18 HOLLY ST - BUILDING INSPECTION CITY OF SALEM
i t PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL` //1 P 1 7 i)
MAYOR /IJ}('p�r'/Or/✓�1 120 WASHINarON STREET 1 SALEM,MASSACHUSEMS 01970
TEL 978-745-9595♦ FAX:978-740-9846
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information ( /mPlease Print Legibly
Name(BuLLC
siness/OrganizatiotJln// rrdividual):�L�C7t t1(1���— �� ^�D�t �S
Address: In f .P ��
City/State/Zip: -Pgi�o -t; . M-G, . Phone #: g7
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 1 6 ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. �• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp. insurance. 9, ❑Building addition
(No workers' comp. insurance 5. e are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 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 12.0 Roof repairs
insurance required.]t employees. (No workers' 13.❑Other
comp. insurance required.)
-Airy applicant that checks box tit must also rill out the section M;low showing their worktas compensation policy information.
'Ilomcuwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractcus that check this box most attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
1 out an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name:_
Policy#or Self-ins. Lic.#: Dd3aJ.. Expiration Date: A,.,
Job Site Address: 20 u�2 rI� 54• City/State/Zip:1� O J S TD
Attach a 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.MGL 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ul'ihc DIA for insurance coverage verification.
l do hereby cerr'y under the pain2an penalties of perjury that the information provided above is true and correct.
Sienawre Date: — Z
phiii1e , 9 g'- 531— 9ss
Official use only. Do not write in this area,to be cumpleted by city or lawn official
City or Town: Permit/License 0-
Issuing Authority(circle one):
1.Board of Ilealth 2. Building Department 3.City/town Clerk 4.Electrical Inspector 5. Plumbing inspector
6.Other
Contact Person: Phone#:
r -
Information and Instructions
bfassachusetts 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."
:1n 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 rustee 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 ofsuch employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shag 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 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 nuniber(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
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 Officlals
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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/license 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.
l'hc URicc 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.
'rhe 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 5-2G-OS www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPERTY
I � N DEPARTMENT
FI\MF.RI.EY DRISCOLL
MAYOR 120 WASHINGTON STREET♦SALEM,MASSAC 4 SEITS 01970
978-745-9595 0 FAx:978-7404846
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: bptsrs4 Building:
Property Address: 0q0 �11� Ctt` • „ �' S4�� .
Property is located in a, Conservation Area,Y/`N�-- Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land (,-A
Name:
Address: j ���� Se�� • $4 L2�
Telephone: 97$' 7'HJ'`'
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
86-J Description of Proposed Work:
C % Q ('oo�r w ► Obo �bbQC
Mail Permit to: In �e n 5} �, ,d 1 ��'• 619�c�
What is the current use of the Building? 0 f r
Material of Buildingw.S ( If dwelling, how many units? c2
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name 5k—y-Lr%- Lo. hA,Un Lc�
Address and Phone j a'Z) I
Construction Supervisors License# HIC Registration# j3 dr
Estimated Cost of Project$ 1, Permit Fee Calculation
Permit Fee$ Estimated Cost.X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
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
specifications. Signed under penalty of perjury
Date
q
0
N
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c: \ 1 Oa
F o
ate' cN E a a
CITY OF SALEM
+1 PUBLIC PROPERTY
f DEPARTMENT
KIARIERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET 0 SALEM,MASSACHUSETIS 01970
TEL:978-745-9595 ♦ FAx:978-740-9846
Construction 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 debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
"W
name of hauler)
The debris will be disposed of in
(name of facility)
(address offacility)
signature of penntt applicant
date
debmaff.diK
e
Proposal#6152006
Page # 1 of 2
From: Steven Lamonde
SML Roofing & Roof Repairs, LLC Job Name: Vancelette
6 Felton Street
Peabody, Ma. 01960
(978) 531-9557
To: Mr. Henry Vancelette
20 Holly Street Job Address: Same
Salem, Ma. 01970
H (978) 745-9897
C (617) 571-2344
I hereby submit estimates and specifications for: 4 Squares of a 060 rubber.
I will first strip and remove the V existing layer of roll roofing and leave the
existing layer of metal underneath. Then I will remove the first 3 courses of shingles
so that I may ride the rubber up under the shingles for a water tight seal. Then I
will begin laying out the new ''/z" insulation boards over the existing metal roof and I
will fasten them down with 3" plates and screws. Then I will lay out the new 060
rubber and cut it to fit, and then I will fold the rubber in half and apply a bonding
adhesive to it's backside, so that it may adhere to the insulation boards. Then I will
ride the rubber into the threshold and terminate it as well as ridding it up where I
removed the first 3 courses of shingles and then I will re-install the shingles. Then I
will nail down 3" x 3" mill finish drip-edge to all of the perimeters and then I will
apply 6" rubber flashing over the metal as well as flashing the 1 existing stink pipe
and I will use a splice adhesive as well as a lap sealant on all of the scams for a water
tight seal.
All material and debri will be supplied by and removed by SML Roofing & Roof
Repairs, LLC. This job comes with a 10 year guarantee to the present Owner Mr.
Henry Vancelette. These terms above to be voided in the event of new Ownership,
and or if any future work is to be done to or on the above areas mentioned in this
proposal, unless done by the said Contractor.
Page#3 of 3
1 hereby propose to furnish labor and material-complete in accordance with the
above specifications for the sum of$1,600.00 One Thousand,Six hundred DoIIars.
With payments to be made as follows,a deposit of$400.00 for the stock and permit
will he required in advance along with the signing of this proposal in order to start
this job. The balance$1,200.00 to be paid In full upon the completion of this
proposal.
If this proposal is to your satisfaction and you are accepting these specifications and
conditions along with the payments to be made as follows,then please sign below
and return a-signed copy with the deposit.
Accepted Signature: ew W 3 V, ;& 0g/zoo�
Date:� GRt� y� 2DD f
Contractors
Authorization to do the work as specified,
2.&a—z-
PleasLeL return a.signed copy of this proposal with the deposit for our records.
Thank you in advance,
Steven Lamonde
SML/tdl
02/27/2006 23:08 97877Y8415
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