14-16 LEACH ST - BUILDING INSPECTION (2) ITS OF SALE
` PUBLIC PROPERTY
DEPARTMENT
Kl%iBFJU.EY DRISCOLL
MAYOR
120 WA$HINGl'ON STREET*JAtEu,M,tuACHLStITS 01970
TEL-978-745-9595*FAX 978-740-98"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: ,-_ 3 Building:
Property Address:
1q- i (o - CEAco 5i
Property is located in a; Conservation Area Y/N-N(—Historic District Y/N aJ
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land e
Name: _ 2VE ( I IU D►"�1� _
Address:
A-j E PE V CYL✓
Telephone: 6 4Z
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing y PEC W-r
Renovation Number of Stories Renovated
Change in Use J New
Demolition Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: �7 1
K'zv\6v�I o� �K, S'T\✓�� �'aG Icy S �g:yl
Mail Permit to: i I- I, t e-A oZ.tS 1 -
f
Y
What is the current use of the Building? 2e
Material of Building? WI)ar If dwelling, how many units? S
Will the Building Conform to Law? J�j Asbestos?
Architect's Name
Address and Phone
Mechanic's Name oZ� 'r
Address and Phone
Construction Supervisors License# Q&6-? HIC Registration# 3 �,
Estimated Cos l�ct$ 7
�00� Permit Fee Calculation
ro �
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 o o th ove stated
specifications. Signed under penalty of perjury X
Date V - 3
0
N
o p w
I- 0 0 C7 0 > o
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xA1aER1J:Y ntuscou
MAYOR 120 WASHNGTON STREET•SALEM,MASSACHUSE TS 01970
TEL.979-745-9595 •FAX-979-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Apiplicant Information Please Print Legibly
Name (Business/Orpniation/Individual): Ff'�'ilZl `1 /".IT2i�t!i'f1U
Address: 6 1 3uc il/U ^'1 ST
City/State/Zip: 1iyUelcf& &LW 0244q Phone#: 6/3 3L -((Dq-
Are you an employer?Check the appropriate box: Type of project(required):
1.LD 1 am a employer with -3 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. alkemodeling
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. [1 We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers' comp. c. 152,¢1(4),and we have no 12.❑ Roof repairs
insurance required]t employees.[No workers'
comp. insurance required.] 13.0 Other
*Any applicant that checks box#1 must Alm fill on the section below showing their workers'compmution policy infmmatlea,
t Homeowners who submit this atHdavn indicating they are doing all week and then hire outside eons eceors must submit a now aflidwit iodieatlog such.
rContraUon that check this bore moat sthched en edditierul sheet showing dig name of the stub-eontraetoe and their worker'comp.policy infamaden,
I am an employer that Is providing workers'compensadon insurance for my employees. Below is the policy and fob sUe
information.
Insurance Company Name: Jam-_ f fTcf�i?�T p 1�7y'�� Cjrcrace
Policy#or Self-ins.`Liic.#: �7 'Z X i Y 0 Expiration Date- �Q ' l ' 0
Job Site Address: IT`f6 clG�CW --7 Ciry/State/Zip: 'f � 9,/L4
--
Attach a copy of workers'2oropentation 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 S 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
Investigatio the DIA for insurance coverage verification.
I do hereby ce r a* and penalties of perfary that the information provided above is true and correct
Sin / t • /1- 3-o to
Ph • to
Off7cial use only. Do not write in this area,to be completed by city or town offleiaL
City or Town' PermittLicense#
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 a ofloy;
Pursuant to this statute,an employee is defined as"...every person in the service of another under any
express or implied,oral or written-"
An 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 shall notmaintenance,
because construction e o r reap be deemed to work on h dwelling emp house
or on the grounds or building pp
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 Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or parmeM 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 fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemaittlicense 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.,Anew aFdavit 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
(i.e. a dog license or permit to burn 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 CotnfnonwmIth of Massachusetts
Department of Industrial Accidents
Office of Investlgadons
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 VVVVw.mass.gov/dia
I
CTI'Y OF SAL.EM
PuBuc PROPERTY
DEPARTMENT
w,aaaur o.aaoia
N.rua 13tw�a�wZorsnaar•swa,4areseaa�resOt!'f0
1ti<:MUS-ft"•Fete W&74&U*
Construction Debris Disposal AiRdavit
(mquired fot aU demlition and muvadon worst)
in aceordame with the six&edition of dw Sham M"ns Coda.780 CMR section 111.5
Debr*and the provision of MGL o 4%8-%
gyms ft. N is iswed with tits condition that the debris resulting Ilan
Lhia wart shall be Almond of in a peopaly licensed wum digmW WiUty as defined by Mt3L e
111.31SOA.
The debris wiU be transported by:
/SD ket""iewi &m.Lr7: �i2vc
(same albsaq )
I
i
The debris wiU be disposed of in
G%p�/LU.9�TF � �J Ts•✓
(Hama oll4eili
(ad&m of rcaay)
si o/ oat
data
C17-
Board of Building.Regulations and Standards
.HOME IMPROVEMENT CONTRACTOR
Registration: 137154
Expiration: 10/11/2008 _
Type: DBA
AMERICA'S CONST.CO.
