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395 JEFFERSON AVE - BUILDING INSPECTION (3) 3�� `� �� �d CITY OF SALEM , � - �",. i PUBLIC PROPRERTY -':o+S�. . .� .rR_ "''`�'-�~�' DEPARTMENT \�� ;U\tlli'RLP.7'URIR:OLL �'��l'(� 12C.\C�AtiHI\GI'O;v S'fRCL•7 �S:\LE\d,M:\SSACI II1.lICl'Iti G197C) � 'Icl.:978-74i-9i9i �Fax:978-74�934G Workers' Compensation Insurance Affidavih l3uilders/Contractors/Electricians/Plumbers \ �nlica�rt Infunnation Plcase Print Legiblv �l�friZ (f3ucincsslOrganizatioNlndividual): 6R?N�/ ,y ����R��L� :�dd���ss: 39'3 ✓Ex'F'F.B�^--�/ �/'F CitylStacc:'7..ip' .�Sl��,/7j f�9Af O/9�X1 l'hone #: ��^ 7'S�S'" 73�0 :�re qou an employer'.'Check the appropriute box: 'Pype of project(rcquired): I 4. Q 1 am a gcnural coutrac�or and 1 1.� 1 am a cmploycr with G. �New cons[ruction em lo�ces fidl ancVur ero-umt).' have hired the sub-cuntractors � � � � listzd on the attached shcet. � �� ❑ 2emodeling 2.� 1 am a sole proprietor or partne[- sliip and have no employces Tl�ese sub-conttactors have 8. ❑ Demolirion �� ���orking for mc in uny capacity. w'orkziy' comp. insurance. 9. � Building addition -Ko workers' coin insurance 5. � We�re a coiporation and its � p. 10.0 Electrical repairs or addicions �` �i��i��� ofticcrs havc cxcrciscd thcir ri ht of exem tion u MGL ll.Q Plumbing repuirs or udditions 3.�I am a homcowncr duing all work. � � P' myself. [No workcrti comp. c. 152, j l(4),and we have no �Z.� RouFrepairs i�uurance reyuired.) t employee.. [No worktrs' 13.0 Other comp. nisurancn n�quircd.] . �-nny applicum thut chccks box dI must alsu lill um ihe u:clion Ixluw slwwing�hcir aorkerY cumpenwtion pulicy in(nrrtwtim�. 'I lomcuw�u;n whu su0mil Ihis,ffidavit indicuing Ihcy are doiny�II worlc and thca hire ou�siJe commeton must euhmii a new al'�Javil iodiwling such. �Comnc�on thu�el�cck�his bos must atlacF�xi:m additional s6u:�shnwing thc namc of thc sub�<omracwrs and�hcir workers'comp.pulicy infurmatiun. /wn ui� empluyer lhat is providing wurkers'compensn�ion iusuraure jor ury empl�yees. Belmv is rhe pulrcy u�id job site rnjormurion. In,urance Company Name: � ._.__. ______.._ ......._------------ � Poticv�t ur Self-ins. Lia ?:: ----..__......_..._._-_ Expiration Date: Job Site Address: Cily(Statt/Zip: � . :�ttrch n copy oC U�e workers'w�npens•rtiun pulicy declaration puxe(showing the policy nwuber and expiration date). I�uilure w sccurc covtrage as required under Section 25A uf�SGL a !52 cau ltad to ttte iroposition of criminal penalties of a tinc up «�$1,�OOAO and/or one-year imprismm�enc,us wcll us civil penaltics in the 1'orm uf a STOP �tiORK ORDER and a fine of up ro S'_i0.00 a day agains� �ht viulatoc 6c advi�cd that a copy of this siatement m�y be forwarded to the 017ice of lur'cs�igations of thc DIA for insurai:ct ct�vcragc veritication. !da lierchy cenrjy uiidur[he pn�ruid pesulti�•ujperjnry�hut dee infannution pruvided uGovr is«ue«nd corr�ct. Sicnamre: . �( D��tc• � � .C7'�-/ Ihiic. 7 7�d �rf! �i� OjJiciu!use ae(y. Do i�nt uvite irt N�i.c urra, to be con�p/eled by cily orlmvn ojficiul. City or"1'o�rn: PermiULicense#_---.—__..