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135 NORTH ST - BUILDING INSPECTION — ;�\ PUBLIC PROPERTY � DEPARTMENT AISLHFJU.EY DRISCOLL 1 MAYOR 120 WASHINGTON STREET♦SALL K MASSACHLSLM 01970 TFL,978-745-9595 0 FAX 978-740-9846 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: 6 NORM 5F Building: Property Address: Property is located in a: Conservation Area YIN IV Historic District YIN Al 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: } Address: N©OW? 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 (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: Mail Permit to: c 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 Address and Phone Mechanic's Name Address and Phone �� L7�N 114-/��G�Qa,� Construction Supervisors License HIC Registration#.# _ 9 Estimated Cost of P cje $ �4�'-oh Permit Fee Calculation Permit Fee$ 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 X Date vlO 0 N w `1� `�. a y o � F °o C7 d -�._._ -4. . _.-- - ------ - _ --- _ _— - -- CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT xutaEteLev oarscou MAYOR 120 WASMNGTON STREET a SALEm,MAsSACHUSETCS 01970 TEL 978-745.9595 a FAx:978-740-"46 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leefbly Name (Busineu/Organiadowindividual): Address: IC ` ayk, City/State/Zip: l.0 r1 Phone#: r — �Z Are you an employer?Check the appropriate box: Type of project(required): 1.14 I am a employer with 2 4. ❑ I am a general contractor and I 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 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its 9. ❑ Building addition required.] officer have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.M Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.M Other 'Any applicant that cheeks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit due affidavit indicating they an doing all work and dim hire outside contractors must submit a new affidavit indicating sack. rContnctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy informadon. l am an employer that Lr providing workers'compensation insurance for my employees. Below is the policy and Jab site information. (I Insurance Company Name: //'' Policy#or Self-ins. Lic.#:-- W & e7o? / ZxL Expiration Date: [per o Job Site Address: � Yam_ T �' / City/State/Zip: � �-numb - °- Attach a copy<of ebe,worF:ers�ompewation policy declaration page(showing the poUcy 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 S 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. J do hereby certify%+�/nArr the pains and pens! ' s of perjury that the information provided above Is true and correct Sienarum //` �� `� � Dat • lint QrO�CG Phone#: 20 — Official use only. Do not write in this area,to be completed by city or town of jiclaL 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 thin 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 shaft 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 nor 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 bien 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-contactor(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 parmers,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 app riate 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 fdo.for future-permits.or licenses, Anew af;,drvit must be filled out each year.Where a home owner or citiun 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.niass.gov/dia CrrY OF SALEM PUBLIC PROPERTY DEPARTMENT Wra. tsowwmwZowsnaas•s.tna�4a�aannsOtl70 ,t Construction Debris Dispmd Affidavit (nequimil far all demoiidos sod rwovatiom wodt) In acmda me with dw sixth adidos of ft Seats Suitdinf Coda.7W CUR section 111.5 Debris.and tit*provisions of MGL a 4%8 Sot Suildia8 Permit 8 is lamad with dw condtdm do dw debris mad&g floss We wort AM be disposed of in a propady Hem" dtaposd&CiU y as dd lud.by MCIL a I L t.3130A. no dd xfs will be t:ansponed by: alz (a.m.deaJsnl The dcbris will be disposed of in: (mob a ttatyt cis of ter) s�awaua otpem�ir a�iC,as Of- 0C date COBq CERTIFICATE OF LIABILITY INSURANCE 09/21/2D20 6 PRODUCER (781)890-3740 FAX (781)890-1198 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Paul Burrage Incorporated ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 460 Totten Pond Rd, suite 630 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Waltham, MA 02451-1965 INSURERS AFFORDING COVERAGE NAIC# INSORED Milan Kucik dba Action Construction INSURERA: Nautilus _ 1Sa Bolton Street INSURER e: Granite State Waltham, MA 02453 INSURERC: NSURER D. NSURER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 N&N TYPE OF IN POUCY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR GENERAL UABUTY NC583213 07/29/2006 07/29/2007 EACH OCCURRENCE S 1,000,00 X COMMERCIAL GENERAL LIABLTIY DAMAGE TO RENTED $ 50 ,000 CLAIMS MADE OOCCUR MED EXP(Any one Person) S 1,00 A PERSONAL S ADV INJURY $ 1,000,OO GENERAL AGGREGATE $ 2,QQ0,00 GEMLAGGREGATELIMRAPPLIESPENt PRODUCTS-COMPAJPAGG $ 1,000,00 POLICY j LOC AUTOMOBILE LINBUTY COMBINED SINGLE LIMIT ANY AUTO (Eaaccident) $ ALL OMaEO AUTOS BODILY INJURY $ SCHEDULED AUTOS (Par person) HIRED AUTOS BODILY INJURY NONAVNEDAUTOS (Peraa nt) $ PROPERTY DAMAGE $ (Per accped) GARAGE UABUTY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAAOC $ AUTO ONLY. AGG S EXCESSNMBRELLA UABUTY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ g DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC8724357 01/22/2006 01/22/2007 WC STATU- OER TH. CRYEMPLOYER$'WIBUTY E.L.EACH ACCIDENT Is 1,000,006 B ANYPROPRIETORIPARTNERr BCUTIVE OFRCE%NIEMBER EXCLUDED? E.L.DISEASE-FA EMPLOYE $ 1,000,00 IT tleacnl0e under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS AWED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE 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 MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATNES. Milan Kucik AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 . y 9fie -Camlm� a��e Board of Building Regulattions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration r - Registration: 143685 _ Type: DBA ✓ Expiration: 7/21/2008 ACTION CONST. MILAN KUCIK 15A BOLTON ST \C f WALTHAM, MA 02453 l ` �V.\ :d1 '• ire Update Address and return card.Mark reason for change. DPS-CA1 aS 50M-04/05-PC8698 ❑ Address Renewal ❑ Employment Lost Card