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32 MASON ST - BUILDING INSPECTION 1 What is the current u e of the B •lding? Material of Building?" `^ if dwelling. how many units?� Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone l ) Mechanic's Name Address and Phone Construction Supervisors License# HIC Registration# Estimated Cost of Projed$ Permit Fee Calculation Pelt Fee S-O— • > o Estimated Cost X$7/$1000 Residential Estimated Cost X$11/111000 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 Pe ` lt to build to th ve stated specifications. Signed under penalty of perjury /� O Date vl 0 N O M x � � a o CL u 4 �,�D,a CERTIFICATE OF LIABILIV INSURANCE DAM /22/z 0 PRODUCER (781)681-6656 FAX (781)681-6686 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Driscoll Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 93 Longwater Circle ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 9120 Norwell, MA 02061 INSURERS AFFORDING COVERAGE NAIC# INSURED Marshall Roofing & Sheet Metal Co. , Inc. INSURERA: Colony Insurance Company PO Box 655 INSURERS: Safety Insurance Company 20 Waite Court INSURERC: Steadfast Insurance Co. Malden, MA 02148 /j� wsURERD: American Home Assurance d y INSURERE: Travelers Property & Casualty COVERAGES 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 BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'ITR A. TYPE OF IN POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY AR5360019A 05/01/2006 05/01/2007 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ SO,000 CLAIMS MADE Ffl OCCUR MED EXP(Any one person) $ exclude A PERSONAL BADVINJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 ., GEN'L AGGREGATE LIMIT APPLIES PER: DESIGNATED LOCATION PRODUCTS-COMPIOP AGO $ 2,000,000 POLICY X PE° Loc AGGREGATE $5,000,000 AUTOMOBILE LIABILITY 3952223 05/01/2006 OS/01/2007 COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO 1,000,000 ALL OWNED AUTOS BODILY INJURY $ - X SCHEDULED AUTOS (Per person) B X HIRED AUTOS BODILY INJURY X NOWOWNEDAUTOS (PeraccidenQ $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLALIABILITY AUC380799302 05/01/2006 05/01/2007 EACH OCCURRENCE $ 5,000,000 X OCCUR CLAIMS MADE AGGREGATE $ 5,000,000 C $ _ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC9689207 OS/01/2006 05/01/2007 X WC STATU- orH- EMPLOYERS'DABILITY E.L.EACH ACCIDENT $ 1,000,000 D ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1 $ 1,000,00 OTHER Installation Floater QT6609894A76ATIL06 05/01/2006 OS/01/2007 $700,000 job site/ $150,000 E transit/ $150,000 temporary location DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS. E: The Highlands at Faxon Woods Quincy, MA Roofing Refer to Attached Addendum *** Evidence of Insurance for work performed within the Insureds scope of normal business operations. otice of Cancellation provision is 30 days except 10 days applies for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL XFdC 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, anson BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE B. Driscoll/MCG + ACO D 25(2001108) ©ACORD CORPORATION 1988 MARSHAtt MARSHAL'L ROOFING & SHEET METAL CO. INC. P.O.BOX 655 MALDEN,MA 02148 TEL. (781)324-3332 MICHAEL D.KELLV FAX (781)324-6605 TREASURER CELL (781)389-8935 20 WAITE COURT W .marshallroof.com MALDEN,MA 02148 Email:mkelly®marshallroof.com d� i CTTY OF SALEM PUBLIC PROPRERTY DEPARTMENT MAroa ►20�AssmacroarsntrsT•sine,MwssAaa��trsol9T0 Workers' Compensuloa Insoruce Affidavit: Bull ere/ •FAX 9n8r$M 4 denlContraetora/EIKWetaWpbmbers Name 1 ). Address: d U Ciry/StatdZip phone#.An yo an employer?Check tYa approprlab Yon 1. am a employer with 4. ❑ 1 am a Ynewd contractor and IFECI&Wding apdree.. 2. I am employees a sole(!Wl and/or part-time).• have hired the wb eoatnctonactioe P Or pamW6 listed on the attached sheet 1 ship and have no employees These wb caatracmes haw working Per me in any capacity. workers'comp ionvaop required.](No workam•�monanee 5. ❑ w��a dm aod;t. du[m 3.❑ I am a homeowner doing all work right of have exercised� ❑Electrical ropaies Or additiooa myaeli(No workers'w exampti�Per MGL 11.�Phrmbing repairs or addietona mP. a 152,41(4),sad we have no insurance fequire&]f employees.[No workers• i ' mP+W gyp.ianaanca required.) 3.O Other ;Any+rMtaet dwt cheeks beat rl covet ales Im cut r6a saeuaa two.s6aad��-- ----- SM tC �d�knM box eaweanach �p��i aaaeoftie UNS bMaSAM fadke tmay addltl0eat shavedMSAAW6�e sort adieh•asw attidwa one aw easptoya that h rovldln �0o°WMS and dwk rake*'eowp DOW k P s warAara'cowPeneedoa Anaraw* or injanwodoa I cry emPtoyees. Bekw js&OPoBey aedJol:Atr Insurance Company Name: Policy#or Self-ion.Lie.#; \)J C Expiration Date: 1 o L,--) .. Job SiteAddrep;1Z Maw, 'S,+— atd2➢P� �V'1V� `4'_�1Dn Attach a copy of the workers,com saatlon City/S Pe potlry doe, Page(showing the Policy number and r: Failure m seeum coverage as required under Section 25A of MGL c. 152 can lead to the t�don A ofa fine up to s1,5U0.00 and/or one-year impriaonmeM as well a civil imposition of DER an eta of up m 5250.00 a day against the violamt Be advised that a c Penalties in the form oea STOP WORK ORDER and a fine Investigations of the DIA for inatraoce coverage verification SPY of statement may be forwarded to the O(&A of 1 do here ardA Mader and panald"eperJary Thar the In o/raradow provided above h dtre and coffees • `1 � - 3L �3 3 �- OJJlclal use Ofi1A Do not write la Thh art&,to be completed by cUy or town oJJleAd City or Town: PermlNLiame# Issuing Authority(circle One): 1. Board of Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: information and Instructions 152 requires all employers a Provide workers c ���onvut trig Laws chapter of ono tts General � in the service hose ...av Massac is defined as ere PeflOa Pursuant to this statu^an sa+Pfe " oral cc Willem. or more or implied. an two or e�aa or other legal entity. Y An•arpfeiwr is defitsed as"an individual.Parma tP �ves of a deceased emQ� wevar, the of the fore4om{mWfp in aloiat anamerae.aliV.asaooistim or other legal CuW-emPloYfOfi ddo hom ownerreceiver house or trustee f another m des mainreoarw.conao o°or�work m such daralgni owner of aom@ofdwelling be doemed to be an employer.' or on the dsa .shall not becaur of such employment or on the grottnda a bue2dlag apPurtesaat wttishow i saaeee or MGL chapter 152.4�6)also ata0°athat"everY date rx{Deal smuova b f a iW I t� _ rawwal of a aces"or PORION to OPWaaa a IdOMMS et eor to om am�inawaaa eOvente rM� Applicant wM tOO sat produced1 �e7� Nep�the commmwesldt nor erne of�w th the Worm" eYWGW shall nter into �� for the� presented of a the contracting au>boritY work until gemptsble evideaee rcgWremeroa apter be" APPII<aata the boxy that aPOY sa your'sinrarion and.if affidavit eo s)andlp.by cnumbef Of PleaaMceseam�lY out tuPPll, a suib-countietta�j°�ab awes)a0d�0°0 nParaerahiW(LL>') no r(s)along with their a)other lion the insurance. Limited Liability Comp!aiea(l I�woLimited �comLpmnsation in�0' If an LLC or LLP does haw to cant mega at PaIRNM�I�tns�ed�Be advised that this af6davia mere be submitted to the afn& iL of Industrial A"date the atadavlf. The affidavit should Of inamance Aloe be sure a alga of Accidents for Confirmation coverage a license is being requested.sot the Department be resumed to the city or town that the application the�law a if you no required to obtain a wO*a' Intdnstrial Accidents. Sbould you have any Department a*o nt osiber lid below. S&insured companies should cum their comDetuab°e policy.plow call the Departteemt has. self-hsa new Ikea number on d0 anormidl City or Tower Ofbdab has provided a space at the bottom Please bs sure that the affidavit is Compete and printed legible. The Department has to c of the affidavit for you a fill out in the event the Office of Investigations has to contact you regarding the applicant Please ba sure to till in the fill ou"I i ense number which will be used as a reference member- In addition an applicant applications in any given year.need only submit one affidavit indicating current that must submit multiple PermttAecease S�Addrese"the applicant should write-all locations in deity or policy infocros�(if necessary)and under or marked by the city or town may be provided to the town): A copy of the affidavit that has been officially stamped or licenses. A new afudrvu must be filled oat each applicant as Proof that a valid aidavit it on file fa fonae permits not related to any business or commercial vtmarre Year.Wleere a home owner or cidzea is obtaining a license a permit (i.e. a dog license or Derma to berm leaves am.)said person is NOT required to Complete this affidavit. ou in advance for your,cooperation and should you have any gaasions. The Office of Investigations would like to thank y please do not hesitate to give ur a ca1L The Oe st°t,s 'telephone and TM COMMMVM lth of MLUMhusetu pepu neat of Indtutsial Acd&nts Own of 1RTUdVdoas 600 WLAW&M Stleet Boston,MA 02111 TeL M 617-727-4900 CA 406 cc 1-877-MASSAFE Fax 0 617-727-7749 Revised 5-26.05 WwwmAwVv/dk { PUBLIC PROPUW DEPAE'iUMoCr maim Combutdoit Deeds 01s9e1 1 AAldw t (�. .�sx ereeudo�yet 1- ",aloft to ioeouireoe wide��hcf.dfdes ddrs'�r Dosdt��7f0 Ct+a rw{o�11t.! Lm D.brt�sei dryrorldaar of 3ra s��S11 �r �d■.i.rs m.eee�{e.sir sy erb�b n.ddy mas rb.sbo dwoud dim opt►somodwar aw"soft ag&&Qrbyera.s eu.s iso�. rho ddwb wM b4 nampWW bye d � Tho & rW will be dlopmW OW: �o ' (�Jdnrr aI heir V "�. D+R+b�OPlfaer � 1 CITY-OF SAL El i----- --- PUBLIC PROPERTY DEPARTMENT Ki%aFXLSY DRI5COLL MAYOR 130 WASkUNG cw SMEEr•cAJ.EK MAcsnaLSt-1-rs 01970 Tft.9-8-74S-9S9S 0 FAX 976-740.98" 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: a Property Address: `3 S A U Property is located in a; Conservation Area YIN Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land y Name: Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing a Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (so Renovated (� construction or renovation of existing building New Brief Description of Proposed Work: --Mail Permit to: - -