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29 PALMER ST - BUILDING INSPECTION City of Salem ward .21W /,,,,iz �� APPUCATION FOR PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCT IINPORTANT-Applicant to compote aI Msrm in ssctlom:4 4 ^ IV, and DL L ATA.00AYK" �,dl Pa I w,ei St per, _ LOCATION 1Mot OF BETWEEN AND BULL DUr�3 fPO S"MM oeoae LOT SUBDIVISION LOT BLOCK SIZE L TYPE AND COST OF BUILDING -All appticants complete Paris A -D A. TYPE OF MWROVEMENT D. PROFOM UM-FOR"DEMOUT1pM USE MOST RECENT 113E 1 ❑ Near tki- Me.,. . l Note.adenrr 2 ❑ Addition(I Ma:dentyM1 erau rwnnee,oe nwe 12 ❑ One femty is ❑ Amnere rent,reO�lwna housing units addee,I any,A pear a 13) 13 1913 Omsft adr wivas 3 ❑ AlienationAlienation(see 2 above) Two raelsmW-Fiyr number unite 20 ❑ kwismew • ❑ Repair repleownat 14 ❑ Ttariar rotst metst a mnnlWy- 21 ❑ Par"pawl Entsr aanper of Una —_-_____ 22 ❑ Service shoom reinetr Prove S ❑ M/reolcinp P^+ nnU'reetderreyl entsr nunreer 23 ❑ NoeDtbl, or units dmr A bq APat A 13) 1s ❑ Owwe ieldvkw s ❑ MOW g(relocation) is ❑ OBfdR track p di is 0 crpat 25 ❑ Public wevy 7 ❑ Fou demn only 17 ❑ other so.cn 26 ❑ 3dwA library.other educational IL OWNERSHIP 27134 mew B ❑ P&�W(idlvidUA corParetien.nonprost 26 ❑ Taros,to.ae ineN dior%W-) 2g ❑ Oliver-spwjv B ❑ Public(Fodaral,steel,or toot w,arinnat V..- a COST (gier ow" Naeeederer t-DaaviDe in deW Mooted use of hued"M eg.tsod processing otarK MICIA shop bw%*V h,idw at 1+osoI k Ownartsry e - I seeandary ecrnooL coaegw 10. Car of lnWOrerronl —_—_-- _. • 'Y I Z>7 e O Parochial I Mw � gngcal PWrt e d ug Ony hime i,anew, use. To 0e Installed but nee Actuated u� �t @�_- in the abovs`OW T Yai/nl % Df�-�/�♦-S AWO aPharwi.w ..___........_...._..._-------_--------..___. c Hewins a.o0rtmtloning lulu----....—........._. -- - N(Yw Ptte-bwx' Pv1 *Ceps 4-o h.104 - 4 Odra lsYrator,.re)---------------.._.._... _.. 11. TOTAL COST OF IMPROVEMENT IIL SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E -L; demolition. com is on Parts✓A M al/others skio to IV E. PRINCIPAL TYPE OF FRAME F. PRNCIFAL Ty"OF iEATWO FUEL O. TYPE OF SEWAGE DISPOSAL L TYPE OF MECMANW-AL 30 ❑ Lseuorry(wall Dev^p) as p c..❑ ao p Prcac or Pma.DarpanY �Kd dr..t»unrrr r Of 32 p str,.ct,a,r aeeal x ❑ Electcay e1 ❑ Private(septic ynk e1C.) cvNil Yes . os r 33 ❑ Re:Aorc.d mrr ey x p taut it TYPE of WATEII SUPPLY 44 ❑ ❑ 3e ❑ �r-spec" 7H p oe+.r-sP.cM 62 p Public err nrvats oargenY 'Y•)hare bra,etavdon asp Yee e7 ❑ 43 0 i d J.odaNsroNe y M. DEMOLITION OF STRUCTURES: aNrme.dsowr _._-_.____. ..._._ u .ow,a,■. f"d door arse. Hoe Approval from Historical Commission been received ,a Imo b 346 W 6'4 for any structure over fifty(50)years? Yes— No_ ; Dig Safe Number ,l W MM or OFFFSTRM pAW-eeo SW10Ea Ped Co nba S, Erckow ._ __._ __.__..____ HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED? yes No 52 QSAoon _..-_.._...-..-..—_.._..---.-----...-__.. i. L eEMININTMl DULDWA OfU WBctr Electric $a FndorO ..__—.__.— Gm Fdl_—___._._..._ Sewer 5' Marrow o1 DOCUMENTATION FOR THE ABOVE MUST_BE ATTACHED °idW00" parer___._____._...._.. BEFORE A PERMIT CAN BE ISSUED. fV. COMPLETE THE FOLLOWING: Historic District? Yes_ No— (M Yes,piwes widow doc urtentatlan from Hist.Can.) Conservation Area? Yea.— No_ ("yaa,plessa encose Order of Conditions) Has Fire Prevention approved and stamped Plans or applications? Yew_ No_ Is property located in the S.RA disfrict? Yea_ NO— Comply with Zoning? Yes— No_ (it no, enclose Board of Appeal decision) Is lot grandfathered? Yea_ No_ (d yes,submit documentatlortld no,submit Board of Appeal decision) If new construction,has the proper Routing Slip been endoWd7 Yes_ No--!f� Is Architectural Access Board approval required? Yea_ No i� (If yes,submit documentation) Massachusetts State Contractor Licenser b (010` t; Salem License • Hone Improvement Contractor tt ) I I �if INOa12 Homeowners Exempt form (d applicable) Yes— No.— CONSTRUCTION TO BE COMMENCED WITHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT If an extension is necessary, Pleasis submit CONSTRUCTION IS TO BE COMPLETED BY: in writing to the Inspector of Buildings V. ,IDENTIFICATION - 7o be completed by all applicants . 