92 OCEAN AVE - BUILDING INSPECTION (2) EI`�'� �F��E - - --
�' ' PUBLIC PROPERTY
��` �'� DEPt1R'T�iENT � ���
1:uWE1LLEYDRI5(:ULL ` �
\lwvoa � 1'A WwnHcrcua S�r�"'�:,�cH�st.1�rs O1970
- 'l�t:9?&7�5-9595� Fn7t:978-7i0-9846 �
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION,
DEMOLITION OR CAANGE OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTLJRE OR BUILDING p�-rr o a, a g a c�0 7
, 1.OSITEINFORMATiON DwN �f� oCcuPlE.D.- 3 UlU /T f��1VT�L sIPT.
Locatlon Name: 901 C�7C �A N JE V E Building:
Property Address: c� a �P F' A- lY /�- � C
S A � C /`1 N'l f1
propeAy ia located in a;Conservation Area Y/N Historic Dfstrict Y/N
2.0 OWNERSHIP INFORMATION D Fa V ( D M M ! �H%�u D
2.1 Owner of Land ,�F} V ( P M M l cit-/�u n
Name: � VID M f'11C1-IflVp
Address: C�� � C �l-�- N ,4 V F's
S �}c. �fk MA
Telephone: ! � 9'9� 74-1 3 9'.8 3
3.0 COMPLETE THIS SECTION FOR WORK IN EXIST�N� BUILDINGS ONLY
Addition l�Cl Existing 7 ,GE /( �E
Renovation )/� S Number of Stories Renovated S H M�
Change in Use N� New S j4 M�
Demolition �E S' Existing g p p,
Approximate year of Area per floor (s� Renovated S A-M L-
construction or renovation New S y 1�j�
of existing building
8cief Descriptian of Proposed Work:
� � PLAc � � �cISTlN6 � NrR ,�} N � �.
� i�h N � W :Dopf2 l�ND 5 / p �- �- � TGSf
f� Np ��9- � NT N � W Wa2l< .
__ _ - _ ---
MailPermitto: D� V( D J"i Mlc (��fc�p, qa oc��-av � v� s��� M
What is the current use of the Building7 ��It���z�
Material of Building? /��6� �` '���"� If dwelling, how many units7 �
Will the Building Conform to Law? Y�S — E'il� S7'i N G Asbestos? N�0
ArchitecYs Name � < <�a��� W. C RI! F� f A1
Address and Phone Sf}Lt31'� �"I A • O
Mechanic'sName �Au�- -� ���s�g� C�/�
Address and Phone h� �'���'��` '� �� Ih�- � �� Sy� J/119
ConsWcGon Supervisors License# C 5 Ci 3�7��HIC Registration# /1S/r.�r-,�
Estimated Cost of Project 3 �$�a • Pertnil Fee Caiculation
Permk Fee S �' � Estimated Cost X$7lS1000 Residentiai ,
l�l L� 7�iN6�3•c� EsUmated Cost X$11/51000 Commercial
An Additional $5.00 fs added as an
AdministraUve charge.
