The URL can be used to link to this page

50 PALMER ST - BUILDING INSPECTION CITE'-OF S -_ PUBLIC PROPERTY DEPART11 &NT oc� �umF�u.fiv ouscwi. ✓ l MAYOR 120 WAvunwTom!bnE,T �i �"v.. 5r.��s.�anst�•cs01970 - TE3-978-745-959S• FAx:97&740.98i6 APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING r STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: 7i9zm&r2 Building: Property Address: 5v l�alw.e Sf Property Is located in a; Conservation Area Y/N Historic Distrkd YM tJ 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land ` Name: ScL"[e A_ ry e�a,L Q�VArn�. J4 Address: Telephone: &D7/ I r 3.0 COMPLETE THIS SECTION FOR WORK IN EX sT1uc I *New NLY Addition Renovation Number of Stories Change in Use Demolition 1 Existing 3L> YFr Approximate year of Area per floor (sf) Renovated construction or renovation IaR3 of existing building New 9cief Description of Proposed Work: 2ww I15� Kee�eS �u 'z �' ,�e1�c� --__------_ Mail Permit to: - --- �DCL iecl - What is the current use of the Building-- if dwelk9n how many units? /� Material of Building? Wa"p — • _cs' Will the Building ConfartIn to Law? Asbestos? �rnc� �s .� c_ ,.�� /�LA1pt Architect's Name Zy5 16b:30 Address and Phone 2�i"`&� (v wlrel,) J* — AN/Dm rc Sr "`ems on Mechank'sName � �, 9�l-�/3&-�f7� Address and Phone *(t) Mkt,r,.3 ST- �i 'wj- R Construction Supervisors License ft DF7 3Fs3`F HIC Registration# S �S Permit Fes Calculation Xtion Estimated Cost of Project Estimated Cost $7IS1000 Residential Permit Fee$ $1000 Commercial Estimated Cost X$11/ An Additional $5.00 is added as an Administrative charge. Make sure that all fields are property 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 Date ! I I N � a S O �. p. A e F :Z 'o o• - ----__ �'--- CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KA1aERr1Y DRIsCOLL MAYOR 120 WA4RNGTON STREET Is SAL EM.MASSACHUSEM 01970 Workers' Compensation Insurance Affidavit:ffi Builders/Contractors/Electricians/Plumbers ApipUcant Informado Please Print Legibly Name (Business/Organuation/Individual): /—At,3 St��ec3 Address: Yqo AAt � St - City/State/Zip_S1c1tA-- , KA OZIsn Phone g�c --S/rinn Are you an employer?Check the appropriate box: 1.® I am a employer with Z general contractor and I TYPO of project(required): �P Y � 4. DIama 2.❑ employees(full and/or part-time).• have hired the subcontractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet. t 7. ship and have no employees These sub-contractors have ❑Remodeling working for me in any capacity. workers'co $ ®Demolition [No workers' come. insurance 5. ❑ We are a corporation nd i 9• ❑Building addition and its 3.El required.] officers have exercised their 10.0 Electrical repairs or additions I am a homeowner doing all work right of exemption per MG L 11.❑Plumbin myself.[No workers'comp. c. 152, §1(4),and we have no 8 repairs or additions insurance required.]r employees. [No workers' 12.❑Roof repairs comp.insurance required) 13.❑Other fAnY al,patam that eheC bax Ml mua also fill out the nation below showing Honteowem who submit this&f%'wit' a their wmkan'comPanwion policy iafonwtioa, d4. a wodt am thm mWid,cao �n.atticating_ =Cootraeton that check this box mun �ate to � 4ire nacteaa moat submit a new attached as additiotul s ahowinx the time of the solo-contractors and their !am an employer that is providing workers' Y or compensation insurance m em !o ees Below comp.poi rat utnstiao. information 1 � j p Y p icy and Job site Q re—r Insurance Company Name: �I E `/ m � Policy#or Self-ins.Lie.#: \✓C-Z — 3 IS 35 7—AZ 0%6 Expiration Date:_-21-()7 Job Site Address:© t/- A M E.2 ST City/State/Zip: SAis„-. MA - Attach acopy 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 here rtify under thJ p and penalties ajperfary that the information provided above is trite and correct P 78/ y3�s N7� D /0 1a o6 CeL` 1,17 �D3- 08� official:::7 write in this area,to be completed by city or fawn ojJlciaL City or Permit/License# Issuing ne):1. Boardding Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector 6.OtherContact Phone#: Information and Instructions nation for their employees. Massachusetts General Laws chapt er 152 requires all employers to provide workers' compo contract of hire, pursuant to this statute,an employes is defined as"...every person in the service of another under any express or implied,oral or written." two or more individual,Partnership,association,corporation or other legal enary,or any and including the legal representatives of a deceased employer,or the An cMPtoyer is defined as-an tint ear loyees. However the of the foregoing engaged is a joint enterprine receiver or trustee of an individual,partnership.association or other legal entity, a thereingm the occupant of the having not more than three apartments and who resides therein, on such dwelling house owner of a dwelling house who, Person to do maintename,construction or repair dwelling house of another thereto shall not because of such employment be deemed to be an employer.. or on the grounds or building appurtenant MGL chapter 152,§25C(6)also states that"every state or local licensing agency stall withhold ea thfIssor a or renewal of a license or permit to operate a business or to construct buildings is the commonwealth for any produced acceptable evidence of compliance with the insurance coverage tr su��Oons sue applicant who has not P 152.§25C(7)states"Neither the commonwealth nor any P° with the insurance Additionally.MGL chapter of public work until acceptable evidence of compliance enter into any contract for the performance P authority e been Presented to the contracting » requirements of this cbaptcr bav Applicant the boxes that apply to Your situation and,if Please fill out the workers' compensation affidavit completely,by checking supply sub-contractors)name(s),addresa(es)and Phone Our along with rhea cemploy e(s)other of necessary. im Y Companies(LL ,)or Limited Liability Partnerships(LLP)with no employees other than the members Limited Liability not required to carry workers' compensation insurance. If an LLC or LLP does have members or Farmers, Be advised that this affidavit may be submitted to the Departmem of Industrial employees The affidavit should ,a policy is requiredand date Accidents for confirmation of insurance coverage. Also bo sus orolicense is beinBtregtessud,he net,the D°Paran�of be returned to the city or town that the application for the permit to obtain a wotkm' Should you have any question regarding the law or if you are requiredshould enter their Industrial Accidents- tease call the Department at the number listed below. Self insured companies compensation�h�,• amber on the a riate line. self-inurance City or Town Officials Department has provided a space at the bottom don has to contact you regarding the applicant. Please be sure that the affidavit is complete and printed legibly. The eP applicant of the affidavit for you to fill out in the event the Office of Investiga submit one affidavit indicating current Please be sure to fill in the permit/licene number which will be used as a reference number. In addition,an app that must submit multiple !ermit/license application in any given year,need only and under"Job Site Address"the applicant should write"all location in (city or policy information(if necessary) or marked by the city or town may be Provided to the town)." A copy of the affidavit that has been officially stamped applicant as proof that a valid affidavit is on file tat fume permits os of re at A new a urines must m filled out each a home owner or citizen is obtaining a license or Permit not related to any business or commercial venture year'vAicre t to burn leaves