112 NORTH ST - BUILDING INSPECTION CITY OF SALE
&,ql PUBLIC PROPERTY
DEPARTMENT
M KI% FRL /
EY DRISCOLL ` �-5
MAYOR i?p WASHINGTON STREET 0 SALUM.MASSACHLSLT S 01970
'ni 978-745-959S ♦FAx:97&7d0-9&%
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: f Sc1(y Building:
Property Address:
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: (� $
Address:
Telephone:
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 I New
grief Description of Proposed Work: /oao
Mail Permit to; (T 5, c �s y �%�� a41J
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name G � "n U '1
Address and Phone (470 <3f- Cl q U3
Mechanic's Name
Address and Phone
Construction Supervisors License# r S 0'70/YS HIC Registration# /a . 5
Estimated Cost of Project$ O 0 D Permit Fee Calculation
Permit Fee$ 2 0 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�P/ermit to build to the bove stated
specifications. Signed under penalty of perjury
Date
N
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CITY OF SALEM
,. PUBLIC PROPERTY
DEPARTMENT
yjemtwbYosts[oLL - 12DwtiwNGTONS1RF-Er Sn�+.�
MAYORACHLSErM01970
I.M.978-745-9595• Fax:975.740-9816
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
Ia accordance with the sixth edition of the State Building Code,780 CMR section 111.5
Debris,and the provisions of MGL c 40,S Building Permit# is issss
ued 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 1SOA.
The debris will be transported by'-
(nano of healer)
The debris will be disposed of in :
s (name of fxility)
(address of facility)
45i —
f permit applicaat
data
.1clxi.+l7duC
AOMP,,, bERTIIFICATE OF ILLAblLi i T 11M-- rUKA rz A'MATTER-OF.05 29/2006
PRODUCER (G03) 883-5526 THIS CERTIFICATE IS ISSUED A3 INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
CORRIVEAIT INSURANCE AGENCY, 'INC: - HOLDER. THIS CERTIFICATE :DOLS NOT AMEND, EXTEND OR
(1;� MAIN ST ALTER THE COVERAGE AFFORDED RY THE.POLICIES BELOW.
P O BOX 369
NASHUA NH 03061--0369 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER AI NAUTILUS
LONDONDEI2RYf MANCHESTER CONST SERV CORP INSURERB:AIG
pBF,: OLY14PIC INSURER c!PROGRESSIVE
15 TANS+ AY AVE INSURER M
NASHUA NH 03063^ INsuREq E:
COVERAGEfr
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. POLICY EFFECTIVE POLICY EXPIRATION
NSR ADD'L TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YV DATE MMI IONY LIMITS
RD4,000,000
17 / / / / EACH OCCURRENCE S
A GEOIERAL UAB L DAMAGE TO RENTED
100,000
X COMMERCIAL GENERAL LIABILITY
PREMISES Ee PcgvnaflCA S
COM
X R 11502722 12/09/2005 12/04/2006 MEO EXP An on, erson 8 5,000
CLAIMS MADE OCCU
PERSONAL 8 AOV INJURY S 4,OOO f OOO
GENERAI.AGGREGATE S 4,000,000
GEIt).AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 4,000,000
X POLICY 22f LOG
A X AUT)MOBrLE LIABILITY 35190760 05/11/2006 05/11/2007 COMBINED SINGLE LIMIT S 1,000,000
(Es SWdenD
ANYAUTO
'ALL OWNED AUTOS / / / / BODILY INJURY S .
(Per person)
X SCHEDULED AUTOS
X HIREDAUTOS / / / / BODILY INJURY S
(Per eCGdeRI)
X NON-OWNED AUTOS
PROPERTYDAMAGE S
(Pu acdden0
GA eAGE LIABILITY AUTO ONLY•EA ACCIDENT S
ANYAUTO / / / / OTHER THAN I EA ACC S
AUTO ONLY: AGO S
EXDE9SNM9RELLA LIABILITY / / / / EACH OCCURRENCE S
f OCCUR CLAIMS MADE AGGREGATE 5
4
DEDUCTIBLE / / / / $
RETENTION S $
WORKERI COMPWC STATU- D
8 EMnOY RVLAENSATIONAND T4C2791321 09/25/2005 09/25/2006 X TORVLIMIT9 X ETA'
EMPLOYERS LVIBILRT
ANY PROITiIETOWPAfLTNERIEXECUTNE - E.L.EACH ACCIDENT F 100,000
OFFICERndEMSER EXCLUDED? MASS / / / / EL DISEASE-FA EMPLOYEES 100,000
If ym.des(nlbe under - - -
SPECIALPROVISIONSMlow E.L OISPJlSE-POLICY LIMIT F 500,000
A OTHER INLAND MARINE I 8113963 01/13/2006 01/13/2007
190,000
XSCRIPTION OF OPERATIONSA.00ATIONSNEHICLES(EXCLUSIONS ADDEO BY ENDORSEMENTfSPECIAL PROVISIONS
'ERTIFICATE HOLDER CANCELLATION
( ) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER,ITS AGENTS OR REPRBSENTATIV S.
ALIT ZED REPRESENTATIM
d
CORD 25(2001I08) - - O ACORD CORPORATION 198)
�„i INS026(DI08).% ELECTRONIC LASER FORMS,INC.•(800)3 .0545 p1gre I of
i
BOARD OF BUILDING REGULATIONS --
License: CONSTRUCTION SUPERVISOR
Number: CS 080145
Birthdate: 1 012 6/1 9 6 3
)/ Expires: 1012612007 Tr, no: 8042.0
Restricted: 00
GEORGE VASILIADES
515 LOWELL ST C; . f1
PEABODY, MA 01960 Commissioner
� �rn77 p
t � ✓i±,s.:44�a�1.�. o�✓t2�oueaar�weeLA I ,.
Board of Building Regulations and Standards
- IUV..
HOME IMPROVEMENT CONTRACTOR -
J Registration: 24356
Expiration: 6/1212007
Type: Private Corporation
Olympic Painting/George Co., Inc
George Vasillado
515 Lowell st. .�# �. -
m - Peabody,MA 01960. Administrator:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET ♦ SALEM,MASSACHUSETTS 01970
TEL:978-745-9595 ♦FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): 6 ,h 5
Address:
City/State/Zip: -fe_rRe L ca-�i Phone #:
Are yo n employer?Check the appropriate box: Type of project(required):
1. am a etom employer with 4. ❑ I am a general contractor and I
P Y 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ 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.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL l l.❑ Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4),and we have no 12.�oof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
2Contractors that check this box most attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information.Insurance Company Name: Co r r 1 VI%h u'u Ty-, s A Q-Kcy
Policy#or Self-ins. Lic.#: Expiration Date: l 2 F K Lib
Job Site Address: tJ f �-tt_ City/State/Zip: Sci,le r a , �Sli / �� 11 r6
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$1,500.00 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 of the DIA for insurance coverage verification.
I do hereby certify er the pains and pens ' s-ofperjury that the information provided above is true and correct
Sienature: Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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,
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,MGL chapter 152, §25C(7)states"Neither the commonwealth tior any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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 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
self-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 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 permit/license 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 Lc u t 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for 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
Office 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