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8 LATHROP ST - BUILDING INSPECTION i No. Dow awa In Y.�_w� OorMMwMgn Aw�7 Yam_,Ib BU LMS PLVW APPLWATION POIN Pamfk to: (Clfda Whld~apply) ROd, RN00f. Irm" sk ft COfIN�YOI rShed. POC14 RApaidRspbm clowx•,, <'ta,r r l(/yG [A e 1 PLEASE FILL wr LEG Kv A COYPLETIELY TO AYOID DELAYS 0 PpOCESWNIi TO THE WMCTOR OF BUILDINGS: The urfdaraiprfad hamby appYM for a pwmit to build aoowft to tha foYor ft Owrors Noma /GC& o✓-411 Addraaa 3 Phorfa 3 /)d vf�c rl 1-4�1 J607157 0 Ard*o a Name Address A PhoModWft ns j 1 i Name Address& Phww --- I 1 "w k w.prpo..al b~ kaw"a fir P% L". v3 v r al 110,for now wore►l 11 7 wfr burmrq oaram a JW caruo o N A arr • C olS4 5t lmpmvm .t x rao. 0mow• of AppWW soWl IMIDEIi THE PENALTY DESCRrTM OF WORK TO IN DONE oP PMULW �cc five f�,,,trcc-rrf r'ofle-cd U1JAs r� MNL PERMIT TO: T /l A APPLICATION FOR PIMA I TO LOCATION 9 LstTNPoP �T PERMIT GRANTED :Mv()A-PW i4 2bo S- OF The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/PlumbersA Applicant Information " '" Please Print Le¢ibly Name (Business/organ zation/Individual): Yh�� !v✓ r Address: /�U� s l c�/ (' G /City/State/Zip: � � �� phone#: &'07-_Jf_ --; 1W Are you an employer?Check the appropriate boa i " ^ Type of project(required): 1.❑ I am a employer with 4. Ell am a.general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub_contractors 7. 1� �emodeling 2.$I am a sole proprietor or partner- listed on the attached sheet. t Gam"' 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 required.] r .L " ,, officers have exercised their' 3.❑ I am a homeowner doing all work right of exempnon'per MGI: 1 is D Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4y,and'we have no Iin Roof repairs insurance required.]t•. employees. [No workers' 13.❑ Other comp. insurrancc requlredJ1, , Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.' " t Homeownets who submit this affidavit indicating they are doing all work and then live outside contractors must submit a new affidavit indicating such tContractors that cbeck this boX must attached an additional sheet showing the name of the sub-connectors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurariee for myemployees. Below is the policy and fob site information. Insurance Company Name: //�/�� y✓G�C P �t Policy#or Self-ins.Liic. #: 5(�G �2��l�� / ' Expiration Date: 7— ��/ Job Site Address: oj Ze--' /l rO12, ,/�t City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi r the par nd penahks of perjury that the information provided aboovve is true and correct: Sip_nature• Date: Phone# 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 Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and.Instructions Massachusetts 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." An employer is defined as"an individual,partnership, association,corporation orrcother legal entity,or any two or more - of the foregoing engaged7 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." Additionally,MGL chapter 152, §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-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited LiabilityCompanies(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 atffdavk. The affidavit should be returned to the city or town that the application for the permit of 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 fill in the pemtit(license 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 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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The 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 Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia r i ' �' ✓/� �onmxonl�i o��/�.omac%rm� BOARD OF BUILDIRG REGULATION6„ �'I Lreefiw. CONSTRUCTION SUPERVISOf . ' � � Numberi GS 065476 �'�, Birthdate: 03l.Ml966, ` .f,l Expire4. 031bW2007 Tr.no: 654A d06 ROBERT 11 PARK DANVERS, Administrator i CITY OF SALEM, MASSACHUSETTS Is PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAIL: 978-740-9846 Salem Buildine Deaartment Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter III, S 150 A. The debris will be disposed of in: (Location of Facility) Signature of Applicant Date ULTIMATE INTERIORS I23 Douglass Way Date: 12-27-05 Exeter, NH. 03833 (603) 5804986 Proposal submitted to: Joe/Sheri Woods 8 Lothrop Street Salem, NIA. 01970 Proposal -Demo existing staircases on side of building only. - Install new staircases in same fashion as preexisting staircases. - New staircases will be built out of pressure treated lumber. - New staircases will be built on existing footings with permission from the building inspector. All material is guaranteed to be specified, and the above work to be performed in accordance with the drawings and specifications submitted for the above work and completed in a substantial workmanlike manner for the sum of: Two Thousand One Hundred $2100 00 Payment Schedule Uponstart of job ............................................................................................................... $ 1,100.00 Uponcompletion of job ................................................................................................... $ 1,000.00 Respectfully Submitted: