8 HIGH ST - BUILDING INSPECTION - I`�"D��LE --
,�: I . ��O�
PUBLIC PROPERTY
\\ ��� DEPART'v1ENT
AI?LLfERLEY DRISCULL
�IAYOR 1�WASHINGTnN S'I7tE6T��
�i.tN.�t,�iSncH�St�'rs 01970
. 'I�i.:978-7J5-9595 �Fnx;97&740-9846
APPLICATION FOR THE REPAIR RENOVATION CONS�RUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION � �� ' �
Location Name: Buiidfng:
Property Address: C, �I �� C/ C��A^ A^ ^ �/ a '�D
Z� J c> J" 1 .�V l�'/' 1
Property i� located in a; Conservatlon Area Y/N Historic District Y �_
2.0 OWNERSHIP INFORMATION
2.� Owner oi Land `
Name: J p f�f j�f, G�
• Address: �O 5.�11 �1V � S� u.�I�v�J�t"J ; Mi/ 0 i I 2 j
Telephone: q� -- ] 7 — 3Z
3.0 COMPLETE THIS SECTION FOR WORK IN FYicT�Nr gUILDINGS OPILY
Addition Existing 3
Renovation Number of Stories Renovated
Changein Use New
Demolition Existing
7v�
Approximate year of Area per floor (s� Renovated �D�
construction or renovation
of existing building New
BriPf Description of Proposed Work:
�rl�[ rinPCt� �(��/�'S �"/� � /l t' /1/)QLCr�r[��.,'
�O ••'Y /"' �7� Lf�GI" S� CBa� �LP A/
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. ._ _._— __'_____._ _____'__ —_
. ...__ _ __ . _ . .. _" ' _. . _.._ - :. . _
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Mail Permit to: o vt R �eLZ. 0 ✓',� �� /�/, �j Z 3 --
What is the current use of the Bu'Iding?
3 -�a� ►° I� I�e�c�e� �9 � • o
Material of Building? ' if dwelling, how many units? � �
Wi�l the Building Conform to Law?
a,�bestag? Revv�n�v'e�l S i d i�
ArchitecYs Name
Address and Phone � �
Mechanic's Name i r � \o � ,( ,
�ti f �� e,.vrfiv ���iC/
Address and Phone � �
ConsWction Supervisors License# b i t��Z`r HIC Registration#
Estimated Cost of Project$ 2 • �8 Pertnit Fee Calculatlon
Permit Fee $ � ��� EsUmated Cost X$7l$1000 Reside�tial
rL ?� EsUmated Cost X$11l$1000 Commercial
X�'a� b ! M Addftional $5.00 fs added as an
�.yi
r � Administrative charge.
a-
��5
Make sure that all felds are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permk to build to the above stated
specifications. Signed under penalty of peryury '`�`
Date �� a�
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� Massachusetts Department of Environmental Protection
� eDEP Transaction Copy
Here is the file you requested for your records.
To retain a copy of this file you must save and/or print.
I
Username: ,1CAPECE
Transaction ID: �sas5
DoCUment: BWP -Asbestos Notification Form
Size of File: �zs.a52 K I
' Status of Transaction: suennirTeo
Date and Time Created: �/�alzoos::1129:56 am
Note: This file only includes forms that were part of your
transaction as of the date and time indicated above. If you need
a more current copy of your transaction, return to eDEP and
select to "Download a Copy" from the Current Submittals page.
. :
Commonwealth of Massachusetts ■
� '^� 100035807
'` Asb�;stos Notification Form ANF-001 DecalNumber
,;
'"'P°"a"`: A. Asbestos Abatement Description
When flling out
forms on the 1. a. Is this facilit fee exem t-cit town, district, munici al housin authorit owner-occu ied
computer,use Y P Y� P 9 Y' P
only the tab key residence of four units or less? (�Yes �✓ No
to move your
cursor-do not b. Provide blanket decal number if applicable: ' eianke�oecai N�mber
use the retum
key. 2. Facility Location:
� INVESTMENT PROPERTY 8 HIGH ST.
- a.Name of Facilit�r b.Street Address
SALEM �� MA 01970 9783358226
� � c.CitylTown d.State e.Zip Code f.Telephone Number I
WSTRUCTIONS 3. Worksite Location: �
1.All sections of this � N�A � - � �------� �__��_� �_� �__:_���� ���
form must be a.Building4:amelBuilding Location b.Building# c.Wing . d. Floor e. Room .� _,
completed in order � -
to comply with 4. Is the facility occupied? �✓ Yes ❑ No . � .
