3 OUTLOOK HILL RD - BUILDING INSPECTION 9.
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fP T'lm �I ,„PPROVED BY T44E 11106
wy " ItSI�PECJ.Lffl PFIDR TDA_P tt T BEING GRANTED
t
CITY OF SALEM
/d
Date
No
Ward
Zoning District
Is Property Located In Location of
the Historic District? Yes_No_ Building
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, eroof, nstall Siding, Construct Deck, Shed, Pool,
Repair/ ce, Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name DnY7,\n\c eelrn r"o
Address & Phone Z nu\�rY1L Hi,l jq'181 -ILILT
Architect's Name
Address & Phone 1
Gienr\
Mechanics Name Ul"AIM, co
Address & Phone U Mx Vs In &,ios1 m2k (91�1 q'L"l 3Q S b
What Is the purpose of building? J�
Material of building? If a dwelling, for how many families?
WIII building conform to law? Asbestos?
Estimated cost City License a State License a CS 007XQ
Home Improvement
Lic. I1Dy3S"+-
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
r•NrmO4Q '� C\ -('-k Mai a�T u f\e\a (-04 �tt,
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MAIL PERMIT TO: Uenn b&c ell i Cn
P.o . box 4q b
Qeve�ly ImR OlalS
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CITY OF SALEM
�• PUBLIC PROPERTY
DEPARTMENT
KINIBERLEY DRISCOLL
MAYOR 120 WAsHINGTON SIRFEr•SAIFN+%ttiSACHL:SKrrS 01970
1'i 978-74S-9S9S•FAx:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I I1.5
Debris,and the provisions of MGL 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 c
I l t, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of porntit aPPlicaot
date6
GLENN BATTISTELLI
- -PAINTIN(rR00PING-SIDING-CARPENTRY-VINYL REPLACEMENT WINDOWS
-. - KITCHENS-BATHROOMS-PORCHES-DORMERS-ADDITIONS
P.O. BOX 496
BEVERLY, MASSACHUSETTS 01915
(978)922-6338 (978)777-4499
DIRECT LINE (978))927-8956
. , fALX(978)921 9202 C L�617)962-1235
ESTB�/ HEO Y974
GLENN BATTISTELLI CO., hereby a refs to perfor?*the following services for:
o /tom:`G>c `' at 2 45 u 7/o o .f /( S"�
Home Phone: $''� 2 d'
�, `. Business Phone
Sealer applied o avnCpipes arl8 ct�ihtn�ys.
All Flashing wi fe- s acted.
Roofing Nails will be '. ` . inches.
Grounds will be cleaned 6 a roofing niatefials.
All workmen are covered with P.ubllc Liability and Workmen s Compensation.
}
All work will be continuous and' 411 be performed In gnworkman^,like mannee
Chalk lines will be used to line-up the shingles.
Roofing:Shingles are self Sealing.
While installing the new roof, we will protect your home and plantings from debris.
Roofing Shingles to be delivered
Install new fiberglass paper to roof boards when stripping of shingles is required.
All shingles will be secured with four nails.
State and local building codes, along with manufacturers specifications will be adhered to at all times.
Color of Roof to be
All work is priced as specific.The possible occurrence of rotted roof boards or poer fleshingavi9-warrant-aR-add' ' nal cost
Of ft�L�
The homeowner Is responsible for covering their articles within the attic.
Work is to be commenced on
Payment is to be delivered ° �� ° � �r� C + ,rot
Apply V inch aluminum drip edge to the following areas: AL.4'1 7`�f ,0 Ga-�
.S Year Workmanship Guarantee. 02 Year Material Guarantee
Roofing shingles to beOJ
-.( d'f_c�✓:tA.z--7' /l ,/�- re"t ,�lid/./ri+ .c; �:C" �i�- C?/d -7a .v.ca
I
Agreed by Homeowner Agreed by Contractor
Ref. Page Date 3 Day Cancellation Notice Required
� `�" "`Boa d�g�atibns`�n�ards-�
- One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement<Conlxactor Registration
:� .
-, Registration: 104352
- , Type: DBA
Expiration: 7/13/2008
GLENN BATTISTELLI CONSTRU�,7i-O4 ,';: 3i <
Glenn Battistelli
t;
PO BOX 496
Beverly, MA 01915 - -
Update Address and return card.Mark reason for change.
--'�- - I Address I__j Renewal Employment Lost Card
'PS-CAI 0 5OM-WOe"Pce490
0oerdp
uiliSiu'g t�`e`g"ut"eaoa�and taade License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registrati6i-,,*104352 Board of Building Regulations and Standards
Expiratlott 104 /2008 One Ashburton Place Rm 1301
- 2 Boston,Ms.02108
GLENN BATTISTEWL-C1N "k'tilCTION
Glenn Battistelli
r
11 BROAD WAY -
i everly, MA 01915 — Deputy Administrator Not valid without signature
�q' �t1OhIB �l�vts�lt�
F �
001123
Tr.no: 21773
- fALV' t`� 64�1�-� 'sfi4Y�ui '•
.7Cr !^! Gelllb !L JJ rR Ll DGR1 11UIUnl UVJ "'I`1r OVJU Iv I I
1 •
tdbes•ty Mutual Group .
Liberty PO Boa?202
P�ar
7�� estfloalA.NH o3802-7202
lY■Il�. T�PDtaoae{S0p)t 53-7u93
Fax(6M3)431-5693
Sgitember 14,2(N)6 i
DOMINIC PEDRONIO
3 OUTLOOK HILL
•* SALEM.MA 01970-
s
RE: CerWkAW of Workers Comptrass&dm Ina
Iasured: GLENN BATTISTFI t l PADMISIG CO
PO BOX 496
BEVERLY. MA 01915
Policy NtImber. WC2-3IS45546N4W6 E S/f 121NH> Expiration: 5/t i/2()17
Coverilge afforded under Workers Compurt moon Law .the following SWIC(s): 1v1A
Ernntovcrs Liabiliiy
Bodily Injury By Accidcnc S 1`00,000 Each Accident
Bodily lmiury by Disca= S 'mor0U0 Each Person
Bodily Injury by Disuse: $ ;SO vm Policy Limits
el,this i ;c, thcebove-referenced policyholder is jr5w;d by Libenv Muntal Fire Insurance Co under the
po cy listed above. .
TbL insurance afforded by the listed policy is subject to tlthe temis. exclusions and conditions,and is not
:allCrcd by:,nv reGnireftteiit. to')!)or condition of env oT')0cr doe lucrus with rcxpea 10 which this certificate .
i..
mot,be issued.
'Pais ccni�lcat. is issued as it niter 01,information on.) and confers no riglit upon vnu. the certifictic holder
?;xis ceaif7+care is not ;In insurance policy and does not mend. extend. er aher the Cot'eragc alTnrded by the
Poi1C) listed above.
if U+i;police is c:mcelled bcforC the stated expirution .j'Libeny'Mntu.il will ends.ivor to notify you arsuch
,anceikafiou.
AUTHORIZED P.t:PkFSNNT:>:rtvt:
L.IRF.R'rY WUfUAI.IN.m1RANcE(rR()A:P
[1L.C:ml..�b ..crr.waFy l.iBiRry XIV It bV.rvsVP..\VfL GkilVPy exn mauruu nu:xGmktl u�w+.e uogialL..
cc. bunrtxl. Producur of Record:
GLENN 9ATTISTELLI PAINTING CO STERLING INSURANCE AGENCY INC
PO BOX 490 P O BOX 493
BEVERLY. MA n1915 •i:. BEVERLY. MA 1)1915
- 1.
m+rma\
CITY OF SALEM
160) PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHNGTON STREET ♦ SALEM,MASSACHUSETTS 01970
TEL:978-745-9595 ♦FAX: 978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n y� } Please Print Leir_ibly
Name (Business/Organization/Individual): Cs10 r,SI IJtw\I 1.V L1`I Cot
Address:en- &ix y a1 ((s
City/State/Zip: t 1 b Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1,/I am a employer with�_ 4. ❑ I am a general contractor and I ❑
■ have hired the sub-contractors 6. New construction
employees(full and/or part-time). Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ g
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
officers have exercised their 10.❑ Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof 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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. J- 1
Insurance Company Name: OnQ& M uU
Policy#or Self-ins. Lic. #: 1 A S-4�SO1 R—O I(J Expiration Date: S 41 t l-LOO-7
Job Site Address: � 06M O I` CiA City/State/Zip: �I�J MR
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 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$250.00 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 under the pains apen AAnd lees ofperjury that the information provided above is true and correct
Signature V �tv /�� Date
i
Phone#: 9--IiC 13`01:� WC
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 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 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 till 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 affidavii rm;st 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 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