107 HIGHLAND AVE - BUILDING INSPECTION Application for Permit to:
Location
Permit Granted
3�J Z D �
A o ed
Inspector of Buildings
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
DRLSCOLL
JtAYOa
t20 WA*CNGMNSraM a Setrss,hiAUACHUSW 501970
T17:971.745.95" a FAX 9783740-9146
Workers' Compensation Insurance Affidavit: Bullders/Contnctorsmectriclans/plumben
Applicant Information Please Print Lesibty
Name(BusineWOrgannauoo/WMdusp: 5R s I�GI�d� j — (�y(/.r-�.L'� /' [e10�/I✓�iJ
Address: Ll /fk—d �r�r
City/state/zip: D/91'UZ43 CIA- e)Q 3 phone ii 4'178 79(5--V9Z6
Are yea an employer?Check the appropriate best _
1.❑ am a employer with 4. 0 I am a general contractor and I elm Project( :
�entployeee(tWtand/or paR-time).• ve hired the subconpaerorg 6 ❑New camaptsction
2. 1 am a soh proprietor ar partner ptistedon the attached sheet.t 7. 0(remodelingship and have no employees b compactors have 8. ❑Demolitionworking fen me in any capacity, s'comp,inananen•[No worker' comp.insurance 5. e a corporation and its 9' ❑Building additi�
retl�) offica s have exercised their 10.0 MOctr cal repairs or additions
3.0 I am a homeowner doing all work right of mromption per MGL 11.0 Plumbing mpW=cc addition
myself.[No workers'comp. c. 152,$1(4),and we have no 12,0 Roof repaira
insurance required]t employees.[No workers' 13.0 Other
comp.insurance required.]
tsVP�+at tba elweb bm al mW W"rfll art the section valor stmwing dwk waskae'
Homeaweae who submit dds snWse@ mdletlieg they em dotes a1 wak and dim Wes aedids aaatraeton mtrt athmh a eew anfdavtt
tCameeetan thg cheek W&box nog a edmd m ddWaul shag showing the toms or the subemtrae fts and thak wakes'O00VaUcy
R tel6amstlao.
f ear an employer that Is pro vhllna women'coaapensdNon lnjarstarlos L"'umms'for py ea yloyea. Below 6 the pocky and Job star
Insurance Company Name:
Policy#or Self-ins.Lie.# Expiration Date:
Job Site Address: Citylstaw7ip:
Attach a copy of the worken'compensation policy declaration pagt(Showingthe PoU<y number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the
Fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of�a STOP WOion of c WORK criminal
ER and aties ffine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations o the D for insurance coverage verification
l do hereby c Rehm and pena/Nat ojper/nry that&e injoramden rovided
P b true and correct
G
Phone#: Q/Q
O,()?eial use only Do not write in this dreg,to be completed by c4 or town o/Jlelat
City or Towp: Permlt(License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.ChYfrown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:
Phone#•
Information and Instructions
all employers to proviso workers' compensation for their employees'
Massacbuscra General Laws chapter 152 requirescontras of tines.
Pursuant to this statuteh an enpWee is defined as"...every person in the service of another under any
express or implie4 oral of written."
se"an individual,partnership.associstian.cotp�tios a other legal eased.a any two a mom
oAn f he fore p is defined and including the kgsl representatives of a deceased employes,a the
of the foregoing engaged in a joint enterprise. � ' employee. However the
receives or oaten of an individus4 partnership.aeaocaton err other legal entity.emp yma of the
and who red"therein.er the oavpant
owner of a dvaeiling bataa having net more than to do apaUDmainteoab nsiVA construe or repair wodk on snob dwelling house
dwelling house of anodw oppurtmsnt thereto shall��me of s����be�ed to be an employer."
