19 LINDEN AVE - BUILDING INSPECTION What is the Current use of the Building?
H dwelUng,how many units?------
Mat"Of Building? Asbestos?
Wit the Building Conform to Law?
AmKaed's Name
Address and Photo 1
Meehenlds Nameress
Address OW Ph"
ci.r. 191 .
Conatnwtioniaora License �c rY)2123 HIC Registration s
o sir — Pen^H Fee Calcuia
Estimated Cst of Project fbn
Estimated Cost X$71s1000 Residential
PennR Fee s 3_��a--- E.*n cost X 511/sl000 Commercial----- -
An Additional $s.00 is added as an
Administrative duvgw
Make sure that all fields are properly and iegibly written to avoid delays in processing.
The undersigned dose hereby apply for a Building Permit to build to the above stated
specftatkau. Signed under penalty of perjury /
Date
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PUBLIC PROPERTY
DEPARTMENTUAVM
r;�"wcw ov pMer.v / /
Suli14 YAnAa/Lselis 01970
TEL MUMS"•FAS 97e•740.984
APPLICATION FOR THE REPAIR. RENOVATr N CONSTRUCTION
DEMOLITION, OR CHANGE MUSE OR OC rp Mery FOR ANY EXISTING
STRU-( U z OR-8 UILDInvr
1.0 SITE INFORMATION
Location Name La 4NNLOr 1 e- flBluddk�iq-
Property
Addreee:- -
dy LArx,,4r) Rv
Property Is located In a:Conservation Arse Y/N Historic Distrlol YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ;- t-e
Address:
lCt I_ar\dec� A,v2 �a1e� � MR 0 kok-1 0
Telephone: 01-1% Z4S7 c(230l
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor(sf) Renovated "construction or renovation
of existing building New
Brief Description of Proposed Work:
S r
StC i 2h"�1 r� C-00 r aroma �PQ1 nC W �OLY� CSN t Co 61�fml, 1 o C d e�rn1,f
-- -- Mail Permit to: 1� l ,n r Ave S Mfg, 0A-10
f
CITY OF SALEM
PUBLIC PROPRERTY
L DEPARTMENT
RINnrRI r:Y URIX:ULL
M. Ay it IMWAstiINGroxSTREET •SAIEvi,MA64ACia:sti'rfs01M7
'fEt_979-745.9395 0 FAX:978.740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information n Please Print Leeiblv
Name lBusnxss/OrganizatiniVindividwi): _rke.,, t36 tS\�''� cbrxIk-f
Address: P-0 , &A 4'1 G
City/SweiZip:�,J�1MfAjolq\S Phone #: 'V7Z aZD $QC(
Are youan employer? Check the appropriate box: Type of project(required):
1.12S-.f am a employer with 1 — 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full andtur part-time).* have hired the sub-contractors
2.❑ i am a sole proprietor or partner- listed on the attached sheet. : 7• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
INo workers'comp. insurance 5. ❑ 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 11.0 Plumbing repairs or additions
myself. [No workers' cutup. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.)
-Any applicant that checks box al must also rill out the secban!stow showing their workers comper ation policy infurnutiwt_
'itomatwra:n who submit this Affidavit indicting they are doing all work and their hire outside cone xton must submit a new af(davit indic sing such.
�Conimiors that chsck this box must anxhed an adifitional sheet showing ate name of the suls ontraaoa and their wurken'comp.policy information.
I am an employer that fir providing workers'compensation insurance for ary employees. Below is the policy and job life
in/urination. `
Insurance Company Name LvbC' 3ltii\"
Policy#or Self-ins. Lic. n:`WC-�-' 'y mLLK.-0%,— Expiration Date: rf II/Loot
Job Site Address: l°1 -tnp@(1 AV2- City/StateiZtp: SnIN,g,nN /M�nITI0
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,uf YIGL 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 form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. 13c advised that a copy of this statement may be forwarded to the Office of
lut'.,Ilgariuns ufthe DIA for insurance coverage verification.
