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6 ORNE ST - BUILDING INSPECTION What is the current use of the Building? Ai�t4 l,� mob, n��If dwelling.how many units?I— Material of Building? r ./ - Wiq the Building Contorts to Law? / Asbestos? - Architeds Name Address and Phone ( j Mechanieb Name Address and Phone Constnrclion Supervisors License 0 HIC Registration S 32 Estimated Cost of Projed Ss 4L�=6'-e Permit Fee CftMtion permit Fee i Estimated Cost X$71$1000 Residential Estimated Cost X$11/51000Commercial ------__..- - _ - -- - 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 N 1 O i 3 G a 01 PUBLIC PROPERTY DEPARTMENT KI.CAMAY Oftsco ,. Nwraa 130Vvwamc Msir•SetbY,MtWO1L5hTR 01970 TEL MUS-MS•FAX M740-98% APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY VUSTINPA STRUCTURE OR BUII.DING 1.0 SITE INFORMATION Location Name: Building b Property Is located in a:Consarvadon Arss YIN=Hkdodc Disirks Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: OLX Address: / 6 ! l / 45 Telephone: Ip 7 L 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 New Brief Description of Proposed Work: Mail Permit to: . 6/94 Z - - - - CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT I wINaYRtFY nAMOLL MAYOR 12C WA+w.wToN TmEirr a SALE34.WssActit rtx019T Tit:9M743.9595 9 Fax:9711-740.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers -un licant Information l�j'y� �f �P �1 Q y n �Pllease Print Legibly NaMe t9usincsWC)WnizatioNlndivtdual): I C 4 ,f`-"d( I/v U �L-/W/ v_-(�1 (?b• AJdreas �—/ I ` `d/�1 d— �j q CitylstateiZip: 1144 © 0L Phone H: A 2- ( 22. Are you an employer?Check the appropriate box- 'rype of project(required): 1.❑ I am a employer with 4.M am a general contractor and 1 6. ❑ New construction employees(full and/or part-tine).• have hired the sub-contractors 7-J 1 am a sole proprietor or partner- listed on the attached sheet : 7• ❑ Remodeling ship and have no amployacis These sub coatnctors have V. ❑ Demolition working for me in any capacity. workers'comp. insurance. (No workers'comp. insurance 5. ❑ We are a corporation and its 9. 0 Building addition required) officers have exercised their IO.Q Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No Workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs b insurance required.) t employees. [No worker' I Other /� comp. insurance required.) •Ant,pplicwr ail chsdts boa at muss also lilt as ate welion bcluw drow•ina their wwkota'tmmpmsuiun Policy infurmutiva. '1 twnatwnma who submit this affidavit iiall mina that an doing as wash and then hoc owsida canlraaIXa mwt autnnu anew affidavit iMialina wok. �Comncmts it a chick this box man anachod an addilienal dw1 showin dw name or the subeontnetwa then,w a and eu ohm'sti^sp.polity infarmarisss l um an amployer that Is providing workers'compensaten hnsurance for any employers. Below is the policy and job site in1 urination. Insurance:Company Name: Policy 4 or Sclf--ins. Lie. ri: w I U- PVIE57 /91�/\ED_ Expiration Date: Job Site Address: 1b 6NV[ city/SlawZip:C trN2j Attack a copy of the worker'compensation policy declaration past(showing the policy number and a piratioa date). Failure to secure coverage as required under Section 25A uf.VIGL e. 152 can lead to the imposition of criminal penalties of a fink up to S1,5000)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 Ile advised that a copy of this statement may be forwarded to the Office of In.cangauutu ofthc DIA for insurance coverage veriflcalion. l do hereby c•rtijy n oder, ..o pains mid en ire ujprrjury that 'njurmWlon provided above is true and cornet tii •scuts•t __ D t t ^� --2 72-7'1 D/Jlciu!use only. Do not write in this area,to be cumpleted by city or own a leAd City or Town: _., Permit/I.1cense M Issuing Authority (circle one): 1. Board of l(ealth 2. Building Department 3.Cit)/rown Clerk 4. Electrical inspoatir 5. Plumbing Inspector 6. Other C.uutacl Person: — Phone q: Information and Instructions Ntassachusetts 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 him orpress or impli.td,oral or unities" An employer is defined as"an individual,partnership.astociatiM 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 a trustee of as individual,par aetship.astcciation or other legal entity.employing employees. However the owner of a dwelling have having not more than three apartments and who resides therein.or tins occupant of the dwelling house of another who employs persons to do maintenance.cuestruction er 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." NtGL chapter 15Z ¢25C(6)also status that"every state or local licensing agency s ag the withhold the issuance or for say renewal of a license or permit to operate a business or toeoasiraet buildings in appUeant who has ant produced acceptable avddence of eompNaaee with the insurance coverage required." Additionally.MGL chapter 152,§23C(7)states"Neither the commonwealth a"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." Appncants Please lillout the workers'compensation affidavit completcly.by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)at me(a)'address(es)and phone nanbe4s)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 worker'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 low 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 OfAcdsls 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 till in the permiulicettse number which will be used as a reference number. In addition,an applicant that must subunit multiple permitilicense 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"Lill locations is (city or town)."A copy of the affidavit that has been officially stamped"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 be filled out 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 burn leaves etc.)said person is VOT required to complete this affidavit. The 0111x of Investigations would like to thank you in advance for your cooperation and should you have any questions, pic:ue do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents O®a of[avestipdans 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised i-26-05 www,masg,gov/dia i i of pmading HOMEIMPRQVEMENTCONTRACTOR Tri 126786 � a�o KT.MAGGANARISRObfiPtG ICES,COMPAN KONSTANTINE M,�G GANARI$r" 7,9 BEACON HILL AVE LYNN,.MA 01902 Admireukkator CITY OF SALEM PUBLIC PROPRERTY 0- DEPARTMENT l.0 W.%i1"-'0NS.WV•SAUM.%L%%U:.tl 74:VW4549" F.%x:9W40UK Construction Debris Dispose[ Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code. 780 CNIA section 1l1.S Debris.uld the provisions of viGL c 40.S 54. Building Permit* _ . _ 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 e IL1. S1l0A. The debris will be transported by: me debris will be disposed of in C&j� A I ,uame of I�dlty) I l ♦.g..�lb::of,Xf16lC.t:a.IC 1Ar � �_ •.a4 ACORD� CERTIFICATE OF LIABILITY INSURANCE DATE9/4/D/Q/YYYY) PRODUCER THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION Divirgilio Insurance Agency ONLYANDCONFERS NO RIGHTS UPONTHECERTIFICATE 270 Broadway HOLDER THIS CERTIFICATEDOES NOT AMEND,EXTEND OR P.O. Box 8065 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lynn, MA 01904 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: FIRST FINANCIAL INSURANCE RYAN ROOFING S CARPENTRY INSURER B: MARK RYAN INSURER C: 165 LYNNFIELD ST INSURER D: LYNN, MA 01904 INSURER 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 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 O'L POUCYEFFECMW iDUCYE(PIRATDN POLICY NUMBER LIMITS GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 A }{ COMMERCIAL GENERAL LIABILITY 553F001437 9/24/06 9/24/07 PREMISES Ea renca $ 100,000 CLAMS MADE OCCUR M ED EXP(Any..Person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO $ 1,000,000 POLICY PEA LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIM IT ANYAUTO (Eaac di ) $ ALL OWNED AUTOS BODILY INJURY SCH EDULED AUTOS (Per parse) $ HIRED AUTOS BODILVINJ) $ NON-OWNED AUTOS (� cOderrt)a PROPERTY DAMAGE $ (PeraWdtl ) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANVAUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ III EXCESS/UMBRELLAUMILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ VrC STATU WORK H2SCOMPENSATION AND T RV IM IT- I OTHER EMPLOYERS'LIA®UITY El-EACH ACCIDENT $ ANY PROM IEfORIPAR TNEREXECUTI� OFFICERMIEMBER EXCLU DED? E.L DISEASE-EA EMPLOYEE $ Ifps,de ub u w SPECIAL PROVIS ON Sbebw El-DISEASE-POLICY LIM IT $ OTHER D ESCRIPTIO N OF OPERATIONS/LOCATIONS/VEH DUES/EXCLUSIONS ADDED BY END ORSEMENT/SPECIAL PROVISIONS ROOFING/RESIDENTAL AND COMMERCIAL CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIESSE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER W ILL ENDEAVOR TO MAIL 0 DAYSWRITTEN' ROGER GAGNON NOTIC ETO TH E CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO D O SO SHALL 6 ORNE ST I MPOSENO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SALEM MA 01970 REPRESENTATIVES. AUTHORIZED REPR NTA IVE ACORD 25(2001108) 0 ACORD CORPORATION 1988 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT riHtflrRIF.Y UKLS(:ULL M.vv(tn lY'1TXsw.wravS EET 4 SAtrW,AtAssnun. l l tr0197: Tra_9711.743-9595 4 FAX:97x-740.9946 Workers' Compensatton Insurance Affidavit: BuildersiContractorsiElectriclans/plumbers Applicant Information Please nt Le ib Name tauvncssi)rganintiont n v,dualy Addreac• cityismtelzip: Phone 52.E �SS7 A�rar�e you an employer'Check the appropriate box: 'type of project(required): 1 t•�lv,am a employer with 4. ❑ 1 am a general contractor and 1 6. Q New construction employees(full and/or part-time)."' have hired the sub-cuntnctors 2.0 1 am a sole proprietor or partner- listed on the attached sheet : y' ❑ Remodeling ship and have no omployees These sub-contractors have S. Q Demolition- working for me in any capacity, workers'comp, insurance. q, Q Building addition f too workers'comp. insurance S. Q We are a corporation and its required) officers have exercised their 10.Q Electrical repairs or additions 3.Q 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myselL (No workers comp. c. 152.§1(4),and we have no 12.0 Roof repairs insurance required.) t employees. [No workers' 13.❑ Other comp. iawrance required.] *Any applicant toll etV=U box el MUSS also fill out the wcheo taluw dtowing their wwkon'cumpmuUiva policy infunmuiwa 'I Ilxnls,wntas who submit this of davit indimins Shtry an&4111 1111 work acid OWNS him atttsida 9011imson mot.ubmit a now amdavit indicating uwAl. ('untracutrs the chssk this boat Mot anaclW m addilicnal Awat Jawing the natoo of the sub-coninict n and their wurken'eanp.policy o olbonatim. I um ton employer that Is providing Ivor ers campensaton Insurance for my,employees. Below is the pulky and job site infarmalloa C Insurance Company Name: Policy 4 or Sclf-ins. Liicc..it: /� / z l 2 _ _ Expiration Date: % z2 07 Job Site Address: Cityistaterzip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). l..uilurc to":cure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a fine up to Sl•500.00 and/or one-year imprisotnncnt,as well as civil pcnallics in the form of a STOP WORK ORDER and a(ne of up to i250.00 a day against the violator. lie advised that a copy of this siatcmunt may be forwarded to the Office of In�•cangmuuts of the DIA for insurance awcragc voritication. I Jo hereby certify under the pm"MV14ed pe uIti ujpprdury that Noe iuformallon provided ubov is bee ur J corrcrt 7 S/ z lS Of lcial use uniyt Donor write in this area,to be ramplded by city of town offlc iat City or'rown: __ Permit/IJcense M Issuing Aulhurity (circle oitc): -- I. Iloard of I caith 2. Building Department 3. City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Cunlact person: ___ Phone p: Information and Instructions Nlassachtscus General Laws chapter 152 requires ail employers to provide workers' compensation for their employem 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 eropooyrsr is deluded as"an individual,partnership.astocfanoo.corporation or other legal entity,of 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 kgal entity.employing ernPleyeea. However the owner of a dwelling ham having not more than three aparaneab and who resides&train.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 15Z I25CM also states that"every state or local licensing agency$ball withbold the issuance or renewal of a license or permit to operate a business or to construct buUdiags In the commonwealth for say applicant who has ant produced aeeeptabla evidence of compuanee with the insurance coverage required." Additionally.MGL chapter 152,325C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfortnance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely by checking the boxes that apply.to You situation and,if necessary,supply sub-contractor(s)name(s),addresses)and phone nurnber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employee$other dart the members or partners,a not required to carry workers'compeosatioa insurance. If an LLC or LLP does have re 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•rffdavit. 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 low 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 0(Acials Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant. phase be sure to till in the pormitllicetue 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 be filled out each year. Where a home owner or citizen is obtaining a license or pennit not related to any business or commercial venture i i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. l'he 0111,x of Investigations would Gee to thank you in advance for your cooperation and should you haver any questions, please do not hesitate to give us a call. 1 The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents o®et of Investigations 600 Washington Street Boston, MA 02111 Tel. M 617-7274900 ext 406 or 1-877-MASSAFE Fax M 617-727-7749 Revised 5-26-05 www.mass.gov/dia