38 NORMAN ST - BUILDING INSPECTION (2) 0 7
Application for Permit to:
Location l/
/�nr- MH, Sf
Permit Granted
Ap oved
v
Inspector of uildings
L, '
A.
CITY OF S U EM, NANSSACHL'SETTS
• BUILDING DEPART\C2IT
' 120 WASHINGTON STREET,3'n FLOOR
a f TEL (978)745-9595
FAX(978) 740-9846
KINiBERLEY DRISCOLI
i�fAYOR TrtoatAs ST.PtERR&
DIRECTOR OF PUBLIC PROPERTY/BI:ILDING CO\L%MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
�-
Name (BusitxstiOrganizatioNindividwtl):�{A 7��IC.1� &AK^ ' Y` �
Address: I o Col i" 4 SFJt+r,
City/State/Zip: -Sa61'11- i 0k{'- -01cl-` Phone #: (9
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet.t ?• 10 Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp.insurance 5:: '',We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing ail work right of exemption per MGL I - Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 130 Other,
comp. insurance required.] .
•Any applicant that chccks box bl mutt also fill cut the section below showing then workets'compensation policy infomnriom
'I lomeoweem who submit this affidavit indicating they ate doing all work and then hire otmide contract.must submit a new affidavit indicating such.
;Contractors that check this box must anached an additional shwa showing the name of the subtiommelom and their worker'comp.policy infmnation.
l am an employer that is providing workers'compensodon insurance for my employees. Below Is the policy and job site
information. {�
Insurance Company Name: Pb '/ �+
Policy#or Self-ins...Lie.#: , )C. T7 1r �l ✓ _ Expiration Date: � t �_
Job Site Address: I4ymcty`3t" City/State/Zip: <G,t9'r,, n, OM-
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 of MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations or the DIA for insurance coverage verification.
l do hereby certify under the pains and penalties of perjury that the information provided above is true and correel.
Signature: Date'
Phone#: 1 01 '7 E1 W rJ' — wt
Official use only. Do not write in this area,to be completed by city or town eyticiat
City or'rotvn: Permit/I.Icense#
Issuing Authority(circle one):
1.Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: __ Phone#:
AN-16-2007 TUE 10) 11 AM JENKINS INS, FAX N0, 7812459563 P. 01/01
ACORD,,, CERTIFICATE OF LIABILITY INSURANCE DATE 1/16/Om7YI
PRODUCER THIS CERTIFCATE IS ISSUED ASA MATTER OF INFORMATION
Wayne C. .Yenkins Insurance Agy ONLYAND CONFERS NO RIGHTS UPON T HEC ERTIFICATE
50 Salem St HOLDER THIS CERTIFICATE DOES NOT AM END,EXTEND OR
ALTER THE COVERAGE;AFFORDED BY THE POLICIES BELOW.
R.O. Box 69
Y,ynnfield, MA 01940 INSURERS AFFORDING COVERAGE NAIC#
INSUR B] INSLIRERk Sa£et}t_Insurance
TremblayContractors Inc.
INsuRER B: Ohio Casualty
10 Colonial Rd Ste. #4
INSURER C:AIG
Salem, NA 01970 — - — -
INSURERO: .... _- ..__ _.. ...._
IN5UHER E
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 RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
-MTR D' - �- POOCY NUMBER ATE1 POUCYE TiVE FOUCYFXPRATDN LIMBS
nAA CE
GENERALLIABILm EACH OCCURRENCE. S 1,000,000
DAMAGETOTRENTE9-
13 ��( CO.IMERCLALGENERALUANUITY rlKW52519622 4/15/06 4/15/07 PREMISEStEnmc r.. E _ 50,000__.
_ CLAMS MADE XIOCCUft MFAFXP(Mryq.A 'sw) S _ 51000
X bfpd, xCn, cont_ PERSONALS ADV INJURY_ 3 1,000 D,_00
X Contr. Protenti GENERAL AGGREGATE - E 2 _000yQQO
GEN'LAGOREGATE UMR APPLIES PER: PROCUCTS-COMPIOPAGG L 1 ,0001 0-QO
POLICY X pCT I LOC
AUTOMOBILE LIABILITY COMBINED SINGLE UMV S 1,000,000
p ANYAUTO 1500143 4/19/06 4/19/07 (Eaaa:�nO _ _
X ALLOPMEDAUTOS BODILY(NJURY $
IF&pe cml
X SCHEPULEDAUTOS - - -
X HIRED AUTOS ROPILY INJURY
S
Pu ac4dmt)
X NON-OWNEDAUTOS - ..