Make sure that all flelds are properly and legibly written to avoid delays in processing. �
The undersigned does hereby appiy for a Buiiding Permit to build to the above stated
specifications. Signed under penalty of perjury /����
Date Z v
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CITY OF SALEM
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PUBLIC PROPRERTY
DEPARTMEN'I'
KAIBERIEYDR6COLL �
�rIAYOt
I20 WA4�VGTpH StxEBi�$ALEM.MwtEACIiU�Ti'S 01970
'1�1:97f.71S959S �F�x:978-7�49&6
Woricers' Compensatlon Imwaace AfAdavit: Bnilden/Contracton/Eleep{eiam/plom�
Anoticant Intormadoe ���.�� .* ��
Name lBusineWoraaniauoo�in�viA�al): _l� s`7'Ll�- �e�Q�� Li� Ds'v¢L2��-scF�l�q Cc1X��
Address. � ,���y�2 � �T
c;ty�sffite/2ip: '�-Y/v�2 /LI/��Y'6� Phone#:? �/ �S5 9 GLs' �
a
Aro yom ee employarT COeelt tB�appropetaq bon —
1.�I am a employar with i 4. [] 1 am s Sa�a�(conoutor aod I Ty���l°�(n9dre�:
empbyaa(l41t and/�part eme)." have hired the wbconaacwrs 6• ❑New eon�uctiou
2.� I am a aok propciemr a p�cmeo- listed on tha aduhed sheet t 7�odelin�
s1�ip and have mo employea 'ibese�nascoon have 8. []Demolitiaa
woridni for me m any capuiry. worken'wmV•lnnuance. 9. Buildia
INo workan' comp.iaauanee S. Q Wa aro s caponpm and ita ❑ i sddition
n4�d�� oHicm Lava execeised t�r IO.Q Electrical repaia or additlon�
3.0 I am a homeowner doin�all worl� right of ac�pp�P�MdL i l.[]PlumbinQ repaitr ar add�tton�
myxlf.(No workers'eomp. c. 132, §1(4�and cve yave no
�D��d�� �P�aYea.[No wocken' 12.�]RaoPrepain
�omp.inwraoce requirod,] 13.�Other
f�Y�PPlfeae�tlut�Aecb boo[MI maw a4o ftll aut��eedm bolo�v r6owdn�i6dr waduo'eampowia Vo�'�md(aa
Nmrovoa�w6o a6oit Ihb�AId�W mdkatln��Y w du��tl wadc md iha I�dn auh�emb�etan mwt ai6mN t oar dRdrvY
�Coatr�aa�Urt cheek�4 bm[mu�t alhe6d m W�tlood�haM�ho�rto�tM o�of Id�e�n md thdr rorbn'eamR teAtmuka �
!a�u aw emotoya lhat b prov/d/nt worRen'compenaatlow lnawranc�jor my eniiployaea. Balow!r NY�polfcy andJob.sltt
tnjoreratiow,
Insurance Company Name: t��>J G�,e 7` o � IA/
poi��y r►�s�u�n,.t;�.�: t/s�oo i� ov � a -� i -rc t o 10 �/a v/d
p Fup'vuion Date: 7
_ 1ob Site Ad�pc__ L O� �C f�-AJ /7--s^� Ciry/State/Zip: S�L F"�'( 7��
Attic6 a eopy o(tlr worken'eompensatloe poticy daluaqo�pap(�howM the
f nnmber
, Fa�lure ro secure covera s� P��7' and e:pindo�daPej,
Ye mNued andu Secdon 25A of MGL c. 132 can lad to rhe' penaitia of s
fine up w S 1,300.00 and/or one- eu im �P��n of criminai
, Y P��rnt,as we11 as civi! nalda in
of up w 5250.00 a da a P� d�e fonn oP a STOP WORK ORDER aad a fine
Y B��he violatoe Be advixd t}�at a copy of this uatement ma be f
ocwarded
Inves[igarion�of the D(A for' y ��he Otlice of
uuuraoea coveraga verificarion
!Jo bere ra �n My and psn ojp�r�ruy thm t/u Injonirodow provtded v�!i and eoned
l�C�)
Z�
O,Ijletd aa onl�t Do not wrltt!w th(r areq to A�conrplelsd br elly oi Www o,/JIclaL
Ctty or Towo: PermtbLleenx N
Is�ulnQ AutAorlty(ctrcle one):
1. Board of Ha1tA 2.BuUdln�Department 3.Cirylfowp Clerk q, Electrical Iaepector S. ptumbin�inapector
6.Ot6er
Contact Person: �
P6one#•
�i-
Information and �nstructions
Massuhuseas Generat Laws chapter 132 cequires all employecs w provide workas' compensaaou fa their emPl�Y�
p�ant w this smmoe+�►e�P�OY��
is defined as"...every peesue in tha secviu of anothec uoda wy conaad othire.