or on the grounds or building
MGL chaper 132,$2SC(6)also states that"every ate"or local*=Sbng agsacY theses tbs butanes or
b operate a buainea or b costa-ad buildings In tba commoaweafth for arty
renewal of a kents or permit o er t e a evidence of eamptlaau with the Insurance coverage required'"
applicant wbe bas net produced "Neither the c PHasseealltb nor any
of its political subdivisions shall
Addidow an.MGL chapter e p $performance
states le evidence of compliance with the We rews
retinas for the perfurmanee of public waft until acceptable
rinto
egWsmanse of this chapter be"been presented to the contracting authority
Apptlesnb sit�jpp and if
Please fill out the tyorketa'coMpOusetion affidavit completely,by checlang the boxes that apply to Your
necessary,supply s)name(s), ea addre(ea)and Phone number(s)along with their eertifieate(a)of
insurance Limited Liability es(LLC)a Limited Liability PartaersbtPs(LLP)with no employs"Other
than
members of partnass,are not serf
uired to catrY workers'compeosstfou insurance. if an LLC or LLP does have
advised that this affidavit may be submitted to the Department of ladustlsl
employees'a policy is coverage Al"be stun b sign and date the atfidavlG The affidavit sh of
ould
for confirmation !leaden for the permit a license is being requested,not the Department
be returned to the city a town that the app the law m if you are required ro obtain a workeea'
Industisi i�Ote Should yet have any qua number 1�below. Self-maned compenm should enter their
compensation POHO,please Call the Dep rMent litat th
self-insurance license number on the
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 nest to fill out in the event the Office of investigations has to contact you regarding the applicant.
Please be sure to fill in the permitftcnse number which will be used as a reference number. In addition. is applicant
that must submit multiple permiHlncense applications in any given year,need only submit one affidavit indicating current
1 information(if necessary)and antes"Job Site Address"the applicant should write"an locations in_--(City or
policy or marked by the city a town may be provided to the
town)."A copy of the affidavit has been officially stamped permits or licensee. Anew afudrvit must be filled out each
applicant as proof that a valid affidavit is on file f r fisture a license permit not related to any business or commercial venture
year.Valera a home owner a citimn is obtaining is NOT required to complete this affidavit
(i.e. a dog license a permit to burn leaves etc.)said person
The Office of investigations would like to thank you in advances for your cooperation and shook!you have any questions.
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Comm vmdth of Massachusetts
Dqut nW of lnthis1nd Accltbmts
081a of lavatlptlons
600 WUWn&M Street
Boston,MA 02111
Tel. #617-727-4900 W 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mamgov/dia
i CITY OF S.UJ&M, UNSS.-LCHUSE=
BL'IIDING DEPART.%cDiT
120 WASHINGTON STREET,No FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DROLL
,NMAYOR THOMAS ST.PMRJM
DIRECTOR OF PUBLIC PROPERTY/BumniNG com%aSSIONER
APPLICATION FOR THE CONSTRUCTION;REPAII;REWWATnoK CHANGE IN USE OR
OCCUPANCY,OR DEMOLITION OF ANY BWLDINO OR STRUCTURE
This secdm.fbr 011k"Use Only
BuBding Irropsctor:: - �gre�%-.
_Estimate Project DaEes Start End:,
Comments:
1.0 SITE INFORtt1ATION
i Locatlon Name: k/aLi Wt7�5 Buif kw
Property Address:
07 UE
Assessors MaplBkxk LotlPatcet
Q11YNilloitlwl
INFORIt111nON
2.1 Owner of Lend
p
(�o = n; Aug � 0 9lv
losses of btd/d/rrs a s&uehwo
Telephone:
3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name: Pamim 001 0 i �rEIL
Address:
07 1� E3
Agency Project Number.
Project Manager Name: UC,116j Tet Z$-a6-
BOARD OF BUILDING REGULATIONS
t License CONSTRUCTION SUPERVISOR
Number.,CS 088095-
- Birthd 03115/f972
t `aEzpireei 03ft512008 Tr.no 88055
�fi t
Re9W ,ir00 7J
! STEVE J: KNIGHT"� j , +„•
61 HIGH ST. �'�. -r' y"✓ �/' /f ��
i tt DANVERS,YMA 019221J`5 commissioner k
��ie �iammio�uieall�i- o�..
Board oT Building Regulstions and Standards
lug HOME IMPROVEMENT CONTRACTOR
Registrati611149373 .
Expiration .V5I2008.
i' k^ T Type•:DBA
KNIGHT CARPENTRY
s F
STEVE KNIGHT,j� @;?'"
