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32 MASON ST - BUILDING INSPECTION (2)
What is the current use of the Building? Be V\ 4, 1 l -e5 i J Material of Building? )003 TFw"^<— if dwelling. how many units? Will the Building Conform to law? Asbestos? Architect's Name r Address and Phons l ) Mechanic's Name Address and Phone i y 3L H ce s/e Y h l \ Sao S i e 1 r�c 9 Y Constriction Supervisors License S !07 y20 HIC Registration# Estimated Cost of Project S j Permit Fee Calculation Permit Fee S If2 8 Estimated Cost X$7/$1000 Residential Estimated Cost X$11/$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury Date 5-Arlo � N 0 a 0 V b V E^ G7 0 3 V r I -� crrY op sant PUBLIC PROPERTY DEPAE'TMENr MAN* rota•.ao�eru.aarat�tonx+e�aa�+aa+:s t�n�t+Lasa�•rnr�►r+NW Co is- Iark ObPOW AMBsvit bft"hrd A evtldos ad I— do w4 ft tsa aoamdmo wi&dw"000 at&$Uft DWWMSCok 7M C!R saw til.! p"ad des peowWWo dUIOL s,Ol t A 9�i�ni� bti 6awai wtA�aeed'Ote�:lat t!s dlib ntauli�� war ddl tto d *N"opts a w4rob loww craw d gmd Ad t M&&Wbrums tau,s►A4► Tha ddwk wM bs oanapaa I bri ITCe - wr d art The d&W wilt be dispoW alin: A« Q� 50osc� (�oW— cy:a�r hea4» I CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT i>aacott MAToa W WAMMI TavSTRUT a W ak M&gAaWWM0[s70 Workers' Compensation Insurance Atadawt: 13un �IContracto7� AooUcant Information ra ecMcian*jumbera Name(9usinew0rpnira�ua1):_DCLVr rX t �Yi i.-Tyi-Prwi j Address: &R R a `l/ awstatemp: �'� % Phone Al* �9Yg Agate as employer?Cheek the approprbell 1. I am a employer with 4.C7'1 t em ae°f�eJ�( atr�: b genera[cmttacW and[ 2.❑ 1 am a (lWll aad/arp�et-time).• have hired the wb coatncton d ❑New eooaYttcyon ole ProPr+emr a Farmer Based m the aaached sheet t 7. ❑gemodeling ship and have no employees These have g, working for me in any capacity. workers'comp insurance. ❑Demolition q insurance 5. ❑ otAcarahav �andits U ❑Building addition We am 8 3. I am a mmmsed their ❑Electrical Main or additions ❑ homeowner doing an work right of eamnption per MOL 11.❑Plumbing�at addidons myself.(No workers'camp. c. 152,41(4).and we have no ❑ Rpm 1A°�nce�N�J t employees.(No workers' 13 EOOf Ql^' comp ioarancs required.) Other S� i f / ;Any wh dwdm box o arardt ai ow sdrvai4o NI w raa.eerica Ldoe d aw,t,s Ihak workers' policy inseam" tCoaaaetwa rkr tide bow am ruokad so sd&ye d� n ��e0°�°ma.e4.mrr airait.ne.daderY Mcatiag M& and rkdr WON kas'000a I am AA employer tlYat i!prosddbrg'worht»'COAIpfAse�OA In7AraAce er p0g0Y�e•matlaa Injormotlow j mY rarployeet Below IS the ` t"Arcy An djobsite rnsurance Company Name: Policy N or Self-ins.Lie. Expu�adon Date: �—O .. Jab Site Addretc_ �� ck S'G n S� S�/-ls� / AttacY a copy of the workers'com asadoa Ciry/StatelZnp:�Q/tsL �e, �j�� Z� Pe policy deciaradam pogo(showing the policy number and ea �Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to the' p.radom date). fine up to S 1,500.00 and/or one-year imprisonment,as well as civil rmpoaition of criminal penaldes of a of up to MOM a day aping the violame. Be advised that s c opfe this statement nalna m the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verificadoo may forwarded to the Owe of /do hereby ce ' wad pays and Aa/dea ojptril"that the lnjornsetlow rovldel p tt 07re and correct of efel Ast only, Do not write IN this area,to be coarplemd byC4 or Iowa o/Jfe/aL City or Town: Permit/L(eeme N Issuing Authority(circle one): I. Board of Hesltb 2.Building Department 6.Other 3.Ciry/rows Clerk 4.Electrical Inspector S.Plumbing Inspector Contact Person Phone q• information and instructions b provide worker'compensation for their employees Massubutens General Laws chapter 1 S2 requites all MVWYeia P of hire, p .�to this sun^an ampbY"is defined as"...every person in the service of another tunes any coaaxct expreaa of imp"art or writes" at other legal entity.or any two or mow as an individual.parmash*association.. O6 mradves of a deceased employer,or the An the f goinp gam in aioior a MPr:w. toying employees Howcvar the receiver a trustee of m individual.pattaerahtp. and who resides thamb,are the oaeupaea of the owner of a dwelling boom having not nwrs than m do Vie.ec om or air wort m such dwelling hD1 dwaM boner of another who emplOya Peter" "not because of such employment be to be m empbYer• or on the Venda or buffing aPp�re shall withhold the mnatKe are 152.12=6)also saran tbat"every stab ere �buddhW h•the commonwealthMaw for arty MGLalofchapter&Mesa"ne to operate a buslam ere b .M with the intersnp coverage rMdred" Applicant whe has art produced acceptable a"d""Of compile the comm mr am of i4 political 132.$25C( of MGL chaP� le evidence compliance pddidonaltY• &rmano of public conk until acceptable enterOf��pm� prcswtod to the corruscting authettty-" req Appncaab affidavit completely,by checking the boxes that apply to your s�t�and'ref Pleas flri out the�anes)ad&UKGG)and� L�n (��wh no yother tyen the Partnership insu , LLneces"n supply Liability Companica_w 5.congenation Vie. If as LI.0 or LLP don have members or partner.are not rerpiised to that thin affidavit may be submitted to the Department of Industrial 04 a policy is required. He advised and dab 00 affidavit The affidavit should Accidents far confirmation of 1D O coverage. Also M sutra b sfga Dgpumgd Of be returned to the city or town that the application for the permit a license is being regtieemd. a worker' Should you have My 4 regarding dw law a it you an required should enter their compensation policy.plan call the lamed. number Wted below. Belt-insured companin self-im on license Member 0°tb0 City or Town 016clar ent has provided a space at the bottom Please be air that the of idmo is complete and printed legibly. The Departm of the affidavit for you w till out in the event the Offiea of Investigations has to contact you regarding the applicant Please be core m fill in the pamMieense number which will be used n a ceferenee number. In addition. sic applicant applications in any given year,need only submit one affidavit iMdicatina current that must submit Multiple pe rejulce f0�"Job Site Andrea"en applicant should write"all ktcadow in--(city or policy iatotmarion(if neeestary) or marked by the city of town may be provided to the town)."A copy of the affidavit that hae been otAcialll'stamped of licenses A Mow at-davu mart be filled nut each applicant n proof glint a valid affidavit u on file for flier o rmiu not related to any business of commercial venire year.Where a home owner or citizen is obtaining alicense as Pcsmit s NOT required to wmplcm'hie affid"L (i.e. a dog license a permit to burn leaves etc.)said pawn. Me would like to thank you in advance for your cooperation and should you have any queatiors. The Office of bivestigatio please do not hesitate to give us a call The Departmene address.telephone and nth of Mim"Whusetts Dgm=ed of ln&uud A=denta Omeg of lavudPdona 600 W&AM&M Serest Boston,MA 02111 TeL M 617-727.4900 eat 406 or "77-MASSAFE Fax 0 617-727-7749 Revised 5-26•05 WWW.IIla &0V/& STPAUL _ WORKERS COMPENSATION TRAVELERS AND EMPLOYERS LIABILITY POLICY QUOTE PROFILE — VERSION 01 POLICY NUMBER: (7PJU6-777X858-4-06) RENEWAL OF (7PJUB-777X858-4-05) INSURED'S NAME AND ADDRESS WORKERS COMPENSATION MATHEWS, DAVID 0 INSURANCE PLAN 142 HAVERHILL ROAD k A/R (WCIP) N MA TOPSFIELD MA 01983 POLICY PERIOD FROM: 08-04-06 TO 08-04-07 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 358 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 142 TOTAL ESTIMATED PREMIUM Soo TAXES AND SURCHARGES 2 DEPOSIT AMOUNT DUE 502W Employer's Liability BI Limit: $ 100000 Each AoCk1eW 500000 Policy Limit 100000 Each Employee a.. INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Adqustmstas of Premiums shall be made ANNUALLY rltttlrlHHHtffrHlHtlHt!!R Deposa Amourn Due: $ 502 HlHrrfrttHlHtHttfHrrfrtf POLICY NUMBER: (7PJU13-777X858-4-06) DATE OF ISSUE:06-09-06 WC ST ASSIGN:MA OFFICE: DIRECT ASSIGNMENT701 PRODUCER: EUNICE F FOLEY INS AGCY 75HSR May. 7. 2007 7: 18AM MARSH'ALL ROOF;NG SHEETMETAL No. 2013 K i x O6 VI-VI V4.L9FIR nw-A +973 39I 11699 T-330 r.uvl/002 F-f09 ! CERTIFItCAtE.© ittVUR`AN I sl3rxon�ll': PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Divirgigo Ineurance Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 270 Broadway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Lynn,MA 01004-2726 COMPANIES APPORDING,INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Andy Ralschl 14 Spencer Ave Saugus,MA 0100"000 COVERAGES.i :, • . THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IB SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 00 Lyn TYPEOFINSURANCE POLICY NUMBER POUCYO EOTIUE OATS POLICY EXPIRATION pA 1 A ORXER C M AP NO EMPLOYERS'LMSIM LIMITS He PROPA15TOW ARTNER&EXECUTNE HCLO ExOL❑ 1820344 11/13/2006 11/1312007 HATUTOW LIMITS ,, .,,., ;:•• . ,. ,r•- . 0THER w -Jjd AFPFCS 0 MA 01WA90hi ONY CH AOCIDFNT $ 100,00 ISFASF POLIOYLIMIT $ 500,00 SE"EAC EMPLOYE OO DESCRIPTION O PPIRATIONSNEHIC 3 3t pEC AL ITEM CERTIFICATE HOLDER CANCELLATION MARSHALLS ROOFING SHOULD ANY OFTIMA80VIIDESCRIOEDP041C1ESSECANCELLEODEFORSTNF ATTN:DAVIDMATTHEWS EXPWATIawDATenreREDRTiiEISSUKOCOWANVWUENDFAVORTOMAILIA 142 HAVERHILL RD DAYS WRITTEN NOTICE TO THE CERTIFICATE HOWES NAMED TO THE LEFT.SLIT TOPSHEILD,MA 01983 FAILURE TO MAR SUCH NOTICE SHALL IMPOSE N000Li0AT10NCUMILMYOF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATIVE MAY 07,2007 07:51 7813246605 Page 1 w ." ' r �1re�aa�,rmronr�ealGb o�✓Lfa°°ac�f j g gpARD OF BUILDING REGULATION$I' ak License CONSTRUCTION SUPERVISOR �. Number C 067420 k Blrthdats�,04114/�958' I;ia g4f148 Tr.no: 21213 C I DAVIDD MAYHEM 142 HAVERHILLLAR019 I.I r TOPSFIELD Commissioner Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR ReglstraUon;,t2254f Ex{riraUon --Wl61 8 "�F -=,.Type Individual l- t DAVID D.MATHws: { DAVID MATHEWS ��` �:,.. 142HAVERHILLRD'�.1- ='� De u A I TOPSFIELD.MA 01983 p ty - PUBLIC PROPERTY DEPARTMENT I:I�MERLEY DIIySI;ULL - Mnroa 130 WASMNG cw 5MEffr•5UkA.%tA5SntHtst1-M 01970 I'm,976-74S-9595 0 FAM 976.740.96" 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: a soVN, properly is located in a; Conservation Area YIN Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: 1 Rz j Address: Telephone: r7 Ll3 oZ 3.0 COMPLETE THIS SECTION FOR WORK IN FY1QT1Nr= BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition I Existing `Q Approximate year of Area per floor (so Renovated construction or renovation ig New of existing building Brief Description of Proposed Work: Lo (U ,3i� �I�c� 71 S �c 2oJ V'1K n S 1�l, ►:� �3 s i�-e S j'l-�ds< yn - ---- -- ---Mail Permit to: