6 PARADISE RD - BUILDING INSPECTION (2) Exry-orSALEm -
PUBLIC PROPERTY
DEPARTMENT
IJMWFALEY DRISCOLL
MAYOR lA WmmNa"N'mEEr*"LEK MA\sACxl:ShllS 01970
TM-978-745-9595*FAX.97&7i0-99"
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
-- —
Property is located in a;Conservation Area Y/N K Historic District YIN A-f _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name:
Address: cW;W sT
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition 24vww-i � 4-� I Existing mse� 5f
t
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building I INew
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of the Building? Itis �s
Material of Building? &2P22!!;z� If dwelling. how many units?
Will the Building Conform to Law? Asbestos? f�
Architect's Name
Address and Phone
Mechanic's Name in
Address and Phone
Construction Supervisors License#4S&'*-"TG8 HIC Registration#
Estimated Cost of Project$�� Permit Fee Calculation
Permd Fee$ '�� '� Estimated Cost X$7/$1000 Residential
- Estimated Cost-X$11/$1000 Commercial— -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 X�
Date ��0 7
Cr o
o o
O � N
o r a
d96 y
a
i
i
S 1
r�.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
xn,at stint naacoti
Metros 120mA2*4CrotvStzeW 0 s,tts,d.MAMCWWM0lW0
TM-M745-9M a FAX M7/0.9W
Workers' Compensation Insuranee Affidavit: BnilderalContnctorg/Eleeh{ctam/pbmiters
Aooiicant Informadon n ben
Name(Busineworamindowindividual): `l1/1H��ivys C igp,
Address:—lked
City/State/Zip: O/7P-3 phow p; 9 7,'-i
Are you an employer?Check the appropriate bolt —
1.[11 am a employer with re 4. 01 am a General contractor and iIF
Type
project :
employees 01111 and/or part-time).• have hired the sub-coonecwes construction
2. I am a sole proprietor or partner- lisped an the attached sheet t Rem ling
ship and have no employees These aub.00ntnctas have working for me in any capacity. workers'comp,insurance[No workers'comp.insurance 3. 0 We ace a corporation and id addition
required.) ofileers have exercised tbeQ 10.13 Electrical repairs ar additions
3.[:3 1 am a homeowner doing all work right of exemption per MOL 11.[]Plumbing repairs or additions
myself.[No workers'comp, o. 132,§1(4),and we have no nsu 12.O Roofrepain
irance 1 t employees.[No workers• 13.O Other comp.insurance m9dred.]
'Any wtkt eat docks ban a1 mast a"as sot the uedm bdow Aow*Oadrwarksn - -
Fiomsowoas who abmit dds sdkhvh mdl�a dry ore doiaa ae wok ask dM him oabW Pit aka saw aNdrv(t
rCamaasrs tlr dark dda boa most seathad as sddidaest drq showtsa tlr soot ofdr M mmoeom sod uric wortaa•aamo, traamttlaa.
lam ow am Floye►that Is providing workers'conspemadon Insarowee jor my employees. Below is the
Injornadm--- - - Polleyandlobift
Insurance Company Name::r°ri'77%�9su/iz
Policy N or Self-ins.Lie.M: We- 00 044"'31!3
Expiration Date:—Z!��o,)
_. Job Site Address l �Y1t7�r,�i`s,,a �j City/Stawmp:_�i�.r. �,t <--r4F2*7
Attach a copy of the workers'compeandoa policy declarsdoo pace(showing the policy number and e:
Failure to secure coven es plratloa dab)'
lie required i under Section 23A of MGL a 132 can lead b the imposition of criminal penalties of a
fine up b 51,300a d a agaidlornst
one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up b f230.00 a day against the violater. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification
f do hereby eardo anAw Ike paina and pena/des ojPer/ary thar As Injornmyon provided above 4 tetra and comrd
Phone A f2w->7 2-yob
O,Q?clal use only, Do nor write in this area,to be coarpleted by illy or town Offlck(
City or Town: PermitiLleense M
Issuing Authority(circle one):
1. Board of Health L Building Department 3.Cityfrown Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone N•
,i
Information and ins ructions
General Laws chapter 152 requires all employers to provide workers' compensation or then irreempl
of him'
Massachusc s yeeL
is defined as"...every person in the service of another under Y
pursuant to this statuts,an tasploys
express or implied,oral or written" a•
" association-corporation or other legal eatitY,or l y two air more
An sarpfoYsr is defined as an iadivithtal,patmashtP. of a det:eased o;mPloYer•er me
of the foregoing engaged in a joist enterprise,and including the legal representativest tea. However the
association a other legal COMY,emp yml emP Y
giver our trustee of an mdtvidua4 pumerabip, s who raider therein.err the occupant of the
owner of a dwelling boom having not mere than three spartmants �wtult ansuch dwelling boon
dwelling boos°of another or building appurtenant
employs Pawns to do mainteaaoce6 yx deemed to be an employer"
or on the grow s tenant thereto shall not because of such employment
that"every state sr Weal dewLa ageary sbd tt+ltbkdd the Issues"Or
MGL chapter 132.12 tes a busimu ttr to eomairud buildings 12 the eammonwaftY ter any
renewal of a death W or tie pe also stag nit Paraa witl the Insurance coverage rmdred."
applicant w►o Was awl proobaoxd acceptable evidesee of a commonaftwealth visions shad
Additionally.MGL chapter ML$2XM state"Neither the commonwealth her air of its political
centred for the pm%rmaem of public work until acceptable evidence of comp
enter into any
requirements of this chapter have bean presented to the conewung audwity-" MEMMEM
Apptleaats
Please till our the workers'c°mpcnndO°affidavit�W�'by checking the boxes that apply toyer situation and,if
suodwe acwr(s)name(s),addras(es)and phone number(s)along with their caa8catOW Of than the
necessary.supply (LLP C)ter Limited Liability Paimershipa(LLP)with no employees
other insurance. Limited Liability Compsmes •compensation insurance. If an LLC or LLP does have
members or Parwen,are not raprequired to terry workers
� M a policy is� Be advised that this affidavit maybe submitted to the Department of Ia affidavit
Accidents for confirmation of insurance coverage. Abe be son w sign and date the aiiidavif. The afdavit shy
be returned w the city er town
that the application for the permit or license is being requested.not the DOPa UMW
Should you have any quesdona regarding the law or if you are required to obtain a workers'
compensation Policy.Please cad the Department at d number listed below. Self-insured companies should enter their
Belt-iasurasee
litxsn number on the
city or Town Offidati
The Department has provided a space at the bottom
Please be sure that the affidavit is complete and printed legibly.
f InvestiptionS has to contact you regarding the WhcauL
n the event
of the affidavit for you to fill out i number
whichthe o will be used as a reference number.`In addition,an applicant
Please be sate to fill in the partnilicense nulicatioa is any given year,need only submit one affidavit indicating current
that must submit multiple pernWieense app the a licant should write"ad locations in__(city Of
policy information(if necessary)and under"Job Site Address" PP the city or town may be provided w the
town)•"A copy of the affidavit that has been of Am stamped or marked by ry
that a valid affidavit is on file for fbtM permits or licenses. A now afudd alit must be filled 00�
year. h r proof a license or permit not related w any business or commercial
year.Whore a home owner a citizen is es cuobta .)
w complete this affidavit.
(i.e. a dog license or permit w burn lava t:tc.)said person is NOT required mP
The Office of Jnveatigations would like to thank you in advance for your cooperation and should you have any questions.
please do not hesitate w give us a call.
The Department's address,telephone and fax numbs.
The COmmonwalth Of Mmachusetts
DepecWUM of Indusolial Accidents
Otan of lavesd9affeos
600 waslhineooa Sftd
Bost^MA 02111
Tel. #617-727-4900 eat 406 of 1-877-MMSAFE
Fax N 617-727-7749
Revised 5-2605 wWp/•tpM&OV/dia
It
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID 'd
DATE(MW0DrrfYY)
MARTI-3 01 18 07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
DeSanctis Insurance Agcy, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
36 Cumming`s Park ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Woburn MA 01801
Phone: 781-935-8480 Fax:781-933-5645 INSURERS AFFORDING COVERAGE NAIC#
INSURED - INSURERA_Acadia Insurance Company
r�T
INSURER B:
Martins Construction Company, INSURERC:
Inc.
130 Sylvan Street INSURER D:
Danvers MA 01923
NSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWIMSTANDING
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.
IN3K Au"LTR NSR TYPE OF INSURANCE POLICY NUMBER PATE RATIUN
MM/GOTI DATE MPOLICY MIOD LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
A X COMMERCIAL GENERAL LIABILITY CPA008739713 02/01/06 02/01/07 PREMISES(Eeoccurence) s250,000
CLAIMS MADE X❑OCCVR MED EXP(My one person) s5,000
PERSONAL SADV INJURY $ 1,000,000
GENERALAGGREGATE s2,000 OOO
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $2,000,000
POLICY X JEC El LOC
AUTOMOBILE LIABILITY
COMBINEDSINGLE LIMIT $1,000,000
' - ANY AUTO (Ea accident)dent) '
ALL OWNED AUTOS BODILY INJURY -
$
A X SCHEDULED AUTOS MAA008739913 02/01/06 02/01/07 (Per person)
X HIRED AUTOS
BODILY eracci ent) $
X NON-OWNED AUTOS (Peramltlenl)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACC IDENT $
ANYAUTO
OTHER THAN EA ACC $ ,
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ 10,000,000
A X I OCCUR F-ICLAIMSMADE CUA008740013 02/01/06 02/01/07 AGGREGATE $ lO 000 000
$
DEDUCTIBLE - $
RETENTION S $
WORKERS COMPENSATION AND X TORYLIMITS ER
EMPLOYER$'LIABILITY
A ANY PROPRIETOR/PARTNERIEXECUTIVE WC009463113 09/30/06 09/30/07 E.L.EACH ACCIDENT $1,000,000
OFFICERIMEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes describe antler
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMB $1,000,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Project: Beverly National Bank, 6 Paradise Road, Salem, MA, $950,000
Renovations to Existing Building and Drive-Up
CERTIFICATE HOLDER CANCELLATION
SEVER-5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Beverly National Bank 240 Cabot Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR
Beverly MA 01915 REPRESENTATIVES.
AUTHORIZED REPRESEN
ACORD 25(2001108) m ACORD CORPORATION 198E
CnY OP SALMI
' PUBLIC PROPMXY
DEPASTUM44T
Coosftitc oo IAirb Obpad AMdsvit
sYe�oolidos,ndnewaIin - ade
1s�eooedo�a Mrid���s,4'SM ��Codty 7'0 C�:�do•111.!
Dabrl�I sd dr p
S > 14 to hmedva dr oem"M do dw&wk Mumma da
�aiar!dWl�OtsDoad dig s yiv��Monad vrw dtrpowt AdBq>r doted byld0.o
The de6rU win be i mosPoabd bP
(ns d�l�rl
The ddx%will be dlspoad Otis:
saw'
(aas a(AeiGgr�
y�ww dpgas„OPu�ys
'T�4 7
ma