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14-16 LEACH ST - BUILDING INSPECTION EI`I�O�� PUBLIC PROPERTY DEPARTMENT KISRSERI.EY DRISCOLL MAYOR � 1?0 WASHINGTON STREET SAttH•N.%uACHt;StlTs 01970 TELL 978-745-9595• FAX 978-740-9W 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: Building: Property Address: lq- Property is located in a: Conservation Area Y/N_ V Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: L/nlD�2 /j-/6 LfAcNsrv<� �'�vr� ) Address: /2/ �jeoA�atin//� .t-v �vCuet oziS/ Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EX RTtturr BUILqi Addition Exis Renovation Number of Stories Ren Change in Use New Demolition ExisApproximate year of Area per floor (sf) Ren construction or renovation /C(fO of existing building New Brief Description of Proposed Work: AAI) To 60 c Ot'�JF L 4�C 77-1-1 C STjq//rL CAS E I ACC E I 7—(j C'U� l�rh r, v A2<A s , iy!/LO �/002 ST.vYJ 4 1c %y' /s Af�� Ov �nyn #� letvJ Fi✓GCovre r i�. seG ��/�- (�s •�T$ QG / • Mail Permit to: - - - -- What is the current use of the Building? N S Material of Building? W""/ ; 3k 6t-- If dwelling. how many units? Will the Building Conform to Law? Asbestos? .(- Architect's Name l I v,'A Address and Phone�70&x .9 7 /61 02113 _ fed AAe'-ro.es a /,�",,ewe /A�1�•�icr't COa,rra�c��o , C�v . echaniesName l aZ�r`9 �3 jZ7KS Address and Phone 6/ Construction Supervisors License# �g-33 HIC Registration# i 3 -7 Estimated Cost Project$ Permit Fee Calculation 1 �P Cost X$7/$1000 Residential Permit Fee$ Estimated 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 to build to the above stated X specifications. Signed under penalty of perjury N Date 9 — a � s a9i p o 2 w ` te d — - -- ---- 1 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASHNGTON STREET * SALEM,MASSACHUSETTS 01970 TEL:978-745-9595 4 FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le¢ibly Name (Business/Organization individual): Address: /"/ City/State/Zip: 6' ef-ee Ye,4' 071 y 5 Phone #: Are you an employer?Check the i appropriate box: Type of project(required): 1. I am a employer with -t 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. L3Reniodeling 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 officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ 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' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: n''1e-yq�✓ p1'�� - Policy#or Self-ins. 'L/ic. #: L/O5b l3 / �FaX /�5�� Expiration Datecc�� y Job Site Address: � /6 6CAC 5"f 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 iolator. Be advised that a copy of this statement may be forwarded to the Office of Investigatio of the I for i urance coverage verification. I do hereby ce e e pains and penalties ofperjury that the information provided above is true and correct Signature: Date: 6 Phone#: L6 i/3 _3 G-7 a"� 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 f 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 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 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-contractor(s)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 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 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 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 affida-vit mustbe 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 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 +: CITY OF SALEM r: PUBLIC PROPERTY DEPARTMENT