axpeeas or imPlied.°�1°r wriam"
y��o,wiporation or o�her kgai endty,or any ew� �
An�sploys►is defined as"��vidual.Pa�P. � va of s deeeased e�P�Y°�•a
of ehs foce�oiai�4►i��sJoi�edaP� �a ��y�employeet. Howeva the
ceceiver oc avatee of m individud.P�'0. �who caaida�.ar the aocuW�of tbs
ownu of a dwetlin�����ro do mainomwce.e�o�O°°��W�m�be�houa
dweltini�"°oi�oother �ro shaR not bxausa of such emP�
or oo�a S�°�ar buildini BPW�°�
MGL ehaPtar 112.425C(��O���°Y�stW or Ined dee�[�Y��Y slar NlthYdd tM ivaaaa or
paraq a businaa oc te eo�d bnlWlsi�h thr eommo�wesNi tor aal
reu�d ot s tleasw or�LO°���L evtdeaa et eomplWn wtti th�fa�uranereoverap reqdrid.
app���rYs ha�sot P� 13 23C shma"Neither the eommenwwlth aac mY of ib politi�al��
AddiamallY.MGL ch�p� Z•$ ('n le evideece ot eomplisnee
cantrad far dm parfo�'m�°f P�►�lie wack until�eeeptab
�uiremenn ott6is c�p�hsve b�P�to ehe conaectenS su�►�Y•� II
ppptlea�b i to att situ�d�+nd.if
Plesee 811 out the w��co�°II s�vit comPUWY.�►Y���the boxa i�Y�����
s name(�).addcea°(°�)�P6one numbc(s)ataoi with no empleYea+ot�thaa t6e
necessatY.s�'PP1X��ontru�to�( ) ����L��Liability PastnenhiP�(�)
�nsursnce. [.imiocd Liability Comp���wockas' co�ms�°°1D°�' If an LLC rn LLP doa luve
��y���s,are not r� �thu aHidavit m�y be aubmitted w[hs Depsttmeo�°f Induetrial
���y�p��pelicy is requi�� HO°��� �M�an to sl�and date the amdavlf. 'I'he a6idavit s6ould
Accidena fa couArmat��of inausnce �license is b�in�n4����0��ot
be rehuned w the city or mwa that tEa applicatien f�t�e pa�mi� ro obtain i worker�' �
�d����, ghould yuu 6ave s¢y q��n�d�e hw ar if You aze raluired I
at the numbar lisoed below. seif-ioaied eo���d�� I
compeae��n P��•P�0 call the Dep� �
selt-inaasn�x 1iee�°°�°II the a
Clty or Tow�O�ei�
Pleasa ba suce that the afFidavit is complete and printod legibly. The Depemamt har provided s space at the botrom
of cha affidsvit for you w fill out in the event the Office of Investigatiom has w contact you regardinQ the applica�.
Plesse be sum w fill in the pesmit/liceax number which will be uxd as s reference num���indieahni c�°� I
lieatious in any givm yest,need only submi
thae must wbmit muitiple pe�mi����„Jab Site Addreas"the applieaot should write"all locatiom ia__—(�l�os
���y infacmation(it nec�+s�*Y) off[ciallY stsm�or marked bY ehe ciry a wwn may be provided w dm
town)•"A copy of the atfidsvie t6at has been or ticeaset A mw af;id�.vi�mu�t be filled cwt ach
aPPu��p�OOf that a vakd afHdsvu u on fik for t6turo P�d aa related w any buainw ar commeroial ventute
yeat.Whece a ho�°�or citizeu is obtsinini a Gcense a P�
u NOT re4air�d t°�°mPlete this afRdavit
(i.e. a dci lieense or Per�u m!wrn tesva ero.)said pe:aon.
nr would like w d�anlc you in advaau for your eoope�atien and should You hava any q���+
The OfHce of iaveuiBatio ve ui a call.
please do not hesitata w gi
The DePec�°t���'���O�O ,��w�t�l OEMi4SiC$11SCtq
�epectment of Ia�iv Accidenb
Otaee ot Isvadpdoas
60o w��oon so�e
go�on,MA 02111
Tel. #617-727-4900 ext 406 oc 1-877-MASSAFE
Faa N 617-727-7749
��„��i s-2s-os wvvw.mess.gcv/dit
ACORD CERTIFICATE OF LI`ABIL' ITY INSURANCE oz�zsizoo�
PRODIICER (g7g)744-7110 FAX (978)741-2059 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Soucy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P. 0. Box 4467 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
201 Washington St.
Salem, MA 01970 INSURERS AFFORDING COVERAGE NAIC#
INSURED LeBrasseur Construction INSURERA: TI72 Tf'aVE�EfS
2 Bickerton Street iNsuReae: AIM Mutual
Lynn, MA 01904 INSUftERC:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.N07WITHSTANDING
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' 7ypE OF INSURANCE POLICV NUMBER POLICV EFFECTIVE GOLIGY EXPIRATION LIMITS
GENERAL LIABILITY I680170Y6271TCT06 09/24/2006 09�24�2�0� �CH OCCURRENGE $ 1�QQQ�QQQ
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 3OO�OOO
CLAIMS MADE a OCGUR ME�EXP(Any one person) S . 5�QQQ
A �� PERSONAL 8 ADV INJURV $ 1�OOO�OOO
� GENER4L AGGREGATE $ 2�OOO�OOO
GEN'LAGGREGATELIMITHPPLIESPER: PROOUCTS-COMP/OPAGG $ Z�OOO�OOO
POLICV PRO- LOC
JEGT
AUTOMOBILELIABILITY � COMBINEDSINGLELIMIT
ANVAUTO ' (EaaccidenQ $ �
ALL OWNED AUTOS BODILV INJURV
SCHEDULEDAUTOS (Perperson) §
HIRED AUTO$ BODILY INJURV
NON-OWNEDAUTOS (Peraccident) $
PROPERTYDAMAGE $
(Per accitlent)
GARAGELIABILITV AUTOONLV-EAACCIDENT $
ANVAUTO OTHERTHAN EAAGG $
AUTOONLV: qGG $
EXCESSIUMBRELLA LIABILITY EAGH OCCURRENCE S
OCCUR �CL4IMSMADE AGGREGATE S
E
�EDUCTIBLE S
RETENTION $ $
WORKERSCOMPENSATIONAND VWC 6009498012006 09/24/2006 �9�24�2��7 WCSTATU- OTH-
. EMPLOVERS'LIABILITY E.L.EACH ACCI�ENT $ LOO�OOO
B ANVPROPRIETOR/PARTNER/EXECUTIVE
OFFlCERIMEMBER EXCLUDED? EL�ISEASE-EA EMPLOVE $ ZOO�OOO
If yes,tlescribe under
SPECIALPROVISIONSbelaw E.L.DISEASE-POLICVLIMIT $ SOO�OOO
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXC�USIONS AOOED BV ENDORSEMENT/SPECIAL PROVISIONS
CER IFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESGRIBED POLICIES BE CANCELLE�BEFORE THE
EXPIRATION DATE TMEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Cl tY of Sal em lO OAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn: Building Department BUTFAILURETOMAILSUCHNOTICESHALLIMPOSENOOBLIGATIONORLIABILITV
120 Washington Street OFANVKINDIIPONTHEINSURER,ITSAGENTSORREPRESENTATIVES.
Salem, MA 01970 AUTHORIZEDREPRESENTATIVE
Paul Souc
ACORD25(2007/OS) FAX: (978)740-9846 OACORDCORPORATION�1988
.' ' Cl'TY
OF SALP�t
' PUBLIC PR�OPF.B'lY
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EXISTING STEEL LINTEL = � � A�ERI AN EAGLE _ � Z � ' a
GAULK OVER �'� �— — — _ — — —� � 1- � m �
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J I EXTERIOR = �
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TRANSONI � � Z I GL II I G� 5/8 RIGK Q � � �
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PANEL IN MIDDL e � w GLASSRED Q � � � >
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ry =
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5/S" V2" P�YWD �
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TEI"IPERED SPAGER = H I Y4" GRANITE FAGING �
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SPAGER . � G 1�2„ - 1,-�„ c� N �
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S/4" STOCK s�.4�� Jq�..�B '-�m UNIT UNIT DII'1. UNIT
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(SIDES W/ WD TRIM) ,;�- ' ; � �y2^ � �
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