�EPnotifcation '- -�
requirements of 310 -
cMR z�s 5. Asbestos Contractor.
and the oivision DEMOLITIONS INHOUSE OR_HOMEOWNERS NON LICENSED CONTRACTOR FOR SHINGL
� o!Occupational
Safery(DOS) � a.Name b.Address� �,
notifcation NON LICENSED REMOVAL 02108 � 6172925500 � �
requiremenls of 453
CMR 6.12 c.Cit /Town � d.Zi Code e.Telephone Number
AC000000
f. DOS License Number g. Contract Type: ❑Written ❑Verbal
h.Facili Contact Person i.Conlact Person's Title
NON LICENSED REMOVAL NON LICENSED AS000000
6' a.Name of On-Site Su ervisor/Foreman b.Su ervisor/Foreman DOS Certification Number
N/A �
�' a. Name ot Pro'ect Monitor b.Pro ecl Monitor DOS Cerlification Number
N/A
8' a. Nafrte of Asbestos Anal ical Lab b.Asbeslos Anal ical Lab DOS Certification Number
� 7/30/20�5 8/6/2006 .
� 9' a.Pro'ect Start Date mmlddl b.E nd Date mml ddl
o SAM-SPM 8AM-SPM �
c.Work hours Mon-Fri. �d.Work hours Sat-Sun.
N
0 10. a. What type of project is this?
� ❑ Demolition Q Renovation
❑ Repair ❑ Other, please specify: b.oescr�be
11. a. Check abatement procedures:
� ❑ Glove bag ❑ Encapsulation
o ❑ Enclosure ❑ Disposal only
LL ❑ Cleanup �❑ Other, speciTy: PER POLICY
❑ Full containment b.oescribe
z
Q 12. Is the job being conducted: ❑ Indoors? ❑✓ Outdoors?
� anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3 �
i
:
Commonwealth of Massachusetts ■
100035807 �
�` Asbestos Notification Form ANF-001 DecalNumber
, ,,;
_
�
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
enca sulated:
0 1500 ��
a.Total pipes or ducts linear EToi-a ol—f iF�er su�i aces-(square r
c. Boiler,breaching,ducl,tank � � d.Insulaling cement � (��
surtace coatings Lin.ft. Sq.k. Lin.ft. Sq.ft.
e.Corrugated or layered paper � C� f.Trowel/Sprayer coatings � �
pipe insulalion Lin.k. Sq.ft. rLin.k. Sq.ft.
g.Spray-on fireproofng Lin.� SQ.f� h.Transite board,wall board Lin.L tt� �
i.Cloths,woven fabrics � � � �ther,please specify: L� 150��
Lin.R. S .ft. Lin.ft. S .k.
k.Thermal,solid core pipe � �� CEMENT SHING.
insulation Lin.k. Sq.ft. �.Specify . . .
14. Describe the decontamination system(s)to be used:
PER POLICY
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14�2) �9):
PER POLICY
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a.Name of DEP O�cial b.Title
c. Date mm/dd/ )of Authonzation d.DEP Waiver#
e.Name of DOS Official t.DOS O icial Title �
��
g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver#
N
0 17. Do preva:ling wage rates as per M.G.L. c. 149, §26, 27 or 27A—F a}�ply to this project? �Yes[�✓ No
� B. Facility Description
N
0 1. Current or prior use of facility: RENTAL PROPERTY
0
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes ❑✓ No
JOHN CAPECE 30 SPRING ST. �
� 3' a.FacilitV Owner Name b.Address
� DANVERS 01923 978-777-3298
o c.Cit /Town d.Zi Code e.Tele hone Number area code and extension
LL 4.
a.Name of Facilib�Owner s Oo-Site Manager b.On-Site Mana er Address
2 ��
Q c.City/Tovm d.Zip Code e.Telephone Number(area code and extension)
� anf001ap.doc•10/02 Asbestos Notification Form•Page 2 of 3 �
1
Commonwealth of Massachusetts
� -��- � 100035807
'�� . Asbestos Notification Form ANF-001 DecalNumber
B. Facility Description (cont.)
5' a.Name of General Contredor � b.Address
�
c.Cit /Town d.Zi Code e.Tele hone Number area code and extension
� f.Contractor's Worker's Comp.Insurer g.Polic�Numbe� h.Ex�p. Date(mm/dd/YYYY
t
6. What is the size of this facility? a.square Feet b.Number of Floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site (if necessary):
� . Note:Transfer a. Name of Trans orter �-� b.Address .
Stations must �
comply with the c.City/Town d.Zip Code e.Telephone Number
Solid Waste - �
oi��s�o� 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
Regulations 310
cMR ts.000 TBD JOHN �
a.Name of Trans orter r b.Address
� L�
c.Cit /Town d.Zi Code e.Tele hone Number
3.
a.Refuse Transter Station and Owner b.Address
� }
c.Cit /Town d.Zi Code e.Tele hone Number
4. WASTE SYSTEMS INCORPORATED
a.Final Dis osal Site Location Name b.Final Dis osal Site Location Owners Name �
90 ROCHESTER NECK ROCHESTER
N H nal Dis osal Site Address ��� d.Cit lfown
__�
e.State f.Zip Code g.Telephone Number
M
0
� D. Certifi�ation
N
The undersigned hereby states, under the JOHN CAPEC� JOHN CAPECE �
� penalties of perjury,that he/she has read the a.Name b.nuthorized Si� nature
o Commonwealth of Massachusetts regulations pROPERTY OWNER 07/14/2006
for the Removal, Containment or c.Position/Title d.Date mm/dd/
� Encapsulation of Asbestos,453 CMR 6.00 and 9787��3298 ��
310 CMR 7.15, and that the information
COntained in this notifiCation is true and CorreCt e.Tele hone Number f.Re resentin
� to the best of his/her knowledge and belief. 30 SPRING ST.
o Address
LL DANVERS 01923
h.City/Town i.Zip Code
Z
Q
� anf001ap.doc•10/02 Asbeslos Notification Form•Page 3 of 3 �
CITY OF SAL.EM
� PUBLIC PROPERTY
�� � �
� �.�-'� DEPARTMENT
KI1LL4tRLEY DRiSCOLL -
MAYOA - �?p WtiHINGTON$'IREE7'� $AI�.M,.�1.��ACHCSEI"[S 07970
� �i 978-745-9595� Fnx:97&740-9&F6
Constructioa Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,
780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the dcbris resulting from
this work shall be disposed of in a properlY licensed wast°disposal facility as defined by MGL c
1 11,S i50A.
The debris wiU be transported by:
I��v�-f/j S/�Q C4t� / 1 �l`�
��o:naui��) —�—
The debris will be disposed of in : I
���oi'�t •-/. /�i--�it�/
— (n:une of fx.ilitY)
� nC � P7�/' / IA�,
- (�Sdress of fa�ility)
����/ ��
signatuce of pamut applicant
� - l6- 0,6
dau
.�
Jeh�isal7��
� CITY OF SALEM
-,`� ' PUBLIC PROPRERTY
DEPARTMENT
�KIMBEItLEY DRISCOLL
MAYOR 120 WASFIRVGTON$TREET 1$ALEM,MASSACHUSETI'S 01970
� Tei:978-7459595 �Fnx:978-740.9846
Workers' Compensation Insurance AfYidavit: Builders/Contractors/Electricians/Plumbers ...
A licant Information Please Print Le ibl
N3CRC (Business/Organization/Individual): � � `-'V
Address: J� ����"�l �7' �
City/State7Zip:(19 vl�5 � ���2� Phone #: ��$— Z��J J z 6�
Are you an employer?Check the appropriate box: Type of project(required):
1.� I am a employer with 4. ❑ I am a general contractor and I 6. ❑New constructio¢
employees(full and/or part-time).' have hired the sub-contractors
2.� I am a sole proprietor or partner-
listed on the attached sheet. 2 �• �Remodeling
ship and have no employees These sub-contracrors have 8. Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Elec�ical repairs or additions
required.] officers have exercised their
3.� I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repa'us or additions
mysel£ [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infortnation.
r Homeowners who submit t6is affidavit indicating they are doing all work and[hen hire outside conhacWro must submit a new afTidavit indicating such.
�Contractors that check this box must attached an additional sheet showing the name of the sub-contracrors and Ihe'v workers'wmp.policy infotma6on.
I am an emplayer that is providing workers'compensation insurance far my employees. Be[ow is the policy and job site
informniion. .
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: Ciry/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiraHon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a
fine up to$I,500.00 and/or one-year unprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violaror. Be advised that a copy of this statement may be forwazded ro the Office of
Investigations of the DIA for insurance covenge verification. �I
I da hereby certify under thepains and pettalties ofperjury that the information provided ubove is true and correcf.
Si nature: �Q Date: '— �
Phone#• I�l/ / �� l U
' Ojficial use on/y. Do not write in this area, to be completed by city or town o�ciaL
City or Town: Permit/License#
Issuing Authority(circle one): �
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector '
6.Other I
Contact Person: Phone#: II
�
Information and Instructions � �
Massachusetts General Laws chapter 152 requues all employers to provide workers' compensation for their employees.
Pwsuant to this statute, an empJoyee is defined as"...every person in the service of another under any cona�act of hire,
express or implied, oral or written."
M 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 representarives 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 apaztrnents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repau 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 t6e 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 with the insurance
requirements of this chapter have ti`een 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 Partrierships(LLP)with no employees other than the
members or partners,aze 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 Deparunent of Industrial
Accidents for confumation 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 regazding the law or if you aze 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 Ofticials
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 O�ce of Investigations has to contact you regazding the applicant.
Please be sure to fill in the permidlicense number which will be used as a reference number. In addirion,an applicant
that must submit multiple permidlicense applications in any given yeaz,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locaaons in (city or
town):'A copy of the affidavit that has been officially stamped or mazked by the city or town may be Drovided 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. a dog license or pemut to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
plzase do not hesitate to give us a call.
The Department's address,telephone and fax number:
_
The Commonwealth of Massachusetts
Department of Indushial Accidents
Oftice of Investlgallons
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-OS Fax# 617-727-7749
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