61 HIGH ST "'='-�"^- '- C%G==
DANVERS, MA 01923 Administrator
1
4.0 PROFESSIONAL DESIGN SERVICES:-
4.1 Registered Architects.
Name: Seal and S'ignahirb;-
Address:
Fanc
Tetsphmte:
4.2 Registered Protassbml Engineem Ns•ae d+asd r<gseaesary a+id aMach b apprratlay)
Name Seal and Signab '
Addmm.
Telephone:
Nam
Address.
Telephone: Fax
Area of Responsibility:
- — Name: Seal and Signature
Address:
Telephone: Fax:
Area of responsibility:
5.0 DESIGN AND CONSTRUCTION UTILIZINGfdGL C 112 SECTION 81R EXEMPTIONS
(See note below)
Contractor
Name:
Address: f ` 57b1
Area of responsibility: �?l/� /�IrUL�ff Cu/USsv9 /Z
'Ucense Number.'- ' S Date of Expiration.Telephone: o!S ` Fa)c
Contractor
Address:
Area of responsibility:
Ucense Number. Date of Expiration:
E
F�
Address:
Area of responsibility:
Ucense Number. Date of Expiration:
Telephone: Fax:
Note: For portions of work utilizing exemptions of MGL a. 112 s.81 R complete the sectlon above.
Use additional sheets if necessary and attach to application.
F
PROFESSIONAL CONSTRUCTION SERVICES 'General Contractor 5 , � 6 4�Ppu�ress: 601 �,�i I ' SAZ
o,� UE9s 10 04193
n
Q7U ��S �( 0Fax:
Charge of Construction:
7.0 CONSTRUCTION DOCUMENTS -to be prepared by appMeant
item' d as Applicable
7.1 Plans (Note 1 this page) Submitted Incomplete Not R uired
7.1.1 Architectural
7.1.2 Foundation
7.1.3 Structural
7.1.4 Fire Suppression
7.1.5 Fire Alarm
7.1.6 WAC
7.1.7 Electrical
7.2 Specifications f
7.3 Structural Peer Review
7.4 Structural Tests & Inspections
Program J
7.5 Fire Protection Narrative Report
7.6 Existing Building Survey
7.7 Workers Compensation Insurance
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note 1 Areas of Design or Construction for which Plans are not complete at the time of
this application must be identified herein. Work so identified must not be commenced until this
application has b n pp been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
9.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
For new construction cormalete sectla
Exist�g.
Addition
Renovation Number of Stories Renovated
Change in Use New A
Demolitiontin9
Approximate year of Area per floor(st) Renovated
construction or renovation ..
of exiling building New: :.
Brie[Description of Proposed Work
PCPW+QjibT�r� W�I�-(�5 0c-
� S� T
1
8.1 USE GROUP AND CONWRUCTION.CLASSIFICATION(Exlstinp Bupdtngs;OnW
Ri EXISTING PROPOSED Change CONSTRUCTtOt
USE GTroup(s{ In - CIASSIFlCATION
Us@. Hazard Use Hazard Hazard
� gr° -: .. Group Index oup Index Index* ` 0 asavnll )
A Assembly
B Business 18.
E Educational', ZA-
F Factory 2W
H High Hazard 2C±
1 Institutional. 3A
M Mercantile 38
R Residential . 4
- S Storage 5A
U Utility 58
Mx Mixed Use Hazard Index
Sp Special Use U
' Note: Include Hazard Index Modifier for Construction Type as applicable
9.0 CONSTRUCTION COSTS(Sea 780 CMR Appendix L)
Total Construction lion Cost Building Permit Fee Check Number
(1) _(1)x$0.001
10.0 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BUILDING
PERMIT""(when applicable)
I, u rnlu u x.la- . on behalf of the authorizing State
Agency or Authority, hereby authorize. S;�e- l j h to apply
for the building permit for project number.
Signature Date
11.0 SIGNATURE OF BUILDING PERMIT APPLICANT
II
Name
IrZ
Signature a
12. Certificate of Occupancy required on completion of projeW _Yes _ No
Inspector's Notes: