70 LORING AVE - BPA-09-423 SALEM DINER, FIRE DAMAGE ('11"YOF SALEM
PUBLIC PIMPFIRTY
Di7-PARTMENT
120\\,\S If I Nt 11 N
- \I 1K5I-A9.5 I !xM N _ \ I t8-IIf, I I I')- )
I 98-- 95 0 1 9181 ) 9 F—APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: Applicants must complete all items on this page
SITE INFORMATION
Location Name 7 0 4-tPAZW6, .4VOC Building
Property Address
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Holmes R3 114
Residential (3 or more Units) R2
Type of improvement Residential (hotel/motel) R1
(check one) Assembly(Theaters) Al PIN94Z,
New Building Assembly (restaurants &clubs) A2r R:A2nc
Addition Assembly(churches) Al _
Alteration Business B
Repair/ Replacement Educational E
Demolition Factory (moderate hazard) F1 —
Move/Rclocate Factory(low hazard) F2—Foundation Only High Hazard H
Accessory Building Institutional (residential care) 11 —
Institutional (incapaciunted) 12_
Institutional (restrained) 13
Mercantile N11
Storage S I _Moderate Hazard
Storage S2_Low I lazal d
ON%NERS1111' INFORMATION(Please type or Print Clearlv)-1;OWNER Name AL.,J:�, k I A—A I
Address t/A&t?
Telephone
Signature
DESCRIPTION OFViORK TO BE PERFORMED
P-r-PH r f2 t au- P.-a-In.4 &F-
VS I IMA I'ED CONSTRUCTION COST
CONTRAC'['OIt INFORMATION Name d9oy,, , �p�/rtll(�l7/91/
Address 3-PUTV4 1
Telephone g?i' 83(P'0-7(90
Construction Supervisor's Lic # o�OSt3
,%RC111TEC'IYENGINEER INFORNIATION
Name
Address
Telephone
Mass. Registration #
rERNIrr FEE CALCULATION
Estimated Cost x $11/$1,000 + $5.00= aag,
CONINIENTS
44
�1Lo�
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the penalties of perjury
Signed (v (owmIr) (agent)
APPROVED BY :
DA•rE APPROVED:
CITY OF SALEM
,. PUBLIC PROPRERTY
`"` " DEPARTMENT
h I%I It:Rr l'.1'UR ISt:LIs L
Mi%s c it 12C WA\HIKG'ION SIR EET • SAU'U,Mnssnct it sh I s 0197C
978-745-9595 • i':sx: 978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
dame (nucilx tis OrBaniratioNlndividuull: Z —a iv a - uZ -81
t
City,Statc zip: sfi* n)G77/r Phone Is: !;47ie— 7— 221 ?i
Arc you , employer'.'Check the appropriate box: 'type of project(required):
1. am a employer with 4. [1I am a general contractor and[ f+. ❑ new construction
employees full and/or a unto).• have hired the sub-contractors
l > ( P 7. et eling
2.❑ I am a sole proprietor or partner- listed on the anachcd sheet. :
ship and have no employees These sub-contractors have K. Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] o.Msters have exercised their
3.El am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. (No workers' comp. C. 152, j 1(3),and we have no 12.❑ Roof repairs -
insurance required.] t employees. LNo workers' 13.❑ Other
comp. insurance nlquired.]
-Nty:ipjlhcanl dust checks box i!I must also Till out the section below silowing their wurkas'compensation pulicy infiumaliun.
r i Iomeuwms-s whu su+mir this affidavit indicating they am cluing all work and Ihcn him outside contractors must submit a new af'Edavit indicating such.
-C'ontrxtll"that dteck this box must aaachud a n additional sheer showing the Imme of the sub-contraclors and their w'urken'comp.policy information.
l a)n oil employer that is providing workers'conipen.cntion insurance for my enrplayecm Below is the policy and job site
ioforoatian.
Insurance Company Name: ----...__..... . .....
I'olicv#or Self-ins. Lic. i:: ____. ... . .. -_ .______ Expiration Date:
Job Site Address: `1.eP` Cityistatei"Lip:
Attach it copy of lite workers' cumpensatio policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of SIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or une-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. Be advised that a copy orthis siutement may be forwarded to the Office of
Iucrsligaliuns ol'the DIA ('or insurance coverage Neiitication.
I do hereby certi y under the p in 'all of penalties of perjury that the information provided above is trite and correct.
A-91 Sir 1 u If" � �0� � Date' i
Ph" re:i: VVV
official rise Only. Do not sprite in this area, to be completed by city or town ojjicial.
Citv or'fown: _ Permit/License
Issuing Authority (circle one):
1. hoard of health 2. Building Department 3.Cityrfo,vn Clerk J. Electrical Inspector 5. Plumbing Inspector
G. Other
Contact Pcrson: __._ _.. ..-- Phone As:
r r
.Information and Instructions
;Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplgree 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, bIGL chapter 152, �25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract fbr the performance of public work until acceptable evidence of compliunce with the insurance
requirements of(his 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 confirtation 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 are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
coif-insurance license number on the appropriate line.
City or Town Offlcials
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 penmio9icerrse 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 affidavit 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.
l he OI'f ice of lavesrigations would like to thank you in advance for your cooperation and should you have arty 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
Rcviscd 5-26-05
WWW.maSS.gOV/d18
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PUBLIC PROPRERTY
DEPARTMENT
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9,4.74;A;e5 • 1'.\x: 979 74:9841i
Construction Debris Disposal Affidavit
(re(Iuired liar all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it _ is issued with the condition that the debris resulting front
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:
e6
r Iname of hauler)
The debris will be disposed of in
(name of facility)
(address &facilav)
r
lot (e If permit applicant
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f� ��.--1 ✓1ie �aivmn-sure<r�i o�./�laaaar�ueella \t
„n "1 3oard of Building Regulations and Standards
Construction Supervisor License
v License CS 66533
`! Bnthdate --372311956 E
1Expu-a'tt n72
3%2009 TrU 12919
!Xg
'R�esrsct�on
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ate;
` JAMES F NEUMANN
Y16 PO BOX 8191
n " SALEM,MA 01970 Commissioner
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