255 JEFFERSON AVE - BUILDING INSPECTION ' PUBLIC PROPERTY aj- 07
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHING-rON SIREFr • $ALEK MAISACHLSLI-M 01970
TEL,978-745-9595 • FAx:978-740-9W
APPLICATION FOR THE REPAIR; RENOVATION CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
Ass-
Property is located in a; Conservation Area Y/N 1Y_ Historic District Y/N Lt _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: T57F _o:—>/2DLc>
Address: 0/1 S1,O E! �r
S7`Oti0=/f, yr M11- DalgD
Telephone: 8 ( -115 61;)3
17
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated 14,E
Change in Use 3 New J
Demolition Existing . e
Approximate year of Area per floor (sf) Renovated
construction or renovation New
of existing building
BLief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building? G( f=n,.U./
Material of Building? 1f dwelling, how many units?
Will the Building Conform to Law? Asbestos? Ai&tc_
Architect's Name
Address and Phone ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# d�Yf b� HIC Registration# I A9 51't f
Estimated Cost of Project$ S(TKOO 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 -•v-o6
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHING'rON MREE'r ♦ SALEM,MASSACHUSET601970
TrL: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:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
debrisaffdac
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOU
MAYOR 120 WASHINGTON STREET♦SAI.EM,MASSACHUSET S 01970
TEt_978-745-9595 • FAX:978-740-9846
Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4 t licant information \ Please Print Legibly
141frie (BusinesslOrganizationllndividmi): ].J�,S kkt �'e't.
Address: IF try'—A =
City/State/Zip- . to Phone #: 60- Ufy 052
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees full and/or art-time).' have hired the sub-contractors
( p' 7. ( Remodeling
2.� 1 am a sole proprietor or partner- listed on the attached sheet.: ❑
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. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
quired.) officers have exercised their
of per MGL I l.❑ Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work right exemption p P
myself.(No workers' comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. LNo workers' 13.❑ Other
comp.insurance required.]
•Airy applicant that chucks box cal most also till out the sectiun below showing their workers cumpeniation pnhcy infurmation.
'ftomeowa:ra who submit this affidavit indicating they are doing all work and then hire outside contmmon must submit a new amdavit indicuins such.
�Contmturs that check this box most attached an additional sheet showing the narne of the sub-contractors and their worker'carp.policy informarim.
i ani air employer that is providing workers'compensation insurance for my employees. Below is the policy und/ob site
information.
Insurance Company Name: wr< t
Policy 4 or Self-ins.Lie. r: At?P 101 j Og6 Expiration Date;— ��Off•
Job Sire kc1dress;2 5-S j r%r1L Sew ✓l/ f City/State/Zip: Stela . Z�1 R .r71Q2t7
Altach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
I-'ailurc to secure coverage as required under Section 25A of.VIGL c. 152 can lead to the imposition of criminal penalties of a
tine up so S1,500.W antllor 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
IncrstigatiLliss..�ul'thc DIA for insurance coverage verification.
/da hereby��"litter pains crud pens/tics of perjury that the information provided above is true and correct
StL t our
fr// Date• ��`j6- 06
Phonc
Official use only. Do not write in this area,to be completed by city or town official,
City or Town: _--_------- Permit/License# -------- -------- . . .----
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 0:
r �I
Information and Instructions
Nlassachusetts 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."
:fin 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 trustee 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 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 the insurance coverage required."
-:Additiunally,1v1GL chapter'132, §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 nwnber(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 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 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 pennit/license number which will be used as'a reference number. In addition,an applicant
that must submit multiple penmirflicense 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.it dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
1'hc Office 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.
The 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
Revised 5-26-05
Fax#617-727-7749
www.mass.gov/dia
AC ORD CERTIFICATE OF LIABILITY INSURANCE o7i1o/2006`
PRoDUMER (978)51S-7700 FAX 978 SIS-8800 THIS CERTIFICATE 16 ISSUED AS A MATTER OF INFORMATION
N A Consoles / CFR Ins Agency LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
LDER.THIS CERTIFICATE DOES NOT 100 Corporate Place. Ste 110 AALL ER THE COVERAGE AFFORDED BY THE PO CEIES BEL W.
Peabody, NA 01960
INSURERS AFFORDING COVERAGE NAIC 9
nSUREO BPS Limited INSURUTA: Western World insurance Group
DSA: David P Saia INSURERS:
65 f Wharf Street INSURER C:
Salem, NA 01970 msuRe--
INSURER E:
CONRAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY RECUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS,
NI�e TYPE OF INSURANCE POLICY NIINBER P T: TfON 1L0TS
GENERAL UAINUTY NPPLO11096 01/12/2006 01/12/2007 EACH OCCURRENCE P 500,00
X COMMERCIAL GENERAL LIASIOrA oAMAGE rQ REnreD41— S SO 00
CLAMS MADE ®OCCUR NEO EXP(wa Panora) S 2,sOO
A PEW &AOV WURY L 500.000
OEMERALAGOREGATE 5 1.000
OEN•L AGGREGATE LIMIT APPLIES PER PRODUCTS-00e - PAGO S 500,000
POLICY IE7 LCC
AUTONOINE LIABILITY COMBINED BINGIc LIMIT T -
ANY AUTO (Ea a:tlO 0
ALL OWNED AUTOS BO01[Y!AJMT
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HIREOAUf ROLNLY WJUAY S
NON-OWNED AUTOS (Pw awdw)
( aP A.I.FR911I1AMAGE 5
GARA"UAJI n AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC S
AUTOCNLY: AGG S
FYCESSAII6RELL1{LUUTWTY EACH OCCLm Nce S
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OFFICEAMeEMBER EXCWOEDT f_L OLSEASE-FA EMPLOYEE S
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BPECU L PROVISIONS Ww+ E.L.DISEASE-POLICY LIMIT $
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DESCRIPTION OF OPERATIONS/LOG TIONS/VENICLBB/EXO`U$ON5 AOpe0 BYETmORSENEUTI SPECIAL PROVISIONS
to Job Site! 255 7ef arson Avenue Salem, PIA
CERTIFICATE HOLDER CANCELLATION
SHOULD ANYOF THE ABOVE OESCRIOM POLICIES BE CANCELLED BEFORE THE
EXPmATON DATE THEREOF.THE RRUINO INSURER WI L ENDEAVOR TO MAIL
1O DAYS WWITrN NowA TO THE CERTIFICATE HOLDER MNIEO TO THE LEFT,
City Of Salem BUT FAILURE TO NAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY
44 Lafayette Street OF ANY Teem UPON TTIEINSUREH.ITS AGENTb0 PRESENTArrvE&
Salem, MA 01970 SENTATIVE
ACORD 26(2001/Q8) FAX: (978)74S-1997 ®ACORD CORPORATION IBM