42iq address .V�mbf.StMK Car,ar10 sla/1 ZIP Loft 'al MM Car r 2. Cmvacbr ,,rang. j r, Ems':ea' g s�� s�r:�M�� i(e' I hereby certify that the proposed mo(k is authorized by the owner of record and that I have been authorized by the owner to make this application as his au"zed Nerrt and we agree to Conform to ad S Address dd a laws of this;udsdictxxL of q�� q date /Y O� DO NOT WRITE BELOW THIS LINE VL VALIDATION FOR pEpMgTMEM USE ONLY Building Permd number Uaa GmW Building t g Fra Gramq Permit issued PbmM Fee S Lcw Certificate of Occupancy $ Approved Drain TTileS $ Plan Review Fee i NOTES AND Data (For department use) I- nTh S 0 N C J i - PERMIT TO BE MAILED TO: DATE MAILED: Construction to be started by. Completed by A ZONING PLAN EXAAAINERS NOTES DISTRICT LISE FRONT YARD SIDE YARD SIDE YARD REAR YARD NOTES ffiTE OR PLOT PLAN-For Applicant Use O ! I N I i t l ACORDTM CERTIFICATE OF LIABILITY INSURANCE °"'E'3/17 8 PRODUCER THIS CERTIFICATE IS ISSUEDASA MATTEROF INFORMATION Divirgilio Insurance Agency ONLY AND CONFERS NO RIGHTS UPON T HECERTFICATE 270 Broadway (781-592-5220) HOLDER THIS CERTIFICATEDOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 8065 Lynn, MA 01904 INSURERS AFFORDING COVERAGE NAIC# �( INSURED INSURERA FIRST FINANCIAL 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 CONTRACTOR 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 D'L POUCYEFFECTIVE P°UCYB(PIRATDN LTR POLICY NUMBER p AT LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 OOO,OOO A }{ COMMERCIPLGENERALLIABILITV 553F001903 9/24/07 9/24/08 PREMSEs EaEoccur. $ 100,000 CLAMS MADE OCCUR MED EXP(AMom person) $ 5,000 PERSONAL B ADV INJURY $ 1'000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-CCMP/OP AGG $ 1,000,000 POLICY ] JECOT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Eaa Kant) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per acdtleM) $ PROPERTY DAMAGE $ (Per amide ) ,7EV LIABILITY AUTO ONLY-E4 ACCIDENT $ EAACC $ OTHERTHAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERSCOMPENSATIONAND WC STATU- I OTEL TORY LIMITS ER EMPLOYERS'LWBILITY ANY PROPR ETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT. $ OFFICERAIEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ Ifjes,desaibeu r SPECIAL PRO07SCNSbebw E.L.DISEASE-POLICYLIMIT $ OTHER D ESCRIPTION OF OPERATIONS/LOCATIONS/VEH ICLES I EXCL USIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIO FS ROOFING LOCATION: VITO VENUTI, 29 PALMER ST, SALEM MA 01970 CONTACT OUR OFFICE FOR INFORMATION REGARING WORKERS COMPENSATION COVERAGE CERTIRC ATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESC RI BED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF SALEM DATE THEREOF,TH E ISSUING INSU BEER W IL L EN DEAVER TO MAIL 0 DAYSWRITTEN 93 WASHINGTON ST NOTIC E TO THE CERTIFICATE HOLDER NAM ED TO TH E LEFT,BUT FN LURE TO D OSO SHALL SALEM MA 01970 1 MPOS E NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRffENTNnw , ACORD 25(2001/08) ©ACORD CORPORATION 1988 br CITY OF SALEM j '' PUBLIC PROPRERTY 1- DEPARTMENT KIMBERLEY DRISCOLI. MAYOR 120 WASFUNGTON STREET ♦ SALEM, MASSACHUSErTS 01970 TEL:978-745-9595 ♦ FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Ple a Print Le ibl r Name (Business/Organization/Individual r Address: City/State/Zip: 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 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2. I 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. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 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.❑ 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. 'Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. /J / Insurance Company Name: �(/// Policy#or Self-ins. Lic. #: zpiration Date: Job Site Address: City/State/Zip: 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 S1,500.00 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. I do hereby certify der the tits a td pen s ofperjury that the information provided above - true an correct Si nature: �+ Date: � ®2� Phone#: rJ/ e 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): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: I 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 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 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 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.mass.gov/dia �,.. . ,vim_. ...._..— '�%le t90 \_ Board of Building Regulations and Standards _ = HOME IMPROVEMENT CONTRACTOR Registration: 111126 T# 129857 Expiration: 11/25/2008 Tom; OBA STEVE 8 SONS HOME REPAIRS JOHNNIE DALRYMPLE . 89 JOSEPHINE AVE Ndmi SOMERVILLE,MA 02144 BOARD�nOF BUIL�DINtIRETI License: CONSTRUCTION SUPERVISOR Number CS., 069096 BlAhdete 0813011955 ; Ex"{iires OBI3612008 Tr.no: 500.0 Restiietedt 00 ; _ JOHNNIE S DALARYMPLE 89 JOSEPHINE SOMERVILLE,.MA 02144, Comm as 1 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ':V N L r7 \t.%%c B 12C W.\it 11, JN S - EFT • SdU N1, ..1Aii.\C',n .,L r:i C;91C 7FI:979-745-4595 * F.vc:978.74C-9846 Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5 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 v1GL c 111, S 150A. The debris will be transported by: (name of hauler) I'lie debris will be disposed of in : c:) (name of taciLty) 1iC