etc.)said person is NOT required to complete this affidavit (i.e. a dog license or permit uestions, for your cooperation and should you have The Office of Investigation would like to thank yo u in advance any 4 please do not hesitate to give n a call. The nt's address,telephone and fax number. The Commonwealth of l��ehu Accidents DepaMent of Indtistti Office of Investigations 600 Washington Sheet Boston,MA 02111 Tel. #617-727-4900 ext 406 of 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 VWyw mm.gov/din 1 CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASHINGTON MREEr ♦ SALEM,NIASSACHUSETI'S 01970 TEL:978-745-9595 ♦ FAR: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 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 MGL c 111, S 150A. The debris will be transported by: Apc l t.t t< i t.14 (name of hauler The debris will be disposed of in (name of facility) --� {address of f nlity) J signature of permit applicant /O�/fs•06 date Al:208D CEKTRCATE OF LIABILITY INSURANCE GPID A DATE IMMAK WT PRODUCER LANDM-1 02/0 8/06 Eastern States Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION y Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 50 Prospect Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Waltham MA 02453 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone: 781-642-9000 Eax:781-647-3670 INSUREDINSURERS AFFORDING COVERAGE NAIC A INSImERA St.. Paul Travelers LanN.SLRERR American Wholesalers 440 Main Ma Street Structures Corp, INsIFER C' Liberty Mutual/AR Stoneham n Stoneham MA 02180 IHanERO COVERAGES NSInSRE. 1NE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSIJI O µAA®ABOVE FOR TE POLCY PERIOD RDICATED.NDTWD/STANDING ANY RECUIRENENT.TERM OR CONDITION OF ANY CONTRACT OR OTTER DOMAENT WTIH RESPECT TO WHICHTMS CERRFIGTE MAY BE ISSIIELI OR NAY FERTAM.THE INSURANCE AFFORDED BYTff POLICIES DESCRIBED,EREN IS SU&IECTTO ALL TIE ICH T. CERTIF CA E N Y BE IS ONB O SUCH POLICES.AGCitEGAIE LIMBS 910MNN MAY HAVE BEEN RED Ca,BY PAID CMAKi. LTR SR TYPE OF INSURANCE PCLICYNUMBER DATE(MMDD/YY) DATE IMMDOVN LNf19 GENERAL LIABILITY A X CO - EACHOCcIRRENCE 21,000,000 MAEROwL GENERAL LIABRm CO 463D944-4 01/09/06 01/01/07 pREMIaEs Ea onirmw 2300,000 CLAIMS MADE OCCIR ME'DET(A,"We .) . $5,000 PERSONAL A ADV N.ORY $1,00 0,000 GENL AGGREGATE LIMB APPLIES PER: 'GENERAL AGGREGATE $2,000,000 POLICY X PTCT La - PRODLICTS-COLA=DP AGG 22,000,000 AUTOMOBILE LIABLRY - Emp Bea. 1,000,000 A X ANY ALUO 810 46SD945-6 01/09/06. O7/OS/07 CCMBINEp SINGLE LNIr ALL OWNED AUTOS (Es eccieem1 2 1,000,000 SCNEDLLED AUTOS BODILY NJFV 2 gFED PATIOS ' NDNLOWNED AUTOS - BODILY IN.L.RY X COmp Dad: $1,000 - - IPar xaca!rtl X Collis Ded:$1,000 - PROPERTY DAMAGE f IP.�ciEad) GARAGE DA&LRY. - MY AUTO ALWOOMY-EAACCICENT. 2 . OIFEfi iWN EAACC i. Al/f0 C"LY:OICE39A1MBR F 1I LMBM ADS 2Y .. B oc EA[N OCaRRENCE 12,000,000 ' aR .❑.cu1MS MODE TBD - OS/09/06 01/01/07 AGGREGATE $z,000;000 DEDUCTIBLE 2 RETENTION WORKERS COWENSATIONAND L, FIIN-OVERT LUBILfry X TORY LIMBS ER Am CIBRACIMR/PER R RACLLCEXEOUFNE - WC2-31S-357507-010 01/21/06 01/21/07. EL EADHACCILEW $500,000 ANYOFf'PROPRIET IMER- If Yes.Eesal W MIdAF - - EL DISEASE-a EAYLOYEE i SD O�OOO SPECIAL PROVISIONS NM OTHER - _ EL.DISEASE-POLICY LIMB $50D,000 �ESC PION OF OPETIATIONSI LOCATIONS IV,"CLE9/IX0.USIONS AOOC-0BV ENDORSEMENT/SPECYILPROMSIONS Evidence Of insurance coverage. ERTIFICATE HOLDER CANCELLATION LANDMAA- .9NOULp ANY THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E IRATON DATE TiEREOF,THE ISSUING INSURER WILL ENDEAVOR TO NAIL DAYS WWMN Landmark Structures Corp. NOTICE TO TNECERDFlCATE HOLDER NAMED TO TFM LEFT,BLU FAILURE TO DO SO SHALL 440. Main Street PROSE NO OBLIGATION OR URBLVY OF ANYNIND UPON TIE INSURER,US AGENTS OR Stoneham MA 02180 REPRESENTATNES. - ' ALfIHORt' V'FMATNE CORD 26(20DT/08) r ®ACORO CORPORATION I BAR