263 LAFAYETTE - BUILDING INSPECTION <, (: hC'1,3I:1C
DI-PARTNILNT
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APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DbVELLINGS
IMPORTANT: Applicants must complete all items un this page
SITE INFORMATION �J
Location Name Z6,3 Building /
Pro f ddress
Located in: Conservation Area Y/N 0 Historic district /1/21
APPLICATION DATE /Z,2
Use Groups
(check one)
Group Homes R3_R4_
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) R1 _
(check one) Assembly (Theaters) At_
New Building_ Assembly(restaurants & clubs) A2r_A2ne
Addition Assembly (churches) AI
Alteration Business B_
Rcpair/ Replacement Educational E
Demolition Factory (moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile M _
Storage S1 _Moderale Hazard
Storage S2_I_ow Hazard
OWNERSHIP INFORNIATION(Please type or Print Clearly)
ONVNER Name
Address .2,bS .C,a A u "x?- �f
Telephone
Signature _
DESCRIPTION OF %%ORK TO BE PERFORMED
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I•:SrIMA fED C'UNS'(RUC'170N CUS'F ez'!3D
cuN rliscroli INFORMATION
C�Name
Address 1-7 .Cho �--v S '
Telephone9/,74-
Construction Supervisor's Lic # C'S 7rZ.77
Home Improvement Contractor# /T/S/3Sl
AItCnrrr;Cr/GNCINEER INFORMATION
Name
Address d//
Telephone
Mass. Registration #
YFACMIT FEE CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
CONINIENTS
The undersigned applicant does hereby attest that all information stated above is true to the best of my bnoivledge
under the penalties of perjury
Signed (owner) (went)
> >
Al 1 ROVCD BY :
DATE APPROVED:
y ; y CITY OF SALEM
'j PUBLIC PRoPRERTY
DEPAR"C�1ENT
lyM V -
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Construction Debris Disposal Allida% it
(re(luircd for all demolition and rcnuvatiun \wrk)
In accordance it,, the sixth edition of the State Building Code, 7S0 CAIR section I 11 .5
Dcbris, and the pro\ isions of'vIGL c 40, S 54;
Building Permit t is issued with the condition that the debris rcsuhing front
this work shall be disposed of in a properly licensed waste disposal facility as defined by V1GL c
111, S 150A.
The debris will be transported by:
luamc ul hauler)
Ile debris will be disposed of in
(name ul Iaalliy)
I uJ\Irca. of I.Jnlllvl
�IL'IW WIC It panut apph.aui
,lur
CITY OF SALEM
' t,• ; PUBLIC PROPRERTY
?'T DEPARTMENT
J,aC K:I )':)Kill t-11
\Ii`tal 1' • SAII•\LM.ssssc.Ill it ) Is0197-
l'cl. 978.71 i-95'15 • 1:\x 979.74C'1846
Workers' Compensation Insurance :\tridavit: Builders/Contractors/Electricians/Plumbers
\ ) )licant Information Please Print LeCihIV
i i r� , ,2
ValTtc lnu.utc,y l)rgaln r:uinNindnldual): '�f4
Address:
City.Slale.lip'
.k re s au an employer:' Check the appropriate box: 'Type of project(required):
1.❑ I :tin a employer with 4. ❑ I am a general contractor and 1 6. Q new construction
have hired the sub-cuntructurs 7 ❑ Remodeling
employees(lull antL'ur part-wne).x listed on rho attached sheet. :
2.❑ 1 aot a sole proprietor or partner-
These sub-contractors have S. ❑ Demolition
ship and have no cmpluyucs
working for me in any capacity, , (workers' comp. Insurance• q. ❑ Building addition
I No workers' comp. insurance 5. h{J We arc a cooperation and its 10.❑ Electrical repairs or additions
I required] /1 officers have exercised their
owilrri ht of cxcm tine er MGL 11.[ Ptumbing repairs or additions
3.❑ 1 an a ho o owner doing all work c 5152, i 1 4 ,Pond w have no
myself. (Ko workers' comp. � O 12.❑ Ruul'npain
insurance required.J cinpluyces. lKo workers' 13.❑ Other
comp. insurance required.)
•nu}.�ppbcaut trial chucks box 01 must:Jan fill wn the.ecuen Itcrow slowing thca wurkui cunipcn W ion pulicy i nian,,tiun
'I lumcuwrwn who snbmil this alTidavi,indiuung the).tie Going all work and Ihcn hire uulside cAnrxsois must athmit a new JIrdavit indiuling rash.
-f,mtrxutrr that shcuk this box moat stlxhcd.In additional atw,el.hawing tlw u:nna of tot¢subContracton and Ihcn wurken'comp.policy information.
/lull tin emplayer that is providing workers'cunrpenevuion insurance for toy employees. Belrnv is ilse pulicy and job site
inJurrnatiom
ImmirancL Company
Itolicv is or Scir-ins. Lic. tt: ___ .. . .. Ewpirauon Date:
Job Site Address: ___. City/State/Zip:
Attach if copy of life workers' cotnpensatiun policy declaralion pale (showing the policy number and expiratiun date).
failure to secure coverage as required under Sectiun '_5A ul'>IGL c. 152 can lead to the imposition of criminal penalties of a
laic tip to S1.500.00 and/or unc-year impl'nonincnt, as w'Cll as LIVII penalties in the loron of a STOP WORK ORDER and a fine
Of up to S2511.00 if day against the violator. lie advi.ic:d that a copy of this slutLmcnl may be Wrwarded to the 011tce ul
I IIt:ill jallnlli ul talc DIA for ui,attar ce :Iwcragv scriliLaimn.
/du hen-by e:rfijr lift, • he poinx and t ,dtics of rjary that the iufbnnifflon provided above is true and correct.
;I•::I: tort_ - -- DtLic Z 6 a�
O/Jie'iul list only Do not irrife in this area, to be rumpleted by city or town official.
('itv or town: —.... _— Permit/License 0. i
Issuing Aulhurily (circle one):
I. Board of lie.'lilt Z. IAuldin� Ucparuneut J. Cit):fosse Clerk 4. L••ILUric:d lu;pecror 5. Plumbing Inspector
6. Other
Canlact 1'c nuac .. _- Phone it:
Information and Instructions
NlaI iacllu.iett> UCnCral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Purstl ult to this .latule,an rmplorre is defined as "_.every person in the service of another under any contract of hire,
express or implied. oral or written."
.%n employer Is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more _
,,I the t0rceoing engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the
receiver or trustee of .ui Individual,paitnehhip, 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 >uch dwelling house
or an the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
\IGL chapter 152. �25C(6) also stares that "every state or local licensing agency shall withhold the issuance or
renewal of it license or permit to operate a business or to construct buildings in the commonwealth for any
applicant wbo has not produced acceptable evidence of compliance with the insurance coverage required.-
Addiliunally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of puhlic work until acceptable cvidenct:ofcompliance 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) name(s), address(es)and phone number(s)along with their certificatc(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 irsurance. 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
.\ccidents for confimtation of insurance coverage. Also.be sure to sign and date the affidavit. The affidavit should
be renamed 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 :md printed legibly. The Department has provided u space.ut the bottom
of the affidavit for you to till out in the event the Office of Investigations has to cuntact 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 penniulicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and tinder"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 filled out each
Year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
Me. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I ha )I llie of lllvesn"aliuns %%ould line to thank ynu Ill advance for your cooperation and should you have sty questions, -
please do not hesitate to give us a call.
The D.parunent'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
Fax # 617-727-7749
www.mass.gov/dia
Xord"rBuilding ertguulat�Ions an tandar s
One Ashburton Place _ Room 1301
Boston, Mass&husetts 02108...
Home Improvemenlbtractor Registration
no m y Re9istrationi 151434
1 ti - - _-- Type: Private Corporation
Expiration: .5/30/2010 Tr# 269140
Cn
i m m,o o D. CHASE CONSTRUCTION CORD I
( N m m DANA CHASE
'0 117 LIBERTY STREET a
Z.' DANVERS MA 01923
it �t�1b I�IIi to - 'vr ¢
\ C
TM y Update Address and return card.Mark reason for change.
Address, Renewal Employment Lost Card
O DPS-CA1 0 50M 07/07-PC8490
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- Board of Building Regulations and Standards License or registration valid for individul use only -
I; - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registrations 151434 Board of Building Regulations and Standards
zpbon 5%30/2010 Trll 269140 One Ashburton Place Rm 1301
E
I lra Boston,Ma.02108
Type Phi ate Corporation
D.CHASE CONSTRUCTION CORD
DANA CHASE r '
117 LIBERTY STREET'-'
,...,,,�.,.. ... - . . . . - Not valid withmd cionnhlre