-----_.. .... - .. .---.— Isxuing Aulhurily (cirde one): t. 6nard uf Ilcalth 2. 13uf�dine Deparhnent J.CilylCo�cn Clerk 4. Clectricnl [nspector 5. Plumbing lnspector G. OI I�er —_ Conluct Pcrson: � .-.--- Phonc#: - � Information and Instructions A�f�ssacliusztts General Laws chapter 1�2 reyuires all zinployers to provide workers' compensation fur their entployees. Pursuant co this stutute,an rmplul'ee is defined as"...every person in rhe service of another under any contract of hire, express ur impliod, oral or written." :1n e�np(nyer is dctined as"an individual,partnership,associatiou,corporation or other legal entiry, or any two or more of the fomgoing engaged in a joint entnrprise,and including the legal rzpresentatives of a deceased employer,or the roceiver or trustee of an iiidividual,pa�mcrship, xssociatiun or other legal tntity,employing employees. Howcver the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwclting house of another who employs persons to do main[znunce,construction or rzpau work on such dwelling house or on the eruwtds or building appurtenant thereto shull noc because of such employment be deemed to be an employer." 61GL chapter 152, fi25C(6)also states thut"every state ar local licensing agency shall wit6hold the issuance or renewa!of a liccnse or permi[tu operate a business or to coostruct buildings in the commonwe•rlt6 for any xpplicant who•has not prnduced acceptable evidence of compliance with the insurance coverage,required." Additionally,��IGL diupter 1 i�;325C(7)stafes"Neither the commonwealdi nor�ny of its political subciivisions shall � znter into any convact for[he perfomiance of public .vork until acccptable evidence of compliance wich the insuranez requirements of�his chaptzr have been presznted ro the contractin�authoriry." Applicants Please fill out thc workers' compeusation aliidavit completely,by checking die boxes thut appLy to yuur situation and,if necess:uy, supply sub-contractor(s)name(s),address(es)and phone mm�ber(s)along wi[h their cer[iFicate(s)of insurance. Limited Liability Compae�ies(LLC)or Limited Liability Partnerships(LLP)with no employees other than[he members or pa�tners,are not required to carry workers' compensation i�uurance. if an LLC or LLP does have employzes,a policy is required. Be advised that this aftidavit may be submitted co the Department of Indushial , .4ccidents for confirniation oP insurance coverage. Also be sure lo sign and da[e ihe aftidavit. Tlie al'fiAavit should be rcturned lo die city or town that the application for the permit or licznse is being requested, not the Department of Industrial Accidznts. Shuuld you have any yuestiuns rzgarding the law or if yuu are reyuired tu obtain a workers' compensation policy,please call the Dep�rtmen[a[che immber listed below. Self-insured companies should en[er their sclf-insurance license number on the appropriate tine. City or Town Offlcials , Plelse he sure thac the affidavi[is complete xnd printed Iegibly. The Deparhnent has provided a spscc xt the botWm of die attidavi[for you to fitl nut in thz even[ehe Office of Inves[igations l�as to contact you regarding[he applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition, an applicant dta[must submit multiple permiUliceiLce applications in auy�iven year,need only submit one affidavit indica[ing current � policy information (if necessary) and undzr'7ob Site Adclress" [he applicant should write"all locations i� (city or town)."A cupy of the aftidavit that has baen ufficially stampcJ or marked by che ciry or town may be provided to che applicunt as proof that a vsslid uCfiduvit is mi file for future pet7nits or licenses. A new affidavit mu,t 6e tilled out each yzar. Where a home owner or citizcn is obtaining a ticense or permit not related to any business or conunercial venture (i.e. a dog licznse or permit to burn leaves ete.)said person is NOT re��uired ro comnlete[his affidavit. "ihu Of tice uF(nvzs[igutions would like to thank you in advance for yuur cooperation and should you have tmy ques[ions, please do not hesi�ate to give us a call. Thc Deparunent's adcltess, telephone and fax number: � . . _ The Commonwealth of Massachusetts> �_ , ,� ,_ Department of Indusuial Accidents Offlce of InvestlgaUons '' � 600 Washington Street Boston, MA 021 l 1 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE a�.s.�d s-�G-os Fax# 617-727-7749 www.mass.gov/dia l __ �'` CITY OF SALEM � � - 'i PUBLIC PROPRERTY �� '� DEPARTVIENT i n:\I::rM1.tT!'�KiNJ.`ll. �l.�t�'K 1?Q W.�il1IXG:JF SiAEET �$.�Li'�1.�f.\�iAC:�I:�i rs];at� TFi.:v7&7�i-•)i95 � f.�`C:97d-7iG78i6 . Construction Debris Disposal .�►ftidavit (requirad fur all dtmulition;uid rtnov�tion work) In accord:uice w i[h tha sixch edition of[he State Buiiding Code, 730 CMR section l l l.i Debris, and the provisions of MGL c 40, S 54; Quil�iing Permit # _ .. __ is issutd with the conditiun that thz dcbris resulting&om dtis work shall be disposed of in a proprrly licensed waste disposal facility as dtfined by vIGL c 111,S 1SOA. The dzbris will be tr�nsporced by: �/�/. `j�MA/dl.F2�Co Cd. �name uf hautar) fhe �lcbris will be disposed uf in : _ O�t A/S/DF. �na4�n.�.rt- (t7:1fi1CJf I�CIlI[Y� . . _ _ �A�6I'I����. . t:.ddrcs. �it'f�ci��ty1 . -- .� r.atui���[,��n�pp.tclot ----- —le_.�'�-07 _ . i ,:lc, � :,. i �fAP 32 LOT 0030 ESTHER REALTY, LLC 296 CANAL STREET rn 50 t i � µ MAP 23 LOT 0187 Zs•0 MICHAEL RICHARD & PAUL RICHARD PROPOSED GARAGE TRUSTEES, RICHARD FAMILY TRUST 14�f � 393 JEF=ERSON AVENUE " �'t sNEo 4't SHED �ed9e °f pOVement �_ SHEDS .� TO BE � � REMOVED i � � MAP 23 LOT 0188 � —AREA— �- _ � � 7,785f S.F. . � conc �I -F{ IPOd �I SHED � � DECK ^ L _ J�� ovER PORcr+ MAP 23 LOT 0189 edge oF hricK STEPHEN V. & RUTH E. HALL � 397 JEFFERSON AVENUE � ;r SHL-^ I 'I I i � i I j I , i I - io't � DWELLING 2 1/2 STORY � DWELLING � #395 I � I I ; I s't I � I I I I I � �, � � ,_ � ��3� � � i ^5o't , '' JEFFERSON AVENUE EXISTING LOT COVERAGE = 21% PROPOSED LOT COVERAGE = 30% ��P��NOFMqSSAn PLOT PLAN OF LAND ��� . � �,�� y�� n 395 JEFFERSON AVENUE � ` � � SALEM � SMITH � No.35043 o- I CERTEFY THAT THE BUILDINGS �o Rf �� w�" PROPERTY OF , HEREON ARE LOCATED ON �`�''si��i�,,�,s°°'� JOHN N. PICARIELLO THE GP.OUND A, SHOWNC'�Z`��� SCALE 1" = 20' JUNE 25, 2007 � �� �� % NORTH SHORE SURVEY CORPORATION A 'REG. PROF. LAND SURVEYOR 14 BROWN ST. — SALEM, MA , #2905 n � 9 r . t I . . . . . . . .. . . . __._.. . ..___"' — .—r--:—.� . �"— ____' :y_._.. ._.. � � .. , . ' '_ —_ . . . . .. . . . .. .. . . . . . . . . . .. . ... .. _. . . . . .... .. .. _ ... . . . .. . . . . . . . . . ._'_ __.. ._... . ' _ "'_.._"_� _ _ _ , . . . . �. : , . . : � : , �: ¢ � � . . . . .._ .._. .t . . . ... 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MARBLEHEAD, MA01945 CALCULATEDBV DATE , _ , � � �� i G i � �� E , q � � _ i : . � E ._ , � � , �781) 631-0310 . . . .. -. - . - _ .-. . � . . . „' r � . CHECKEDBV DATE .3'2S'O / ,.. . . , ' � � i ` � . . .__._ ;. -` � y._.. _ . ..__ ... ............ . E ,........., _. . �. . � _ � _" ._ ..... _ � , .� _ SCALE ���r I'O'I , � _ _ , � J � j � ��� � ` �� � PROOUCT]01-1(PMOEp11"E�GE� PRO�UCT)064(GADDEDITEDGE) � . - EI'I'�C��F� --- ��� PUBLIC PROPERTY . ; , DEPr1R'I14IIEiE�1T IA\o�cN�r DRISC�v� Nwwa 130 Wwutv[rnw�`nF1,T� ' "'_s,�(wasa��strs 01970 . 'I419TL71S-9S9S�FNt 9T{.7iO961� APPLICATION FOR TAE REPAIR RENOVATION. CONSTRUCTION DEMOLITION. OR CAANGE OF USE OR OCCUPw1�iCY FOR ANY EXISTINCs STRUCTURE OR BUII.DiNC- . 7.0 SITH INFORMATION � � ' " Lotatlon Nams: Build(ng: ----- -- ----— --- --_. . .__ _ _ __.. .. --- _ PropertY s�----- -- ---------- ,� ✓ f�E' ,5,9,! . l�lA O/q� Properly(r located in a;Conaervatlon Aros YM Hletatle Dfetrict YM 4.0 OWNERSHIP INFORMATION � 4.1 Ownw of Land � ' Name: O/-/�/ lC'A�>fZ10 Addreas: 3a13 ��� r�- S,4 ,q a� T�p�: - �-�rs- 3�a. 3.0 COMPLETE THIS 3ECTION FOR WORK IN ��aT�N� BUILDINGS ONLY Addition ExisGng Renovation Number ot Stories Renovated Change in Use N� Demolitlon ExisUng Approximats year of Area per floor (s� Renovated construction or renovation ot existing building New Bdet Oescription of Praposed Work: �(.1/.1� � �/�✓' '. .1 L��fZ � A2l,��� f� T�� /���L O� �� �'}�iSTi�,�. �j 1 �i,�/� — -- -- - ---- -- Mail Permit to: �SL�iq��`V� ' ��Vhat is the curtent use of the Bui►ding7 3 Material of BuiidingT `✓�•(�`�f���l(dwelling.how many units? Wip the Building Contorm to Law4 3 AsbestosT N� ArchitecXs Name �Ql/N � //'�2�1�1!� Addreas and Phone . ,s- 3 r70 l ) � Mechanb's Name �/s�i�s� 0�5� ��CAQ/F1� ?GI S .:�'6�'.SCP/ •9dF �SAII�,-J �a� Addreas and Phone � s� isors ucense p HIC RegistraUon 0 Construcfion Pe� 3 Petmk Fs�Calculatbn Estimated Coat of Project S� . Pertnit Fee i � '*�•�' . Estimated Cost X S7IS1000 Reaidentlal d . --- - - - ----- —-_ ____.. _. ------- ----- - EStltnated Eoat X i41/i1000 Catnmerciat= An Addkbnal 55.00 is added as an . AdminiatratNs char9e• Make sure that all flelds are properly and legiby written to avc�d delaya in procesafng. The undersigned does hereby apply fo►a Buildiny PertnR to build to the above stated speciflcationa. Signed unde►penalty ot perJury /� ' Date l ' Z S"07 � � �; � � � � N i y � � , � <` � � •VI � �^� � � • W � � � � �. � .. m � e °� �� � � e E� 's `' v �7� y g` � , � � • a ea !`� � _. �. -- --- _ - - - - -- -� _ ,.� __ ai:— . � �