97 LEACH ST - BUILDING INSPECTION 14..*NS1NtlST.-SEfittg4AD A?PROVED BY T44E
�MSPx=DB.PMR TD.A.PEMff MING GRANTED
CITY OF SALEM
� oats
. J
is Property Located in Location of /
the FUatork Disidd? Yes No Building
Is Progeny Located in 5 ��
the Consera*M Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install 'Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: fir ,011r c? xr s'f n 1. rT fla
PLEASE FILL OUT LEGIBLY r4 COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS.
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name -:I-. C 1M a rf 1 rl Pa U -
Address & Phone gI 7 L e A C--A S+ 75 y— S 3 a 7
Architect's Name
Address & Phone �"—
Mechanics Name i
h Address & Phone ( 1
11
What is the purpose w bWadnp?
Mals"of biwdnp? n a Owe",for how many famines?
5
WE bLAki cordonn to law? Asbestos?
Edmated CON 'a 1-31 �6 so— CAV L Ww C k mob use d
Bone Improvement
Lic. I s a Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
e _22rc% s 3 Story
MAIL PERMIT TO: TDr.�—
Not,.4
APPLICATION FOR
PERMR TO
LOCATION.
PERMIT GRANTED
310 20
A ROVED
INSPECTOR OF BUILDINGS
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KLNEERLEY DRLSCOLL
MAYOR
120 WASHM'GTON STREET♦$At EM,MASSACHUSEM 01970
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Plumbers
Applicant Informatio
(� t Please nt Le
Name (Business OM&nizaaor,nndivi"): E�('h1g d P vt e r u i c e s
Address: y7g !LQ-10�1 Si •
City/State/Zip:—_Qy�1T` M A O l 9 1 5 Phone #: g -�'z-2
Are ou an employer?Check the appropriate box:
I.[ I am a employer with Z 4. Type of project
❑ I am a general contractor and I (required):
employees(full and/or part-time).• have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner_ listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8.
working Demolition form � ❑ non
g e in any capacity. work
[No workers' co P tY era comp. insurance. 9
comp. insurance 5. ❑ We area ❑Building addition corporation and i 8 a
� is
required.) officers have exercised their 10.C1 Electrical
3.❑ I am a homeowner doing all work right of exemption 1EPcira or additions
myself anP Per MGL 1 I.❑Plumbing repairs or additions
y [No workers'comp, c. 152,§1(4),and we have no
insurance required.)t employees. [No workers' 12.❑Roof repairs
comp.insurance required•) 13.0 Other
Any applicant that checks boa#1 must aim fill art the a faeti00 below showing their Homeowners who submit aotltmN eompeoauioa Policy i0fertaati0a.
t thisaffidavitmdtatio
tContnseton that check this box must a they doing all work and then hits outside contaetess must submit s new affldsvit such.
attached an mdditimul sheet showing the name of the sub.con
!am an employer that Is providing workers'compensation insurance or ur emp o ee& Belo and thew w Is tbepol y i��e�
information f Y P Y p icy andJob site
Insurance Company Name: MV Q 1 Q('S
Policy#or Self-ins. Lic.#: aiy I l e
Expiration Date:
Job Site Address:— 97 CPn c( S i
City/State/Zip: -XA I e M,.__,M R O 19 7 O
Attach a copy of the workers'compensation poky 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 3 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.
!do hereby ce fy nder the psi and pegaIdes of perjury that the information provided above Is due and correct
Si
Dt • io I (710
P LM72 — 4 Z-5-L0
OfJleia:::::
t write in this area,to be completed by city or town OJJIciaL
City or Permit/License#
Issuing one):L Boaruilding De artment6.OtheP 3. City/town Clerk 4. ElectNcal Inspector S.Plumbing Inspector
Contact
Phone#:
Information and Instructions their loyeea
wires all employers to provide workers' compensation forth cusp
tois defined as"...every person is the service of another under any contract of hire,
Massachusetts General Laws chapter 152 requires P
pursuant to this statute,an employee
express or implied,oral or written." two or more
is defined as an individual,partnership,association,corporation or other legal entity,or any
o f employer
ed in a joint cnterprisa,and including the legal representatives of a deceased empl°Yu,or the
of the foregoing engaged a association or other legal entity,employing employees However e
receiver or trustee of an urdrvndual.parmershrp, and who resides therein,or the occupant of the
owner of a dwelling house having not more than three spsrtme lion or work on such dwelling house
house of another who'
Persons to do maintenance construction be deemed to be an employer"
dwelling thereto shall not because of such employment
or on the grounds or building appurtenant
or local licensing agency stag withhold the
MGL chapter 152,§25C(6)also states that"every state issuancebtdldfngs fa the commonwealth for hforany
or
renewal of a license or Permit to operate a business°r to construct
produced acceptable evidence of complisace with the insurance coverage litical subdivisions shall
applicant who has not p Hance with the insurance
Additionally,MGL chapter 152,§25C(7)states"Neither the Commonwealth
of compliance
enter into any contract for the performance of public work until accep
resented to the contracting authority."
requirements of this chapter have been p
Applicants applyto our situation and.if
Please fill out the workers' compensation affidavit completely-by checking the boxes thattheir
y
s address(. ) hone numbers)along with then certificates)other
necessary.supply sub-contrOf
actors)mine( )• es and p Partnerships(LLP)with no employees other than the
insurance Limited Liability Companies(LLC)or Limited Liability
members or partners.are not required to carry workers' compensation insurance. If an LLC or LLP does
Be advised that this affidavit may be submitted to the Department affidavit should
employees.a policy is regoverage. Also be sure to sign and date the affidavit. The
Accidents for confirmation
insurance c for the permit or license is being requested,to obtain a workersent'
of
be returned to the city or town that the applicationsalons regarding the law or if you are required
Industrial Accidents. Should you have any qu at estions listed below. Self-insurcd conrpames should enter their
compensation policy.Please call the Department line.
the number
self-insurance license number on the a riate 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
dons has to contact you regarding the applicant
of the affidavit for you to fill out is the event the Office of investigations
number.as a reference applicant
Please be sure to fill in the permittlicense number which will be ar need only submit one affidavit indicating current
submit multiple permivUcense applications in any givenY
policy nformation(if necessary)and under"job Site Address"the applicant should write"all locations in (city or
that must
town copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
i
davit is on file for future permits or licenses. A new affidavit must be filled out each
applicant as proof that a valid affi
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 vruosnald to thank yo
u in advance for your cooperation and should you have any questions,
please do not hesitate to gi
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of lndostrial Accidents
omee of Investigations
600 Wasbington street
Boston,MA 02111
Tel. #617-727-4900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mm.gov/ilia
CTTY OF SALEM
PUBLIC PROPERTY
DEPARTmENT
KI&MUM aV DOW=
NAvoa 130 WAswMCf M STREW•SAS StAaGG"WIS 0IW6
Consimcdon Debris Disposal Affidavit
(required f w afi demolition and movatim work)
In aeeordanm with the sixth edition of the State Buildius Cods.780 CUR section 111.3
Debrist and the provisions of UGL a 40,S-%
Building lsermit 0 is issued with dw condition clot the debris reaultins ftm
thin worst shall be disposed of in a prvpc ft dioensed wasp disposal&duty as defined by MC1L a
111.S 130A.
The debris will be trartap rW bir
Lp C-r o (Z
(Hama a[baatar)
The debris will be disposed of in:
YV
(nanta of hwity)
(adders of f9adiry)
Sivm"*(Pan*apptk,ar
fo �23�0�
data
.:ehriw7.Jus /
fo"
Ott, Aee p
Remodeling Ser'izes
RMS
Estimate e
P.O. Box 426 Date
Beverly, MA 01915 7/6/2006
978-922-5413
Name/Address
J.C. Martineau
97 Leach St. Project
Salem, MA 01970
Description Total
3 STORY BACK PORCH
Install planking and plywood over built-in swimming pool to protect from falling debris
Demo existing 3 story back porch (excluding roof)
3 Story porch size 6'x 13' each floor
Specifications:
*Framing- 2 x 8 pressure treated floor joists
6 x 6 pressure treated support posts (3)
*Trim-1 x 8°Azek° brand pvc skirt on perimeter of floor joists
*Railings- 2 x 4 Red Cedar top and bottom rail
2 x 2 Red Cedar balusters
*Decking- 1 x 4 tongue and groove fir decking
*Stairs(4 steps)- 2 x 12 pressure treated stringers
1 x 12 °Azek skirt on stringers
1 x 8°Azek° risers
1 x 4 square edge fir on treads
MISC.-3 - Ur footings to a depth of W if possible
Steps to rest on concrete footing on bottom step
Roof to be left as is
Lattice under bottom porch to be left open
Ceilings of porches to be left open unless otherwise discussed
Plate for each level to be fastened with 5", 3/r Galvanized lag bolts
2 courses of shingle to be removed and replaced so as to properly flash deck
All debris to be disposed of in a neat and orderly fashion
Contractor responsible for all permits and inspections
Proof of proper insurance and builders license will be provided
Stock& Labor 13,850.00
Total $13,850.00
ar
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3068
7�e
13'-0"
IT DECK
FD 13'-0"x V-11"