KIN DalscoM 5lnroa I�WtiWIJ4Tot+SrRSE.re¢.Lcu \tAiUr3il;5E['i501970 -M-978-74S-9S95 0 FAx 978-740-98" Construction Debris Disposal AMdavit (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code,780 CMR section 111.5 Debris,and the provtstons of MGL c 40, S 54-, is issued with the condition that the debris resulting from Building Permit# this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111,S 150A. The debris will be transported by: �l' ,ce/of f �,alJT af�oa/ /.c,�/"C me mod (na of haulier) The debris will be/disposed of in (n ucu of ility) - (addrees oP facility) signs cant date �rlxi.+lr.Juc ACOJ34 CERTIFICATE OF LIABILITY INSURANCE PawucER (617)763-1160 FAX (617)TB3-2062 THIS CERTIFICATE LS ISSUED AS A IMTTER OF INFORMATION Rapp & .lepsen FI nand al and Insurance Servl ces ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE :I HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 1103 Comm Speal t h Ave ALTER yM COVERAGE AFFORDED BY 714E Fw 9 BELOW. Boston, I% 0221S !NONCE ATdra Amfrlm INSURERS AFFORDING COVERAGE -_ ._- —. INSUREaa- rtf ore I rlsur Inca n IXSIe® Merl ca's Censtruoti On Inc. -__.. ..__.. DBR M9MEA asyeneche RMURERa: 61 Sucknam St. 01 asuRERc: Everett, M102449 ueuRERa rSLHERE THE POUCHES OF INSURANCE U37M BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT-WITH RESPECT TO WHICH TFUS CERTIFICATE MAY BE ISSUED OR MAY Fr31'T AFFORDED AINN,,THE INSURANCE AFFORD BY THE POLICIES DESCRIBED HEREIN IS SUB.IECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.ARiE7Ei[OATE UMRS SHOVAN MAY HAVE BEEN AEOUCED BY FWD CLAIMS. _ _ _.. TYPEOFMSURANCE PoLmOrLSINBF1i v`a rDv PDUDT 11pN UMr19 BIC-RALUAeILnY EACH DCCURRENCe a C DAMAGE 7$IU3+rEO I COMAERCIALOBF.N0.LlWELRY� 211EM�+.--E—P' - 'CLAM IMDE Q OCOUR MEDEW(AW.609MOT) _ B-_ .--- _- - PERaONALaApYIRA1RY C DENLAC,,REMTE LwTAPPILM PER PROpUC19-COIIBgPAGG s POLICY JPEa LOC AUIOaOBDEIIAMUTV - COMBINED SINGLE LINT I ANYAUIO (FuPxHRV1 ALL OMED AUTOS BODILY YHURY SCI®ULEDAUTOa MAED AUTOS B IL RY 3 HOH.DWTB.DAUTOB PROPERTY DAwAfi< y GARAOEUANI riv AUTO ONLY-EA ACCIDENT I 11MY AUTO OTHERTIMN EiAACC 3 AUTO ONLY: ALEG S EXCUFEIIaNSRE1rA WA®tlTT _MHOCCVRNENCE_._ OCCUR I I CLAM MADE AGGREGATE -f - RE'TENRWI a s IAORKMOOHPEISATIOMAND .SMOUI942089904 10/0112005 10101/2006 arA oTx EMPLOYEPS LIAMLRY ELEiACHACCO)EHT_ a 106.0_OQ A ANY pRppplErpRIPARTNEWETECUTIVE _ _ ._ ._. O/FICERIL�ABER EXCIA/DEDP El OISE:ASE-EAEMPLOYE S "I EL DISEASE-POLICY Lwrr 1 a 500,000 OTIUM DESCRIPTION Of OPMATUM I LOCATIONS I VEMCLn/EIOWERONS ADDED BysmODRsENEXT I sFiR LLmovistim I CEMMCATE NOLDEBNCEL ._ SHOULD ANY OF THE ABOVE OEECTAIM POLMIES BE CANCELLED 804M THE man"T;oH DATE TXEREOF.TXE Is511IXG IVSUmR W ENDEAVOR m AWL - 30 DAIS NIOT1Hi NOTICE TOTxECHmnCAIE XOLOHt RANw TD TxE1.EFf. SUM RULURE70NAILSUCHNOT!=XHALL IMPOSE 180M ATIONORUAMM . OFAWIWDUPONTDEE FWU R,n5AGEMORREPitFSE1T ITVP.S. AMORtEDREPNEIEHTAwe Andre Aorim ACDRO 26(RB voB) FAX (617)261-202E CACORO CORFORATION 19118 :s 1 ✓1� �.om�na�uoeizllh o�✓l�amac/u�aetta BOARD OF BUILDING REGULATIONS 1 License: CONSTRUCTION SUPERVISOR Number: CS 081833 Birthdate:. 11101/1966 Expires: 11/0112007 Tr.no: 8585.0 Restricted: 00 MIGUELA GOYENECHE 61 BUCKNA MA 02149 EVERETT, Commissioner 67 nX Board of Building Regulations and Standards. HOME IMPROVEMENT CONTRACTOR Registration: 10/1 54 .Expiration: t0I11/2/2006 Type: DBA A. AMERICA'S CONST.CO: _ .MIGUEL GOYENECHE 61 BUCKNAM ST-01 EVERETT,MA 02149 Administrator -