2A HOLLY ST - BUILDING INSPECTION . .I; I IZ 1 , q<L, ,4 I
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: :1 licanls must complete all items on this page
SITE INFORMATION
Location Narne ZA t-bLLIJ 1J. Building '{ F.4atge�L
Property Address
Located in: Conservation Area /N Historic district
APPLICATION DATE 3--/6 -Of
Use Groups
(check one)
Group Humes R3 114
Residential (3 or more Units) R2
Type of improvement Residential (hotel/motel) R1 _
(check one) Assembly (Theaters) Al _
New Building_ Assembly (restaurants & clubs) A2r_A2nc_
Addition Assembly (churches) Al
Alteration Business B_
Rcpair/Replacement Educational E_
Demolition Factory(moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard 11 _
Accessory Building Institutional (residential care) Il _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile NI _
Storage .SI _model,le I-lazard
Storage S2_Low I lazard
O\\'NERSl11P INFORMATION(Please Ivpe or Print Clearly)
OWNER Name A gcL-c 57: LLB
Address Y t ewf w
Telephone Q7� 9oZ LS�f
Signature
DESCRIPTION OF I%ORR TO BE PERF'OILNIF.D
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VSI MA TED CONS'1 RL'CI ION COST
CUN'I'It.�CI Olt IN FOR>IAT ION
Name ErfjLLC
Address etrve0 ,t&4< so Ctf CA44' CS
Telephone P2? 471 ?F"
Construction Supervisor's Lic # ?Am, lZ e $
Home Improvement Contractor #
:U2C111'175C"I'/Ii N(;INEliR INFOINIATION
Name
Address
Telephone
Mass. Registration #
111.101IT FEE CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
CONEN1ENTS
The undersigned applicant does hereby attest that all information stated above is trite to the best of my knoivle((ge
under th ties of perfury
Sig � r1W"""z ./� iul, IYn— (owner) (a.ent)
1
APPROVED BY : 2
DATE APPROVED: / ` �0 d
CITY OF SALEM
r NoPUBLIC PROPRERTY
.t'
a,Kt DEPART'.'vIENT
I_': \\.tM II\i..,1�ll:t l.(i 4 II M. \, I _I I _
Construction Debris Disposal Affidavit
(rryuired liir all demolition and renovation work)
In accordance \pith the sixth edition of"the State Building Code, 780 CN1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(came of hatter)
I he debris will be disposed ot'in
h (mmne of lacility) ',`A
AvVtaS
(address u((acility)
e
.Iguaturc o(prnuit.Ipplicant
late
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CITY OF SALEM
PUBLIC 13ROPRERTY
- DEPARTMENT
,�vr. M' I 1 rx hl.•I 1
W,%,t a\,.I vN S 1:,LL I * ).\t I \/.Lf.I IS%I I II ,1 I I,J I'17�
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ItYurkers' Compensation Insurunce \fftdoxit: Builders/Contractors/Electricians/Plumbers
1 tliLJnt Infunnrtion �L Please Print Leeibly
NIIITd llLnuw(/,l1)r;lmlraliort`InJl,utuall:
ltldr�.v\: r/� �GCIL!/KOJ/N���Sf l G p `/``
City,slalc Zip--
S lXQ / IN(A - 0/`/70 Phone ii �7,I rd 2— yS"T7
Are)nu an employer'?Check the appntpriaw box: l)pe urprojcct (required):
4. ❑ I :un a general ceuttactor and 1 6, new ewtztrucuun
j.[3 I .un a employer with ❑
em tlu ccs lull mIL'ur art-owe).• have hired the sub-cuntracturs
1 y ( P listed on the anachcd xhect. 7•�QRunoJelin�
2.❑ 1 ant a Tole prnpricntr or partner-
ship and have no elnpluyccs These sub.contracton have 8.�Demolirion
surking liar me in any capacity. workers' comp. Insurance. q. Owlding addition
no workers' cum . insurance 5. ❑ We are a corporation and its
I P 10.❑ Electrical repairs or additions
I rcyuircJ.I officers have exercised their
right of r MOL I 1.❑ Plumbing repairs or additions
7.❑ I :un a homcuuntcr doing all work exam Lion per 5 P
myself. (Ko workers'ctunp. c. IS 2, ¢1(4),anJ we have no 12.❑ Ruof repairs
insurance required.j r employees. (Kn workers' 13.0 Other
comp. insurance ruquired.I
.\... ..,gJau11 that checks box Ill must.dam till out the,l:.Imn Iwluw diewula Ilwa wurkw*eunlpuntr+iw,Iwhq•un1✓maliva
' I lumeowrwn who,u4mii this anlJavit indicating they are Jomil all work alwt dscn him uulslde cuturxrun must.uhtnil a new aorclawil{nJi"ans,u.A.
.f,•nlnctl,n That,heck this box mtrr ammh,d.m adddiunal,Iwel,huwina Ilw.onse c tht suhiYntrx+nrs and their wurhers'comp.rx,llcy mtnrs r anon
/unr on tlnpfu}'tr U�ur i.r pruriJirrg rvurktrs'eurnpent'nrinn inaurru+ct jar any eurp/apte•.v. Be%ry is the pus/icy✓n✓j✓b xilt
iuj✓nn✓fian.
Insurance CDnipauy Name:
Policv is ur Sclr-ins. Lic. N: _... . . .. ___ Expiration Dote:
Job Site Address: City.:StaleaZlp:
.\ltach it copy of Ili* workers' curnpmvtlun policy declarationpuge (showing the policy number and expiration date).
fal lute In,ccure cu%erage as required under SeUiun 25A ul'.'I6L c. 152 can lead to the imposition of criminal penalties of a
ring tip('1'*I.SIIOJIn unllbr one-year imprisonment, as %cell as ei%d penalties III the I'unn of a STOP WORK ORDER and a fine
"Fill ht S250.00 it Jay ,Igainsl the violator Be advLccJ that a copy of thus matc+ncol may be lurw arded lu the O lice✓i
II\:ai•,.I n•nn uI tllc DIA :or io,lu Ircc clner.hc \ailiul:an.
/dr. hereby I:rrify Imo/er the p✓inv✓nd pet+rdiiev✓/perjury that the iujunnulion provided above is Irmo will correct.
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F//�r�cr�it/ 9 7 9 ®a a
t)//ia'iui m,t✓n/y. /)J nit, n•ritt im thiv urea, to be ovi,tpleled by oily of town✓//i,ia/.
( itv ur Iltwn: __.. __. Permivl.icunse 0
I„uinu .\ulhurily (circle nuc):
I. IloarJ of Ilcalth '.. IlI'll Ucp.vuncol 1. l'ih.'funu Clerk J. Llcclrical luspector :. Pluulbin4 hi,pcclor
6. Olhrr _
('Iuuacl 1'c Hole .. .. Phone it:
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Information and Instructions
%I.t>s.n hu.cus Gcncral Laws chapter 1 i2 teguirrs all eutpl a)ers to provide workers' compensation for their employees.
I'ur.u.uv to mils aituic, an emplu tee is Joined as " ew cry peson in the service of another under .sty :untract of hue.
:.pre„Or onphcd. oral or is Wen.-
%n :mpluyer is defined as "an ndlviduil. partnership, association, corporation or other Icgal entity, or any two or more
.a the 1"NeOmg cngagcJ it a joint cmerpnse. and including the :cgaI rcpresen fit,ves of a decei,eJ cnlplu)cr. Or the
rceetver or trustee of or individual,palulenhhp, 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
.hv:lltng 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 in emplo)er."
>1GL chapter 152. ;25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal u(a license or perntif to operate a business or to construct buildings in the commonwealth for any
applicant w bo has not produced acceptable evidence o(cumpllanee with the insurance coverage required."
additionally, SIGL chapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions,hall
cater into any contract for the performance of puhlic work until acceptable es hdence of compliance with the Insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) namets),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
accidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'Itusc be sure to fill in the pennitilicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennith'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 file 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. Anew affidavit nnust be filled out each
rear. Where a hume owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it .lug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he I)tiicc tit Investiyatiuna would It" to thank you in idvarice fur your cooperation and shuuld you lhawc .my questions,
please Jo not hesitate to give us a call.
- fhe DJ p.unncnl's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
0mce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
d 'n u5 www.mass.gov/dia
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