10 LINDED - BUILDING INSPECTION 9
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APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT - 1
ALL STRUCTURES EXCEPT 1 AND 2 FAMILY DWELLINGS J
IMPORTANT:Applicants must complete all items on this page
SITE INFORMATION [.0 l//z 4, �' /VR1Lz>1e/ ,
Location Name / Building
Property Address !n / i;y��/ S/J/gyy M
Map p
Located in: Conservation Area YiTJ Historic district YiN
Use Groups
(check one)
Residential(I or more Units) R2
Type of improvement Residential (hotel/motel RI _
(check one) Assembly(churches) Al _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants,recreation) A3_
Alteration Y _ - Business B_
Repair/Replacement_ Educational E_
Demolition_ Factory(moderate hazard) Fl _
Mobe/Relocate Factory (low hazard) F2_
Foundation Only High Hazard H_
Accessory Building_ Institutional (residential care) It _
Other(describe) institutional(incapacitated) 12_
Institutional(restrained) 13
Mercantile :N_
Storage(moderate hazurd) S 1 _
Storage(low hazard) S2_
OWNERSIIIP INFORMATION(Please type or Print Clearly)
OWNER Name /t/ /��/f]✓� fli�/Vu�U
Address /O L/NDfH S t , Sdi L e—/Iii
Telephone
DESCRIP UION OF WORK"10 BE PERFORMED
//USTh'l� `� ' � ;• Ova .95
%la .�: &0/91/ S/rf %//Q,� &jZ,0CK /A0-9 O602
ESTIMATED CONSTRUCTION COST 0
1
CONTRACTOR INFORMATION
Name
Address
Telephone
Construction Supervisor's Lic #
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signed
Date
r 7)
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A:) � � �
f
CITY OF SALEM
IAIt PUBLIC PROPRERTY
U
L DEPARTMENT
,i\,n;K:I'Y:)N lsewu 1
IZ�W,Kru:\y{I,^SEitiff 6 SAU.M.M.ylSA0 It stunOIW-- _
fi,i., 978-'45-951)5 is psx.978-7469846 -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
t theant Information / / / y
Pleace Print Leeihiv
Aj
Nanit: lnucinc,y OrganiratinlVlndlvulual): %LJ (( `t //U 6 , `Q4�?U/Zliq —/4)1�/
Address: I')')fl2t3C_<
City;Sruc;7.ip: J/!f� Phone �� / ` C� 3 7 / fS 3
Are you an employer? Check the appropriate box: 'type of project(required):
4. ❑ I :fin a general contractor and I 6. New construction
1.❑ 1 ;fin a employer with ❑
employees(full amUor part-tinic).• have hired the sub-contracture 7. ❑ Remodeling
2.Idl 1 aln a sole proprietor or partner- listed on the anached sheet.
lC ship and have no employees These sub-contractors have K. ❑ Demolition
working for me in any capacity.
workers' comp. Insurance. 9. ❑ Building addition
I No workers' comp. insurance 5. ❑ we are it corporation and its 10.❑ Electrical repairs or additions -
I required.) officers have exercised their
right of excn] tion per MGL I 1.[] Plumbing repairs or additions
3.❑ I n s a homeowner doing all work S p P 12.❑ Roof repairs
myself. iKo workers* cunlp. c. 152, §1(4),and we have no /
insurance required.) t employees. (Ko workers' 13.0 Other
comp. insurance rcquired.j
.Am:yphcaot that checks box fit must also fill out the known Inflow showing their workets'compen>ation policy i111111 rlatium
` I Iuma,wtais who Nuhnlil this affidavit indicating Ihcy am doing all work acid then hire outside conli-Won must auhmil a new air "indiubng.uch.
-(' t, 'dm1 check this box mans attaehod an additional,heel.h)wing the nano of the sub-conlmctan and their workers'comp.policy infurmanon.
l alit fill eonployer that is
iujuratation / providing workers'cuinpeusntioti uccu rauce jar my' eiitployeccy. Below is the pulicy and job Nile
4 . Gm • p/ ' tr"SXNi
Ow mo
V T
C , w y
I naurancu m m
Cupauy Vae: ,� np —t--L U5 //U 'S L....-n i4n.G E-
-- - --------- t c,
Pulicv 4 or Sclf-ins. Lic. *:/V - o l O 3 "� -- -- Expiration Date: 7— ,2 * O
�0 G,/N/D e- S T Cuy,Slale/'Lip: Sf! Le/Vt Jvif7 U�57 v
Job Sitc Address: ---
.latach it copy of life workers' compensation policy declaration pale(showing the policy number and expiration date).
P;tilurc to secure covcrage as required under Section 25A of.`,IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the Tulin of STOP WORK ORDER and a fine
Of up to S250.00 it day Igaillst the violator. He advised that a copy of this stuteincm inay be liarw'arded to the Office ut
ncc,u:;aunns ul Life DIA for inuu;u:ec coseragc ]ciilicatiun.
/do hereby certify under thep,ii is tttld trnultic�rl�hat the infurinatlon provided uboye is true and correct.
ir,te g— 6 —
Of
ficial use only. Do not write in this area, to be ratupleted by city or town )Jjiciul.
City or lbwn: --- Permit/License q_
issuingkwhorily (circle one):
I. Board of Ilcalth 2. Iluildin' Deparuncut 3.City rl'ovin Clerk 4. Electrical Inspector 5• Plumbing Inspector
6. Other _ --
Contact Person: -- .-- Phone 0:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fix their employees.
Pursuant to this statute, an employee is defined as "...every pei:son 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
art the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of ;at 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.rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.%IGL 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, NIGL 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 nun,ber(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
he 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 arc required to obtain a workers'
compensation policy,please call the Department at(lie number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur 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 penniu'license applications in any given year, need onlysubmit 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 he 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he r dice of Investigations would like (u thank you in advance fur your cooperation and should you have :my yucbtions,
please du 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
5-2ti-(15 Fax # 617-727-7749
KeviscJ
www.mass.gov/dia
NOTICE OF ASSIGNMENT
EMPLOYER: COMBO I.D. STATUS OF EMPLOYER
WILLIAM ARNOLD DBA WM CORBETT ARNOLD BLDG 000259322 Individual
RESTORATION DIP CASE #08-14131
P O BOX 4532 COVERAGE GROUP
SALEM, MA 01970 0259322
Coverage under this assignment
The Waiver of Our Right to applies to Massachusetts
Recover from Others Endorsement operations only. For coverage
is available on Pool policies. outside of Massachusetts, contact
Contact your agent for details. the appropriate Pool or Plan for
that state.
INSURANCE COMPANY: -
AGENT ELIZABETH S PULEO INS AGCY
OR 20 WHEELER ST HARTFORD UNDERWRITERS INS CO
PRODUCER: LYNN, MA 01902 MS CINDY MAROWITZ
P O BOX 4903
ORLANDO, FL 32802-4903
(800) 453-9843
AGENCY FEIN:042995902
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
REMUNERATION
PAINTING OR PAPERHANGING NOC & SHOP OPERS, DR 5474 $5, 000 4.79 $240
CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 5645 $0 6.80 $0
CARPENTRY-DWELLINGS - THREE STORIES OR LESS 5651 $0 6.80 $0
CARPENTRY NOC 5403 $0 11.46 $0
EMPLOYERS LIABILITY 100/100/500 9845
STANDARD PREMIUM - $240
LOSS CONSTANT 0032 $50
EXPENSE CONSTANT 0900 $318
TERRORISM CHARGE 9740 $2
TOTAL POLICY MINIMUM PREMIUM $500
TOTAL ESTIMATED PREMIUM $610
DIA ASSESS. 6.3% $15
TOTAL EST. PREMIUM PLUS ASSESSMENT $625
INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $625
THIS IS NOT A BILL
COMMENTS
Coverage effective 12 :01 AM on 07/29/08
DATEOFNOTICE: 07/30/08 PREPARED BY: Theresa Schofield
EXT 542
* * VOLUNTARY DIRECT ASSIGNMENT
COPY:
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street • Boston, MA 02110
(617)439-9030 • FAX(617)439-6055 •www.wcribma.org
CITY OF SALEM
PUBLIC PROPRERTY
^ � DEPAR'I'MENT
yl.^�
III 9'S-'Ji. l4K 0 1 \S. 'i71 '4_ '1i 1
Construction Debris Disposal .affidavit
(retluired li)r all demolition and renovation work)
In accordance w ith the sixth edition of the Statc Building Code, 780 CNIR section If 1.5
Dcbris, and the provisions of.'bIGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
Iname of hauler)
I he debris will be disposed of'in
1�k)12-T!7_
Iname of facility)
��ifJ ryIf 414 S' C 0 7/ /C L
❑dJrr;. orf�cllitvt
//a
'wildtulc of permit .ytpllcdnt
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