PROPERTY DAMAGE S
(Par Raidhl)
GARAGE6LIASILITY AUTO ONLY-FA ACCIDENT_ S ._-
ANYAUTO OTHER THAN EAACC_
ADTOONLY: AGG S
EJ(CESSIUMBRS"ALIABILIYY EACHOCCURRENCE $ ._ _ _
OCCUR CLAIMSMADE AOCAEGATE S
S
DEDUCTIBLE . S
RETENTION 8
A -
WORNEiSCOMPENSrGIONANO ORYl —
C EMFLOYERS'LMLITY WC 8948958 7/l/06 7/l/07 ELEACHACCIDENT E 100,000
OFFICRERMEMBERPEXCUJI)EED7 ECUTNE I!LDISFASG_GEMPLOYFE S 500,000
Uy 6 A—LPRQ1-j1�& E.L.DISEASE•POLICY LIMIT II 100,000
SPELTAL PROVIs[N5 beOw
OTHER
D ESCRIPTION OF OFERATIONSI LOCATIONS,VEHCLES I MLUSIONS ADDED BY ENDM5EMENT I SPECUW PROVISIONS
Contracting operations:
CE2TIFIC ATE HOLDER CANCELLATION
SHGULO ANYOFTHC ABOVE DESCRIBED POUCIESBE CANCELLED BEFORE THE EXPIRATION
DATETHEREDF,THE I35UING INSURER WILL EN DEAVOR TO MAIL 30 DAYSWRITTEN
NOTIC ETO THECERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAI W RETO D O50 5HA"
IMFOSENO OBLIGATION OR LIABILITY OF ANY KIND UPON TIME INSURER,ITS AGENTS OR
REPRESENTAnVEA
AUTHORIZED REWIESE E
,k
ACORD 25(2001108) 0 ACORD CORPORATION 1983
ye.� /
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Re IstY%,1, 1 :1 5375 Board of Building Regulations and Standards
9.- ft One Ashburton Place Rm 1301
fz(#iron %1� /2009 TAt 126164 Boston,Ma.02108
e ( ate Corporation
ROGER A TREIVI�. -'4R �TORS,INC. �J
ROGER TREMBLEYQR€y .:/ (/`/,ry 4 .1
10 COLONIAL RD SC113 '�y+-%' --
SALEM,MA 01970 Administrator Not valid witho t si nature
XV
iconsp, ��(,��'jtU�TIQTJ GUP"ERvlsOk
Pin 9
Tr.no: 1$
�'b wa�
0 onity}(omeg
1 I i
f@IINf4IP posses;Sa cgRCntndiPon of the I;
irtag;af♦t90 qs S a Buildf
�4 no'04
Is causf4r rovoGation of this licens r
f
¢ i?IG SAFE CALL CENTER: (008)344-7233
CITY OF SUE,, N'LUSACHUSETTS
BU11DIING DEPALRTNIENT
• 130 WASHINGTON STREET, 3tO FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
iQ\IBERLEY DRISCOLL
MAYOR THoeus ST.PmnE
DIRECTOR OF PUBLIC PROPERTY/BUHMING COMMSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit At is issued with the condition that the debris resulting from
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:
(name of hauler)
The debris will be disposed of in
(name of facility)
-
(address of facility)
signature of permit ap icant
1 l ) /0 7
date
dcbrivlf..dm
I
i CITY OF SMY.M. iN'LXSSACHUSETTS
Bt: DING DEP.jinstENT
130 WASHINGTON STREET,3tD FLOOR
v TEL (978)73S-959S
FAX(978)740.9846
KIJIBERLEY DRISCOLL
MAYOR T HoKu ST.PiEns
DIRECTOR OF PuBUC PROPERTY/BUUMING CON5MIONER
APPLICATION FOR THE CONSTRUCTION;REPAIIf~RENOVATION.CHANGE IN USE OR
OCCUPANCY.OR DEMOLITION OF ANY BuILDINe OR STRUCTURE
Thte SeetIM for OMtW Usb Ow
s
Build<nQ..Irgpec0or:_ 3lpnre~
EstimeEg Pr�6t Dafes: Start End:
Carrrfwft
1.0 SITE INFORMATION
Wcatlon Name: n BuldinT
Pmpsrty Address:
SaleIA Yrw a MO
Assessors 11AapJBlodc Louparcek
24 QYYFaRBHIk INFORMATION
2.1 of Land I
Addrcam-
��C"Lp vn wvz, O IR l J
Telephone:
2.2 Own r or Moe"of balldbrg or sbuclrus
Name:
Address:
Telephone:
3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name: 1 Ftl z k2 „ S nS. CO
Address: tom v r S}
Sa(Prn Yvva 014"Yo
Agency Projed Number. 5'7 6 -ivy C 1,93
Project Manager Name: ja j P2.r,,.I Y) Tet y y 6 la 3
U
i �--0-- ) 9 t,It,I �
4.0 PROFESSIONAL DESIGN SERVICES:_
4.1 Registered Architect
Name: .f to jc4 �r S Seal and SignaWrs-
Address: o o P1��Za Y ckdd �Sc z PLSn S
Tekphonx $ o -34 SqS Fau 144 ((.SS
4.2 Registend Pwtesslonal FAgineario: Ns•admeoial dmod d and.alt *1D awkdb�)
Name: A Seal and 3ignaitre=
Addrem
Telephone: Fax
At�.?f.Respons�i�ty:. -
Nam Seal and Sigiahue .
Address
Telephone Fax
Area of Responsibility:
Name: Seal and Signature
Address
Telephone: Fax:
Area of responsibility:
5.0 DESIGN AND CONSTRUCTION UTILIZING MGL C lilt SECTION 81R EXEMPTIONS
(see note below)
Contractor
Name: �o W YeY vv,01 c, C
Address: C9�lar��Q fZj Sil ` 0- y
,,,SAD r\ YYy
Area of responsibility: - y�G'`�✓
Ucerisei Number' C S b 5 3 6 5 3 Date of Expiradon 51 1 act 1
Telephone: gJys31z�_S�- Fax 5�g � y� 83`7O
Contractor
Name:•:' ,
Address:
Area of responsibility:
Date of Expiration:
license Number.
Telephone: Fax
Contractor
Name:
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax
Note: For portions of work ublWM exemptions of MGL e. 112 s.SIR complete the section above.
Use additional sheets if necessary and adach to application.
6.0 PROFESSIONAL CONSTRUCTION SERVICES: f
6.1 General Contractor \\ p �M YJlF �y� CTs� A C
Address: to
56Lp m mA 0
Telephone: Ci')13 7(%5".3QK3A0 Fax: 9?6
Responsible in Charge of Construction: ROSA ;c e W 1c.,, -14,
F
CONSTRUCTION DOCUMENTS -to be prepared by applicant
Item d as Applicable
Plans (Note 1 this page) Submitted Incomplete Not Reaulred
.1 Architectural
7.1.2 Foundation
7.1.3 Structural
7.1.4 Fire Suppression
7.1.5 Fire Alarm
7.1.6 WAC
7.1.7 Electrical
7.2 Specifications
7.3 Structural Peer Review
7.4 Structural Tests & Inspections
Program
7.5 Fire Protection Narrative Report
7.6 Existing Building Survey
7.7 Workers Compensation Insurance
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note 1 Areas of Design r g o Construction for which Plans are not complete at the time of
this application must be identified herein. Work so identified must not be commenced until this
application has been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
rt �
8.0 COMPLETE THIS SECTION FOR NEW CONSTRUCTION ONLY
For Existing Buildin s Proceed to Section 9.0
Number of Stories above _ Number of Stories Below
Grade Grade-
Story Height Floor Area Per Floor
Total Building Height Total Building Area Above
above Grade Grade
Total Building depth below:. Total Building Area Below
Grade:_ . . Grade
Brief Description of Proposed Work:
8.2 USE GROUP AND CONSTRUCTION CLASSIFICATION (Now Construction Only).
USE tiRQ P' ;' USE GROUP SU&CATEGORY .. CONSTRUCTION
(�as AappUcablel;. (�as-aPP6cable�- CLASSIFICATION
A , Assem
B Business 1 B
E Educational 2A►
F Factory F-1 F-2 2B
H High Hazard H-1 H-2 H-3 H-4 2C
Institutional,, 1-1 1-2 1-3 3A
M Mercantile ' 3B
R Residential. R-1 R-2 R-3 4
S Storage S-1 S-2 5A
U Utility 5B
Mx Mixed Use Specify:
Sp Special Use Specify.
9.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
For new construction comDlete sect a .0
Addition Existing ✓':
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:
1\� b�,aor U `'C d-��1✓P CT' " r�P tJ PA.,41 rS
9:t USE GROUP AND CONSTRUCTION CLASSIFICATION(Ez)stilhtBuild)nge QnW"I
Chan a
EXISTING PROPOSED g CONSTRUCTION
USE Group(s) in CLASSIFICATION
Use. Hazard Use, Hazard Hazard
(10w"' �01� Group Index `Group Index lndek• ` tJ s ajipleabl )-
A Assembly 1Ay {
B Business 1 B {
e
E Educational , 2Ar
F Factory 28' ;
H High Hazard 2C-
Institutional a3A
M Mercantile 3B
R Residential 4
S Storage 5A
U Utility 58
Mx Mixed Use Hazard Index
Sp Special Use
' Note: Include Hazard Index Modifier for Construction Type as applicable
9.0 CONSTRUCTION COSTS(See 780 CMR Appendix L)
Total Construction Cost 8uitding Permit Fee Check/Number
(1) _(1)x$0.001 /
10.0 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BUILDING
PERMIT(when applicable)
on behalf of the mAwdit State
Agency or Authority. hereby authorize, 9CCe �re v�``��Q7 � ra ccl to apply
for the building permit for project number.
Signature oats
11.0 SIGNATURE OF BUILDING PERMIT APPLICANT
1-7 o-�
V'S!gnatfi:ujr,e Date
12. Certiflcato of Occupancy required on completion of project? _Yes _ No
Inspector's Notes: