59 OCEAN AVE - BUILDING INSPECTION (2) Vile (lmunoll%%calth ul :%lds.sachuselt. ---- - _
!' Hodid of liulldll)•• RC"LliallollS .old St.uld:uils I ( IR
t •• ,,Uasxdchuwtts State Building ('r ode. '\II ('SIR, 7"' edition
I ,I
Building Permit :\ppliC:unnt To ('unslruCt. RrP au. RCm11:Je Or I)wnuliah d �/t I ,• •/ 1,,,,,,,,,
lhr,'- I,r Tu„"hr,n, 1 u,'//inl l .•a s
\\
l'hu St(ulrur Ulfi al 1'sr Only. ----- ----—- - -
Y `1 BuIIJtn� Prrmtt .Vum r pp� I 1 tte .\pphtd: _
�Il.tlll(t- VLTG2•✓✓ �1/!/J,_V�
-- - -
HuIWm);(\nnnu..n mcu In 1u.lur of Hull II Ua0.• _
SEC-110N I: SI FF: INFOR.\I:\ 1'I0N -
y, 1.1 Pruperh Address: ^ I 1.2 lissessors flap Y Par(tf�Noun1 rs-- -- -
I.la Is Iht1 all IccClued Ille .l lo — 1111p;Nurllher
:.3 Zoning !::F,rrn:�::,.ta -- i .7 r e„+r.•, .:_rtrnrnsror:v.. ;
----
i Zoning Uulncl Pmlpo,rd Use Lut Arca is III
4 1'I Ulltate l it)
1.5 Building Setbacks (ft) ------- ---"--i
_ I
fnnit Yard side Yards F--- —
RrutlnrJ I Provided __—Rc ucJ PnnIJcd .__." i
t— _� RtyuueJ Pn .ntvd
i
Water Su I tS1 C L c. .40. §54) 1.7 FL•�PP Y� rJ Zone Information: LS Sewage1)isposul Systeat:hli( ❑ -Pnvatc❑ Zune: Outside FlIx1J Znnr:'' Municipal ❑ On site Jnlxrsdl ScNlenlSECTION 2: PROPERTY OWNERSHIP'
[,;11,..6
.1 nerlu 'Recor
.I Name (Prino — Address Rrr Service: ---
� I
7K---v=�— __
I Slgnatu e Telephone
— _ I
SECTION 3: DESCRIPTION OF PROPOSED WORK"((heck all that apply)
New Cu '(ruction ❑ Exislin BwWin ❑ Owner-0ccu ' ---- - "----
_ E' b 1 - glad ' Rep wsl si ❑ �hcran, n;r,) ,7 L \ .a r' I
Demuliuon ❑ Accessory Bldg. ❑ tiun- LmO)h,r ❑ sl•eclty
Br+?f Des 'I •lltu of Pru sad \ nt{,' --
It
La�Oil
- ---_ SECTION J: ESTIMATED CONSTRUCTION OUSTS
Item
h, Official Use Onlv j Ld. ,r ,old \tarrnals) _
�^ 1 Building q 9VAJ- I I. Building Permit Fee, $ Indicate h�rss tet I. ,lctr:ol, l<si-
Filrnn(ul 3 —L_ ❑Standard City/rrnsn Appilcaul,n Fee
i 0 roral Project Cnslll hem o) s m,:itlpiltr ______
I lumhrr2 - -'S------ ? Other Fees: 5---- --
4 Mechanical 'MAC ) 'S 1 Lc,t:_ ------------ -----
Sle(hdnlcal tFue ---- __-- --___---- ---
ltl3�errssl„nl--- rot.11 All Fcts:
Check .Vn ._ ('heck .\m�nmr \n
( ".nil e nnu
}� It focal Project C'usl -
` \__ 0 Paid In Full 0 OulsLutdnl" Ii.l1.1 n.c [)lc
16 joy
� HIC � NJI111. `,^
slgnj
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT tNI.G.L. c. 152. 5 2506))
jelclihmic
this Afffida%it will result in the denial tit (he Issuart the huildin�g lfl:=�
Lj
Signed Atfi&mt Attached? Yes TO BE COMPLETED WHEN
SECTION 7a: OWNER UTHORIZATION
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT
'
�
0on�/ .`�/h� `uhj�oyp`p�nyh�uhy
. � x, ` |
� L -''--_--�-_----------------------- �x �// `." /'.� ��h^|L ." ^|: o"/uu �
i uu�|..m�� �--'-_-'-_--------------- ----------- �
� authorized h /hi� hu8Jing permi, ,Iyy|/can``n.
Diie
S"Ilatury or 0%�Iler SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
behalf. 2
Print Name
Date
� -
h,/�nodw`rkup|^no�u� Pw`m� o"cm"''"'^"," '~'' y J/��` ,/ |^..�h/ �
When substantial /'o�|w]m� �ur��*� 6m,h�J �«`o»u� '«»��`� `
| T..u| d~vs area'S4. Ft�/ H^ho^hle ^*m "'»»/ -----�--'-----� ---
/ U^*` |^mg muu 'jvF/ Nmoher ^t ^�J^wm` - ---� _ - '-
iNumher,, Numher .`, |uirh,11h` - -- - - - '
i � '`` `"� - -------- - --'-
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!! ��� �� G G�� �
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1
r �
Lic.No.047596 - Insured
Steven D.Hayes d/b/a
e L_ DONALD T. HAYES CO., INC.
GENERAL CONTRACTOR
REMODELING -CARPENTRY-BUILDING
(781) 598-2530
f`A
CITY OF SALLM
PUBLIC PROPRERTY
DEPAR"I'.10ENT
:•.I .. 11• ., I •� \\ \J I:\�.. '•.11311 f � 1.\I I \I, \I \..\, .. I _I'I
III v'R '1;. ,aj � I \\. •:-x.v: 1;a�,
construction Debris Disposal Affidavit
(reyui ed litr all demolition and renovation \%urk)
In accordance \�itll the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of 1viGL c 40, S 54:
Building Permit is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by.
( mmc of hauler) -
The debris will be disposed of in
(name ut facility)
I❑ddres. utl]cllilvl �1/ ///)�/ �r ,
H�IIJIIII I' I)Cfll llt .11 111 J[it
CITY OF SALEM
51
PUBLIC 1'ROPRERTY
DEPARTMENT
0111G M:I\'Jnlit I,I 1
vl I\cull I?�Writ u.�a:lai�$ra Eh1' � S,u P\t,Msas.u.rn irl n5117�
1'i li 978-7134545 • IAx. 478-710.9816
Workers' Compensation Insurunce Affidavit: Builders/Contractors/Electricians/Plumbers
\ ) tlicaut Information /r , �j Please Print Legibly
ViNna: Uill<Illesyl�r;tanlr:arinlvindlvldaan: �f F / 1� `�
AVtulle ss: l
City,Scatc,Rip I'honc r': ?a 5W Z�U
:fire you an employer? Check the appropriate box: 'Type or project(required):
I.❑ I kill a employer with 4. El I :kill a general contractor and I ❑
6. new construction
: �_
cnl,loyccs lull and,far art-time).' have hired the sub-contractors
I ( p 7. ❑ Remodeling
?.❑ I um a sole proprietor nr partner- listed on the attached sheet.
Ship and have no employees These sub-contractors have 8. ❑ Demolition
working liar me in any capacity. workers' comp. Insurance. q, ❑ Building addition
l No workers' cuinp. insurance 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions
rcquired.J officers have exercised their
right of cxent tion per MGL 11.0 Plumbing repairs or additions
3.❑ I ys a homeowner doing all work C. 152, i 1(4),and w have no
myself. ItCo workers' comp. s12.❑ Ruuf repairs
insurance rcyuired.J t employees. (no workers' 13.❑ Other
comp. insurance required)
Nin Iho cheeks box/tI must:dsu fill call the secnun ltclow showing their wurkcas'cumperoation pul icy inhrrnraliun.
' I lomeuwnen who submil this afndavit indicating the)are doing all work and then hire outside coruractom must auh.nit a.new atGdavil indiull-g.uch.
-f',murwa,ry dull check this box mail attached.m additional..heel,huwiny the nane of the sub-contrnnom and their uurken'comp.pulicy information.
/am all coipluyer that is pruridinq workers'col»prn.rntion insurnttee fur ury entpluyeec. Beloiv is the puliry and fob site
iufurnwriun. w�v//�� //''qqyy�
Insurance Cunipany Name: t7 ro t^^"f�-._. .. - -. ----
Itolicv a or Self-ins. Lic. r: �J(- d d /9 G ----- . _ Expiration Date:2(1�_
Job 5ile Address: �U C.L, City;State/Zip:
Attach a copy of Ilie +rockers' cmnpcnsation policy declaration page (showing; the policy number and expiration date).
imailwc to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up co S1.500.00 and/or one-)car imprisonment, As well as civil pcnaltics in the form of a STOP WORK ORDER and a fine
of up In )250.00 it day against flit violator. lie advised that a copy of this statement may be forwarded to the Office of
Inve,fl,aunns ul the DIA :or inilu:u:ce co\crago wrilicalam.
/do hereby crlify tiaderthepaini and penahiev of perjury that the infunnation provided above is true anti correct.
Date- l
()flit jai rose only. Do not Ivrite in this area, to be cuutplered by city or rolvn official.
Cily ur Town; _- Pu'tnitll.iccnse X_ _ _
issuing Authority (circle onc):
I. Board of llvalhh 2. Iluildikil; Department .l. Civ%.A`own Clerk J. L•'Iectrical Inspector 5, Plumbing inspector
6. Other ... .
Contact Pcnunt _ Phone d:
Information and Instructions
..%lassachusetts General Laws cha pier 152 tcq Wfes a I I employers to provide workers' colnpensat ion for their employees.
Purnu:mt to this .statute,an empluree is defined as "_.every person in the service of another under any contract of hire,
espress or implied. oral or written."
An vonployer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
or the t0reeoing engaged in a Joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of .in Individual,paninershrp, 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."
.IGL 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 curitpliance 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 perfbmtance of puhlic work until acceptable evidence uf'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-contractors) name(s), address(es)and phone nunrber(s) along with their certificates)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 dale 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur 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 Its proof that a valid affidavit is on file for future permits or licenses. A new at"idavit must be filled out each
year. where a home owner or citizen Is obtaining a Incense or permit not related to any business or commercial venture
(i.e. :t dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
t he I)I'ti.v of Investigations would [ike to thank you in advance fur your cooperation and should you have :try questions,.
please do not hesitate to give us a call. -
The Deparnnctu's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
06/20/2008 12: 16 FAX 1975711UZ60 ..nN.,. •-�---
.4CORDm CERTIFICATE OF LIABILITY INSURANCE 6A2 Coo'
PRODUCER (781)598-4300 PAR: (781) 599-1530 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Cassidy Asaociatea Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
y y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
232 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Swampscott; MA 01907 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER ProBuilders SpecialtV Ins 8288
Hayes, Donald T Inc INSURERS;Pll rim Insurance Codn an
15 Oak Road INSURERC:Granite State
I S ER 0:
Swsmpsoott. MA 01907-2120 INSURER E:
QVIFIRAGES
THE POLICIES"OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWRHSTANDING 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,
MaY HAVE SEE 4 REDUCED RY PAID CLAIMS
INBft ADDL TypE OF INSURANCE POLICY NUMBER DAILY M/balYY FFECTIVE PDAATTE Map TION LIMITS
TR
GENERAL LIABILITY S 1,OOO Y O00
% COMMERCIALGENBRAL LIABILITY DAMAGETORENT50 S 50,000
A CLAIMS MADE OCCUR NB5016911 9/20/2007 9/20/2008 EX ,c Breon S 5,000
INJURY g 1,000,000
GENERAL AGGREGATE S Z,ODO OOO
GEN'L AGGREGATE LIMITAFPLIES PER; _ S 2,000,000
POLICY I PRO- F7 LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
fEa Bcmeanq S 500,000
ANY AUTO
H ALLOWNED AUTOS PGC100007129A32 2/12/2006 2/12/2009 BODILY INJURY
5
X SCHEDULED AUTOS (Par Perm
HIREDAUTOS BODILY INJURY S
NON-OWNED AUTOS (Pel eoelEeM)
PROPERTY DAMAGE e
1 (Pw aaddwIt)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT B
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGO S
EXCESSIUMBRELLA LIABILITY EACH QQ.QURRPNCPyyyYN
OCCUR CLAIMS MADE AGGRF08= 5
DEDUCTIBLE S
ON
(�` WORKERS COMPENSATION AND X VYC STA OTK
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNEPoEXECUTNE E.L.EACH ACCIDENT S 10(),O00
OFFICERIMEMBRR EXCLUDED? WC6849667 5/19/2008 5/19/2009 EL.DI ASE-EA BM OYEES 100,00IF Y09, 0
MW
SPFQAA�PR VISIO ew RL QI8CAS9-POLfC-YLIMrr S 500,000
OTHER
DESCRIPTION OF OPERAMONSILOCATONSNEHICLEBIE=LUSIONS ADDED BY RNDORSELIENTISPEOML PROVISIONS
CERTIFICATE HOLDER CANCELLATION
(781) 199-1530 SHOULD ANY OF THE ABOVE DESCMBED POLICIES BE CANCELLED BEFORE THE
Town of Marblehead EXPIRATION DATE THEREOF, THE I$$UINO INSURER WILL ENDEAVOR TO MAIL
STulding Dept- 30 DAYS WRITTEN NOTICE TO THE CERTINCATE HOLDER NAMED TO THE LEFT,BUT
Marblehead, MA 01945 FAILURE TD DO BO SHALL IMPOSE NO OBUGATION OR LUUMLITY OF ANY KIND UPON THE
INSURER ITS AGrWM OR RSPRESENTATTVES.
AUTHORIZED REPRfiSHNTATIVE
ACORD 25(2001/08) 0 AC CORPORATION 1988
INS025(otoa).oee Pape'I ofs-