77 JEFFERSON AVE - BUILDING INSPECTION What is iu aurert use o1 the Buddk119 —
MM I I of Bu~ le is ay Gr � - ti dweRn4,how merry unils4/�
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Ardftcft Name
Address and iPhons
MeduNs"sNanre FIOI'j
Addrom and Phan. 6Yz S y�?? G 7(0 77
Ccmtn�� lker+es r C9S 3�y/ HIC tatJr
EatirrtMad Coat al PraMu FAG Perm Fos Caltxrlatiat
Permit Fee i LLL`, I? EsWnsted Coat X$741000 Residential
- - - EsMmabd Coat X 841/i1o09 Ca"mwcw -
An AddMonal=t3,00 is added as on
AdmininvalM durpe.
Make sure that as Holds are properly and teo*written to avoid delays in P nfl.
The wdersiprud does hereby apply far a BOOM Permit to but o the above atabd
specrwations• 8iprud under peruttY of PerltrrY
Date
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9
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BOARD OF BUILDING REGULATIONS _
License: CONSTRUCTION SUPERVISOR
Number: CS 053841
Birthdate: 11121/1952
. Expires: 11121/2007 Tr.no: 9409.0
Restricted; 00
ROBERT C PIZA
40 CHESTNUT ST
DANVERS, MA 01923
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Board'otBuilding Re@dadens and Standards'.
HOME IMPROVEMENT CONTRACTOR
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Type .;DBA '
SMSUILT CARPENTRY
DRobert P@a
40 CHESTNUT ST, 4
' DANVERS.MA 01923 DepaWAdminbtretor \
,\
C1TY OF SALEM
- - - PUBLIC-PROPRERTY
DEPARTMENT
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Construcdon Debris Dispose Affidavit
iteyuiml for all demolition and renovatiaa wat)
In=onW ee with dw shdt edition at the State Building CodR DSO CNlA section 111.5
Debri4 sad the provisions o(MGjL c 44 S A
gwldisli pa M _ _ is issued with the roaches drat the debris resuldnS Boas
this wort shall be disposed of in a property licensed waste disposal ibcility as dented by WIL a
It1.sl5"
The debris will be transported by:
c'm t
_. tn,me ar had+d
rho<kbris will be
disposed pof in :
e�
..�6r
,
CITY OF SALEM
PUBLIC PROPRERTY -
o` DEPARTMENT
nAmaf RIF.Y matmt:anl
M.vrsa 12C WAiNL4:143111S'17tlaT a SA It1t.hLu6Ac.7a.�o-71[019T,!
TW 9711443.9595 s FAX:9M740-9946
Workers' Compensation Insurance Affidavit: Builders/Contncton/Electrictaas/PMmben
annlieant Information Please Print Leg
Ubly
Name tHuainWOgpnizariowlndiv"&i„�rin c+�'r L I lrr�CtV f o r
Address: 40 CHESTNUT STR FT
City/srarwzip: DANVERS, MA O18?1 IY: /��8' 77I d rd Y
Are you as employer?Cheek the appropriate boaa FOReawdeling
t(required):
1.Q 1 am a employer with 4. Q 1 am a ycmm d contractor and INewconstruction
tmpluystwl(full and/or part-time).• have hired the sub-contractors
2.�1 am a sole proprietor or partner- listed on the attached sheet t ing
ship and have no omployeea These w4 eonuaetoa haw onworking for me in any capacity. workers'comp. insurance. addufoo
(No workers'comp insurance 5. Q We am a corporation and its
required) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.(No workers'comp, c. 152,91(4).and we have no 12.(a Roof repairs
_
insurance required.) t ;mpbyccs.LNo workers' 13.❑Other 5/L✓/�1�'
comp. insurance requ refl) --7
Any+pPlieaol ran elxdta boa bl tom also 1iU uu arc mecum WRIN rAwioa IMit v4akea'UMMOU 4M pAsy infis,'"ia►
Ilunwrw who submit this amdwu indiwrina dry am&*a YI welt and ban hie etnfida eammamns mma.ubmil a ism,ameavim indtadind such.
�C mein IhY ckvk tbia box must adaobad am artdilsmat shim showiry the name of the and their wwkoo'cony.Policy infamadmm.
I am an employer that fir providing workers I compentaden Gtsarance jor my employers. Below Is the pu/4y Ynrl/ob,sil•
..ryrryw+.w..%NjYfMYflfrAi:' _ �.
Insurance Company Nome:
Policy 0 or Shcf ins. Lie.0: - Expiration Date:
Job Site Address: 71 Mr-,GS-'t So'-� rat/ �_ CityisiatuZip:
Attach a copy of the workers'compensation Palley declaration peke(showing the policy number and expiration date).
Failure to xcum coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties ofa
rifle up to S 1.500.00 and/or one-year impristmment,as well as civil penalties in the form Ora STOP WORK ORDER and a fine
Al'up to S250.00 a day againsa the violator. lie advised that a copy orthis statement maybe 1'urwarded to the Office of
Ito:angauon%of the DIA for insurarcc covcta.0 verification.
/do hereby cerfijy Yoder fir an penu/I s r/Yry chit the in/ormollon provided(i yar is erne and correct.
q 7 T--77 Y ^- )r- -a v
f)/ffriY/are only. Ae nor write is th/r area,to be completed by city or/owe o/JleAd
Ciryor 'rown: _-. Permit/I.Ieense0
Issuing Autburify (circle one); --
1. Board of livalth Z. Building Department 3. CitylfoNa Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other
C„utact Person: Phone p:
1
information and Instructions
Massachusetts Gcneral Laws chapter 152 requires all employ r�t prothevide
service another under anyoctheir onmatxMof hire.
IOYOPursuant to this stamrte,an eapbyee is defined as"...every peso
eapress or implied,oral or written.
association,corporation or other legal cam,or any two or mom
An he foregoing n defined ss"as individual,PAP. to or the
of the foregoing engaged in a joint enterprise.and including the legal representatives eta deceased employer.
usociesio s or ocher Icgal entity.employing employees. However the
receiver err tntsax of as individual,partnership.
spartmente and who resides therei4 a the occupant of tha
owner of a dwellisd house having not'none thin three maintenance.
dwelling house of another who employs Persons o do maintenance.cusstructim or repair work a such dwelling house
or on the grounder a building;appurtenant thereto shall not because of such ample vww be deemed o be an employer."
MGL chapter 132.02SC(6)also states that"every slats or beat licensing agency shad withhold the Issues"or
of a Ilceuse or permit to operate a business or to construct buildings is the commoawedth for any
unusual Insurance coverage required."
r with the lus
appliesst wbo lee act produced accept"evidaaee of commm of its lined subdivision shall
,adt itumally MGL chapter 152.423C(7)states"Neider the commnewesfmviwan of compliance with the insurance
enter into any convect for the performance of public work until acceptable
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 arid.if
necessary.supply sa►cont acor(s)namiKs),address(es)and phone number(s)along with their certificae(s)of
insurrnee. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employes other than the
members or partners,am 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
. Also be sure to sits and date the affidavit. The affidavit should
Accident for confirmation of insurance coverage
be returned tothe city or own that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the low or if you are required to obtain s workers'
compensation policy.please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the line.
City or Town Otlfelab
.. �-
Please be sure that the affidavit is complete and printed)agiblY.The°Department has provided n space at.de bottom
of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicam
please be sure to till in the permitthcense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/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
own)."A copy of the affidavit that has been officially stamped or marked by(he city or town may be provided o 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 cidzcn is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l'hc Oinix of Inves[igatioas would like to thank you in advance for your cooperation and should you have any questions.
please du not hesitate to give us a call.
The M-partment's address, telephone and fax number:
The Commonwealth of Massachusetts
` Depaltment of Industrial Accidents
gAko of Iwestipdtosa
600 Wsshinggan Sfteet
Bosons.MA 02111
Tel. 0 617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
zwi.�a i-'_G-us www.unw.gov/dia
NOV-01-2007 02:41PM FROWPhil Richard Ins 0707741118 T-147 P.001/001 F-097
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AZ+PIICATION FOR TtaZ REIAIA. RZNOVAno cONarQUCTION
DZ [OLI'1'ION,OR CRANGZ OF U3Z OR OCCUPANCY, FOR ANY FaMISMG
s an wFORMATION
Location Name: Bu C*V
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2.8 OWNERSHIP INFORMATION
it Ormai d Land Cr/Y1 G C�
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Addresm Alp 4 rye
T.Iaohale: 97 - .7 SAY yS- 3
a.o COMPLEYt THIS SECTION FOR WORK IN 9—U—M G BUILDINGS ONLY
Addition Exlstirg
Rwwvatbn ✓ Number of storba Renovated
Change in use Now
OemoGtion
y�� c n I
co�Approximate
ayr renovation Area per flow s Renovated
of existing building 08 New
add oescripdon of Proposed Work:
,?e yae
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