19 KERNWOOD ST - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
..W:Jup Aia'►
aLO a tl r.�eeN::Jr+f laeT i�ttr.1Lwt� r.a�1s:.1
r-
Construcdos Debris Dispour Affidavit
(requiml fbr an dentoWios and smovatfon wa t)
is mconlanee with the siudt editios o[the SON Suilditlts Coda M ChUt sccdm 111-!
ocbr*wd the provisions of MCL a 40,S Sdt
gwidies Permit 0 _ _ is issued with dw condldos thou the debris nzy d&s Sots
this work shall be disposed of in a Wopwily liemead was disposal fbeility as dented by WIL e
111.S I"A.
The dcbds will be transported by:
rhe&bds will be disposed ofin :
ta.mr�r r'xd:ty)
�Lt
; .� KIT
' w Ks* ✓/t6 IJOONldIng I 6/s'
Board of BulldingRegulatiofis�endStandarda
Construction Supervisor License
4, License: CS 13075
s�?,5 Blrthdate: .10/26/1954
1 ,Expiration:.10/26/2009 Tr# 5743
+ Restrictlon: 00---
CHR!STOPHER A-MONACO Sr
II 3 ELM PLACE
1
MARBLEHEAD,MA 01945 Commissioner
' .Jlde 'fOdlriH)�4%IG.n..`.. 0�✓viO004�/�.1146Q� �.,
4 Board of 0uildine Reguiatlons and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
p, M' i Board or Building Regulations and Standards
DIY Registration 110147 I One Ashburton Place Rm 1301
Explra0on. 101912008 1 Boston,Me.02108
Type:' Partnership
MONACO JOHNSON GROUP
CHRISTOPHER MONACO �'
3 ELM PL cN- valid without signature
MARBLEHEAD,MA 01945 Deputy Administrator
:r
CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
iwl4atn,tlr geYtall.L
1il\rll� IYr�Iwfi�7G10t�11eT a sR tisl,M+\sst.•tosRrssOl!)Z
Workers' CompMedem issurssee AlMdevir Bsild*rWCOntrtactwWEletbidsssl%mben
Vartuttw.iaaMo.=aai�atioa`rtnyvNh.U• ��'�
Addtr:acs� /�p
City/StutuZip. �''I%� iT�/(i'�i/ 1'boue N:=1 7e �2
Art an as svapleyer! be apps Plato lose
1. 1 mt a employer will e. 0 I ant•gerterol Taoaltaaor and! h1»�pe1 (�trtrdk
employee(full srallot prrwim).• have hint the nub-eutweutats 6. dos
2.O 1 am a sole proprietor or patttter- listed on the attacked,hat,t 1. 0 RemeodgUeS
ship and have no eatployom Three haw u 0 Demolition
working the nta In any capacity. workers comp iaesrastee v.
tNO worker comp insurance s. 0 we an.eoeparation,iagl its O was additios
ngtrired) Of fees have exercised their 10.0 Electrical repairs or additions
3.0 1 am a hatneowner Joins all wont right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(Ho worked comp. G 152,¢1 NL and vre have rq 12.0 Roof repairs insurance tegairrd l r :mployetx(*'o workers•
comp, ittsuraaar requiml. 13.0 Outer
Ally.Ppaer ar ehetda boa n coat go 0Y as an rnme IxAm Aeriy their W~arpesuita pdiuy faawarliea
•IHr\wbtao sure wadi tail aAlewii in"w6q Ay ore dairy/Y wsA eat as ble entries eomovic a P",WHO , a ear r'-010-, s 16r1 card Nis bee anus arhdsst on sdditlmel.brel•aowiq We saes dale eMderil indkorina coca.
/ Masenwsas set taeis aot6ee'oentp Policy iel6ree"
amr�uw am player
, �..v.... .,,-,= r ��,� dew/s the puHa awO 1 .....+- player that
at k prev/dlwx workers cost�wradow huwranee m rw ear o es B,
insurance Com Vamp•
Policy M or Salt--its. Lie.M _ .. EApirauoo Date: O
lob Site Addruss:� I_�f-a' a )D Su— Citylstata2tp: 5 ( C�l4. '174
attack a cupy of the workers,compasatiun pulley declaration,page(showing the policy number and expiration date).
Failure w secure coverage as required under Soctio t 25A of NGL c. 132 caa lead to the Imposition of criminal penalties of a
fine up nl S1.SOO.00 amollor on,-year imprimmncnt,44 wall as civil penalties in The form of a STOP WORK ORDER and a tint
.1f up to S250.00 a Jay Jgainal The violator. 1)e advised that a copy of this slammunt may be turwardod io The Orrice of
n�:a g,uuiu ol'ihe DIA :br insurance carvcr;jp vcrifruliun.
/der hereby ce ♦Ali` td n !les 00rdaty/hat/tile lmf*rmw&a prorided osaw it m"lead eOrrrel.
1i�•:fgt ur.: ]�
z 7l
U/Jlritf wrle owlet /an,lea wrltt is this orra,ro At rowpkrmriip clop or OWN of fid
City or'faws: Permim ccate
lssa(ng Aulburity (circle one):
1. 11414111 of Ileallb Z. Building Deparculelll J. City/foNs Clerk J.Electrical Inspector S. Plumbing laspeetor
b. Other
Gnuact Person: _ Phone N:
F
Information- and Instructions
Mass tehusetta General laws chapter 132 requites all employers to provide workers' compensuion fiat their empb*vm
m this ranee.as -is
dtxfitred r'...6vay person in the service of anaher under anY Contract of bits.