MIGUEL GOYENECHE
61 BUCKNAM ST.#1
EVERETT.MA 02149 Deputy Administrator
✓�ie �ioiivmmeural� o�./f�wv¢r,�suaelte
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 081833
Birthdate: 11/01/1966
"Expires: 11/01/2007 Tr. no: 8585.0
Restricted: 00
MIGUELA GOYENECHE _
61 BUCKNAM G.
EVERETT,RETT, MA 02149-
Commissioner
� r
r
.; SSL`E DiTE
THIS CT^RTIPICAIE IS ISSUED AS A MATTER GF LNTOR.YI Al"la\ONL]'
I PRODUCm AND CONFERS NO RIGHrs Cl-ON TTE tERTIric ATE MOLDED. TINS
- RAPO& JENSEN TNS SR V I CL6rMC4TE DOES NOT AMEND.EXTEND OR ALTER I FIECOS'CDACE
I I ATPORDEDRYTHEPOLICIESIELOIA.
1758 CENTRE STREET COl�TP4NTFS AFFORDINGCOVERAGEWEST ROXBURI MA 02132 L:DYff AA
LFTEH :.AIIARITORDTINDERWT -IF,16INSURANCEC0
cola wT B
. IF1T'Jt
L\SURED L"D""I 1 C
GOYENECRE,MIGUEL DBAAMFMCA'S LE Tta
cD)vn3�
CONSTRUCTION CO L-FL
61 BUCKNAM STREET#I cmaAPr I E
EVERETT MA O2149 Lrfi� I
.. ..
1 IFBS = STAIR 7[FY THACISE PU111ES OFINSLRINT:E LISTED 8fl.7w SAVE ftEENOROT ER T�A3E)RSD\,li kESPICTI IA - Yi- -- C T-- i;_ATfL�
NOTK7THSCAHDMG AN AIQL7REMEHI,TERM:ORCOWDSRONOFA_NYCONTRA�T-TOR OTHER DOCOMENT K^TEitcSPFCT TO agCH C3�SC'ER:"D1C aTT:AA.
"3=
LSSEFDORMAYFSRTALN.THE MSITRA-NCE AM3RLFD3l'TEEPOLICIESDESCRHIEDi ,RE)NSSLH)ECTTO ALL TFETIIA'�£i.E:.f_ELV�N�w`11Cf1 T�71TC1\SCff cL'CR
iRD R'll K I'A3D S WI N'tl MAY HAY+4�'A R+OIA'HIHY FAC)CI AIMS
CO TYPE OF LVSDRA.NCE POLICY M31BER POLICY FMICI ' LZITTS
L,, EFFECIIs'EDAIE EXPHIATION DATE
LIEWDDr. I 3h6&DD/)Y3
� GENERAL.L;ABE'..�rT GE�R1t vi.3SEG i'IF S
ICVFDLRILV.Jt�tRNLLADLL311 I ! '
fFWV�/V.k 1DL.1."IUEI I
� L f.UMi MAI}E J (KftR
�1 GBYESGCQVIEAC]GP.S YRfA'. I FA[RfifflRtRTNfF
-- I I FILE DANCGE lAq Sae Fv.� S
iJ
YIEP.ECFNSI:�;r,.r i+�".re S
I AUFOMOBEE IAABIGTY ' CG+mOCEL:s-�LF LP�I
AW ALTO
EI:ULL�1N4E1
' ] ALL OBTCED AI3IJT I Iaa fe- 1
I
L YC[OTATFD.uT05 j
1 1RIi1 A11PJ$ EC➢Rl'FT'ES $
j — ; QB M'iXMI
,� WOSfM3ED�EITA
' RCHFEIY UAStAGk 1
L GARAGE IIABL'IY I
I
EXCESS I-LISHAI)!
T' 12tEREi_'+roEY FXHUCCZi[F.YL S
j l7tlgRIBlV GE®BE�SAKims I AGGRE.:AT£ 5
I I
1 51 ATLRVEY 11S3T.'A
wCWKER5'CFP4PELSSATI0N DS94n 490u 1DOD06 1001 IN L. 'KACCWE SIK.94D
.a AND EhBI.OYER'S I.IARII.[IY DLSEAX YOLYY IGCI ;SOC.o[0
The SRIe m/Pv 5 eue):e lXBen v< SIO"--.Oci
OTHER
Dlrro*I OF oe•�AiIDNsrtoc'wT:orsnF�c�kzw.EEmD; "— --�
TSLSHFYIA[:ES wDY PYIOH[BIIIIC AiYRS4]ATroIFPC�IIDICwTEHOID3HwFFOCfLWI wODFi$SCONP:'orF3AGC I
SHOC4D wPTOF TH'e ABJYE DFS[➢.t9ID WL[CIFi B=rA_V,f=trn D'u OFE TRE-
_ REYIRATR)Y DATFTFr1�JF,THE 135["ISAiC.*�n.T1,41LL_T.DLAA'GR CO?:.1R Ir:
DAYS wHEITIIi:1OTScc IOTNE Cmu=AIL 3PJID-�Y.ev�D TC EF'S:Y]'I,
' DHr FAL.VRE roDt.n G�D'.MIFCC SH.J.L (DL'G^.E:1O'JOLICAI30�=C1R
LIAH11:�'OF.V:YRL1DGi✓?\ZAECGSIIA.�Y.TY wGt\ISGS R=PFES�'AT:FE?
YTNOYL[DAEWtLPiAiR'E � '
DIAN_4 JACOBS