:Applicants must complete all items on this page
SITE INFORMATION
Location Name GO/YET -FUlYFe44 Waj ((,Building .,...
Property Address 7 HOtJ MQR✓F r� 't-
Map#
Located in: Conservation Area Y!N Historic district YiN
w
Use Groups
(check one)
Residential(3 or more Units) R2_
Type of improvement Residential(hotel/motel RI _
(check one) Assembly (churches) AI _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants, recreation) A3_
Alteration Business B
Repair/Replacement Educational E_
Demolition_ Factory(moderate hazard) Ft _
Move/Relocate Factory(low hazard) F2_
Foundation Only— High Hazard It_
Accessory Building Institutional (residential care) 11 _
Other(describe) Institutional(incapacitated) 12
`eft Institutional(restrained) 13
Mercantile .N_
Storage(moderate hazard) S I _
Storage(low hazard) S2_ -
OW NERSBIP INFORMATION(Please type or Print Clearly)
OWNER Name >OVID �O✓V�T
Address 2 7- l-041vT-Id 01Q/YF ,Rztl
Telephone �78 L /CS
BES(:.RIP'1 H)N OF WORK'1'0 BE PERFORIIIED
ES'I'INIA'rED CONSTRUCTION COST _-_8000
GN'(( wf-bEn/ 2�Ian 7
a,
a.
CONTRACTOR INFORMATION
Name H,4+P/u1? 2Y5K
Address LOS l�s>
Telephone 9'T8- �36-6 87Q
Construction Supervisor's Lic # O 91705�
Home Improvement Contractor# 1221,39
ARCHITECT/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is trite to the best
of my knowledge under the penalties of perjury
1.4
Signed /t/6Gc t2
Date Of—.24-08
j.:'
CITY OF SALEM
y PUBLIC PROPRERTY
DEPARTMENT
+as v
I
I I I V'S.•4;. ;•,; I �\ 'i'.t '�_ :;JIB
construction Debris Disposal Allidavit
(rayuired litr all demolition :Ind renovation \work)
III accordance \\ith the sixth edition of the State Building Code, 780 CNR section I 1 1.5
Dallis, and the provisions of AGL c 40, S 54;
Building Permit rt is issugd with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by VIGL c
111, S 150A.
The debris will be transported by:
2tK uni, au:lyc �
1 name of huller)
The debris will be disposed of in
(name ut laultly
��Cl
I;u w.a. urtn Jncl
acnatwa •d p:nun .tpplie ant
19 P-;2 6/--to 8
•lal(
CITY OF SALEM
PUBLIC PROPRERTY
'?` DEPARTMENT
,1\1111 K:I Y:)Nli('.I n 1
12C WASHINt:IJ-N SIICLLI' • S.\i L'\4,M,\\9.\(:I It il.'I'Ii 0197�
Tc1.:978-7459595 • 1'.\x. 978-74C-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/El Pease ricians nt Lebers
Applicant Information
VAITC IBuciuesi/0r;;anir:uinNlndry uluaU: ? YsK GodYStt�u �T/v /►�
Addl-(:is: JS 10
City,State,Zip: To?-*�SFlELh 11124' Df`7�3 ('honer': 79
Are aurn employer:' Check the appropriate box:
'Type of project(required):
4. ❑ I am a general contractor and 1 6. ❑ New construction
1.❑ I am n employer with
have hired the sub-contractors ❑ Remodeling
employees(fulluntor r partner-me) � listed on the anached sheet. 7.
?. 1 ant u sole proprietor to partner-
ship:unl have no employees These sub-contractors have 8. ❑ Demolition
workers' comp. insurance. 9. ❑ Building addition
working firs me in any capacity. 5. ❑ we arc a corporation and its
required.]
workers' comp. insurance officers have exercised their 10.❑ Electrical repairs or additions
regaircJ.] 1 I. plumbin+ repairs or additions
3.❑ I um a homeowner doing all work right of exemption per MGL ❑ b "-p.
c. 152, i 1(4),and we have no 12.❑ Rucef repairs n
myself. iNo air d.] comp. cinployces. iNo workers' l
insurance required.] 13.� Other 6 te�
corny. insurance requirctij
-Any:�,phcant tint chucks box net must alms f ill out the suction 1 i luw showing their workers'cumpuns:aion pull y information.
' I tomeuwncn who husk l this netisi muvil indicating they are doing ell work and then his outside contnxtom must autm+il a new:ardavit indiunng ouch.
( tt that ik this box tutus anxhtd an additimal,heel h w"tg the name of the sub-contrxtors and their worken'comp.policy infurmadon.
I n)n nn employer that ix pro vidinr workers'c'w»pen athe"ills"rancefor nsy eenp/o)ees. Below is the policy and lob xete
infonnutiotn
Insurance Company Name: ---.... .. .-_
Expiration Date:
I'nlicv is or Self-ins. Lic. ts: ... .._
Job tiitc -\(Idress:�t a
ef(yr}i,[LCAOIQI)'tr= t5L1 City-StateiZip: S19L-t1Y O/'Q7�
attach it copy of the workers' cumpcn.sation policy' declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Suction 25A of>IUL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51,500.00 and/or one-year intp: onincret, us well as civil penalties in the furor of a STOP WORK ORDER and a fine
of up no 5250.00 a daY against the violator. Ile advised that a copy of this slutement may be forwarded to the Office of
Incan,aunns ol'thc DIA for insurance covcraye \crific,tuon.
I do hereby corrifv nm4'r else pains and penolncx of perjury that the tnfurinution provided above is true and correct.
Gus_ )arc. O.9-2i1-O
;i-r:ruu ro: .... . --
Ph+n:e;:: 9Y P e?3 6'?
O[Jiciul else only. Do nor ivrire is this area, to be completed by city or town official.
City or fown:
Permit/License d._ . _.
Issuing;Authority (circle one):
I. Board of Health2. Iluifdin;; Department .i. Cil)•%I'own Clerk 4. Electrical inspector 5, plumbing Inspector
6.Other
Phone th
Contact Person;
Information and Instructions "r
:Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursu:umt to this statute,an empfuree is defined as"...every person in the service of another under any contract of hire,
compress or implied, oral or written."
An emp/aper is defined as"an individual, partnership,association, corporation or other legal entity,or any two or more
of the t-tregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of m 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 riot because of such employment be deemed to be an employer."
NIGL 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, NIGL chapter I52, S25C(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 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 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
.-Nccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be renmmnd 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 tire number listed below. Self-insured companies should enter their -
self-insurance license number on the appropriate line.
City or Town Ofncials
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.
Pl.ase be-sure to till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/licensc applications in any given year,need only submit one affidavit indicating current
policy information(ifnecessary) 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 burn leaves etc.)said person is NOT required to complete this affidavit.
I he r)i)icc of Investigations would like to thank you in advance for your cooperation and should you have:my questions,
please du 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 Invesdgations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
10-05 Fax # 617-727-7749
www.mass.gov/dia