Pursuant
C%press or implied.oral of wrkte0.'
_ nasrittiea.oorporatioa�other�etatiry,err say two n mine
d dsAaed n"ea iadkvid"L pattaeex.R" ndvm of a deeea"d employer•or the
of the foregoing en lad in aJ�taterprmae.and incl ding ftic if l reptsnea However the
receiver es trustee of an urhvrdttel.pefaterrbF aamatauoa of other legal eorirY.aatVlnYin. erdo occu
horse hnvia{sot memo rhea tbwe red whe reside theesba.or the occuPera of
°�Of a deeiiiiiing of Nt whe employs Persons m do Mainte�r'c`�rr"Co"of repair work on such dwelling lwmw
or otherWild tt� pptaanaar th0 N I shag as issesass of is ah smploymmt be deemed to be as employer.
of an the>Re°� a
btt,l draper 152.f2SC(6)oleo stars that"e"�caw K Meal Omns S agsaryM the ea e
naewd of o"team er permit a ~•badMes er n Cmplhu et btttldlap
evitMam of CeesplMatx+with the IrHaraaM tetrerap relnfred. !hall
who mesa sat pndaad aaep�xbM o coMMUM1931111111 sot ear of ils potitiesl sub8vidoas
additioeaib.MGL Chapter 1 S2.i2SC(7) blic work anal' aoeePnbk evidence of eoraplisoea with the insurance
enter Vasa any nrmses for the perfacmaece m tbs correactiag an�otit""
rcyu;nmtae of tbis ah.pw bave bees prdmrtad
ApplM.na eheoking the boxes that apply to your tiw.aen and.it
affidavit s along with dair certilkate(S)of
Please tell out tbs weekers' cter()�s)6 fie)�Phone noshes( ) ttt
necesssey.supplyCompanies at Limited Liability Parm ablPs( other the the
arb•eantrncror( LLP)with no employee
msumnclL UWADdLiAbilky
ate act required m carry worker'eor�amtiaa rosuranee- if as LLC or LLP does have
members OraPott�.k requited. dBeadvised that this aflidavk may be submitted to the Deparmu"t of ndusirid
employees. pia re insurance. Bev eoverttge Abe be sun to sip and date the NUMAviL rw affidavit should
Accidaa"for conflematiettlicatiaa for the permit a license is being requested. not the Deparmww of
be returned to the city err mwa that the application
regarding the law or it you an required go obtain a worker'
loduW61 Accidents. Should you have any q es the number listed below. Self-muted companies should eater gait
compensation Polk".p�call the Depetunent lips.
self-inearaaee lie
number on the
city or Town of le"
..._ - 1 --- lei The Depseen na her provided a space at tlrn.bottwa.....
Please be wto that the affidavit is complete and punted' g neestigations the lieatrt
of the affdavit for you m fill out in
event
which Office wi of ll be used as as rreeterence to nunrbar. n addition.napplicant
1't.:ase be sure to till in the Pu marked by iyliearxsa apptkatiow in say given year,need only submit one affidavit indicating current
that must submit multiple perm .earn should wrist - may
locations in (city or
policy information lit necessary)and under"Job Site Addr9W rY the city or
tomvtrb"A copy of rta a town ey be provided to the
ffidavit that boa!teen officially stamped or a licenses A now aflldavit nrttR be tilled old eadt
applicant as proof that a valid affidavit is am file n for future permitsPermit
not related to any business or commercial venture
year. What a home owner or citizen u obtaining a license err pan
license or Permit m burn leaves saw)said person it NOT requued to Complete this affldnvit
t i.e. a dog .
• 'uns would like w thank yaw in advance for your cooperation and should you have any questions.
l'he Ot'ticc Jt !nvtxti�an
lea,e do rwt hesitate to give us a call.
The Department's addres& telephone end fax number'
TM COMUMwealth OfMm"htlsm
Depatun90 of 1n�Aaidents
oma.rtawsdP0d
fete w"11106loa S1111rew
Book MA 02111
TeL 11617-727-4900 eat 406 Of 1-877-MASSAFE
Fax 0 617-727-7749
,taviaca i-IG-US WWW.MM-JOV/"
• CK PUBLIC PROPERTY
3 !Q3 DEPARTME,NI T
KI%GWA.sy ouSCLAL
MlAraa 120 wASMNGWw MEET�_ YUYW6 MASSAO/lSETiS 01970
TEL-978-745-9"S•FAX 976.740.98"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR GRANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: ',J11A.-W` / uilding:
Prooertv Address
Property is located in a:Conserve Area Y/N Historic Olstrict Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: '
Address: J /
Telephone:
3.000MPLETE 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 N�
of existing building New
Brief Description of Proposed Work:
- - - - _— -
Mail Permit to: J -
7777711.
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Win the Building Coonffoorrmm to
Law? Asbestos?
ct'Archites Name u' �" ' — S
Address and Phone
Mechanic's Name
Address and Phone 3 z 1
Construction Supervisors License# IC Registration# 7
Estimated Cost of Project$ Gov Permit Fee Calculation
Permit Fee 5 Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/i1000 Commerciat-
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 a ZL —z
Date
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