I no hereby certify uuder the gins turd prnultics ujprrjury that the information provided above is true and correct
Si 1IIIere: _ Date,
Phtn:c;i: 00% q21 R°I&10
Official ran only. Do not write in this area,to be connplefed by city or town official
City or Town: __. Pcrmit/License q
Issuing Authority (circle one):
1. Board of health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Pcrson: __ _ . . _ -.- --- Phone #: j
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,
eapress or implied, oral or written."
:Vt 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 perfortnunce of public work until acceptable evidence orcompliance 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 yuestions 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
,elf-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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please bemire to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense applications in any given year,need only subunit 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 tilled out each
year. Where a home owner or citizen is�obtaining a license or pennit not related to any business or commercial venture
(i.e. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
['he Otlice of Investigations would like to thank you in advance fur 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
Oftice 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
GLENN BATTISTELLI
PAINTING-ROOFING-SIDING-CARPENTRY-VINYL REPLACEMENT WINDOWS
KITCHENS-BATHROOMS-PORCHES-DORMERS-ADDITIONS
P.O. BOX 496
BEVERhy.MAS CHUSETTS 01915
(978 9 -8308 (978)777-449P
Dili CT LINE (978)927-8956 \> y
FAX(978)9 C9102 CELL(617)962-1235
�E$P4 L/SHED 1974
GLERNNN�BATTISTELLI CO., hereby agrees to-perform the following services for:
at
Home Phone: ,,-- 9.2 39 Business Phone
Sealer applied to all vent pipes and chimneys.
All Flashing will be inspected. -
/ O
Roofing Nails will be Inches.
Grounds will be cleaned of all roofing materials _
All workmen are covered with Public Liability and Workmen s Compen'sation
All work:will be continuous and will be performed in`a`workm mike manner .,�,
Chalk lines will'.be used to line-up the shingles ,�� �
Roofing Shingles are self Sealing crg' >
While installing the new roof, we wilbprotect you 'hom6 and plantings from debris.�a
Roofing Shingles to be-delivered C-
Install new fiberglass paper to roof boards when stripping of shingles is required.
All shingles will be secured with'76ur n I
State and local building codes, along with martufacturers��CfYi ation`s wil`g adhered to at all times.
Color of Roof to be
All work is priced as specific. The possible occurrence of rotted roof boards or poor flashing will warrant an additional cost
of `� n r/ go� .
The homeowner is responsible for covering their articles within the attic.`
Work is to be commenced on �..
Payment is to be delivered x 15"0 o e Ec .v - �z �✓ --�z P "moo. "`�. �P`-o
Apply 9' inch aluminum drip edge to the following areas:
Year Workmanship Guarantee. 3 Year Material Guarantee
Roofing shingles to be X"
oil � T 4 // 4— e-Y - S-CA'ee' ez;>-s
milJ70e/ /L&li del,z>s, 61s.��r
Ifew 91 4'e '1i7 I;i'�TJrti. F4.1e .4 o4 '7 c .? Z yc774 7So
4
Agreed by Homeowner 'Agreed by Contractor
d�-- 6.2 7- -2 ' - u'
Ref. age Date 3 Day Cancellation Notice Required
�s 0kf�� Aegu °/`` �a a .
oard o ui uigati ns an tan ar s
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvemen> oir, .ractor Registration
Registration: 104352
�• ' Type: DBA
;•i 7 I: +' Expiration: 7/13/2008
GLENN BATTISTELLI CONSTRUff }�ft
Glenn Battistelli �--�_. --- ':
PO BOX 496 t — --
Beverly, MA 01915 * -------- ---.
Update Address and return card.Mark reason for change.
-- ,�- Address (� Renewal Employment ` ;; Lost Card
DPS-CAI 0 WM-OSIMPC8490 '
Boerd:off,M1 g°l gTitTuai(aud� License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. 'If found return to:
Reglstrat 104352 Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Ex ilraf1AJL /2008 Boston
GLENN BATTISTfl.I , }ON
Glenn Battistelli
11 BROAD WAY RE4Glrw.� ------'--`-'
Not valid without signature
6e`verly, MA 01915 Deputy Administrator
Olt
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