0017 PARADISE RD - BPA-08-411 STAPLES C
pulil-ic
DEPARTNIENT
I A 9-8--15 9.595 0 1 \N 11)98.16
F-APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: Applicants must con ipl-ete all items on this page
SITL INFORMATION
Location Name j"AVeC <"10 C,*Building
Property Address AW /7 R,9024-I)ISer /4?ej,+,6
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes R3 R4
Residential (3 or more Units) R2—
Type or improvement Residential (hotel/motel) R1 _
(check one) Assembly(Theaters) A1 _
New Building Assembly (restaurants & clubs) A2r—A2nc
Addition Assembly (churches) Al
Alteration C Business B
Repair/ Replacement Educational E
Demolition Factory(moderate hazard) F1
Move/Relocate Factory(low hazard) F2
FoLinclanon Only High Hazard H
Accessory Building Institutional (residential care) 11
Institutional (incapacitated) 12
Institutional (restrained) 13
Mercantile Ml
Storage S1 —Moderme [lazaid
Storage S2 —Low I lazat d
OWNERSHIP INFORMATION(Please type or Print Clearly)
OWNER Name Piz,1444 IV " C
Address— 3 - @Lf VARAtise P60)
Telephone
SiQnuture
DESCRIPTION OF WORK TO BE PERFORMED otm ,ivquax-s-
IMF t3 fi-C r-e Asr Wj � C+ t..tp C6 P4 C-LcUMft
FS HMATED CONSTRUCTION cos'r Ono , do
CONTRACTOR INFORINIATION
Name
Address / 2 Li92Cy �0 FOF?GC76WIJ rr///� l$3�
Telephone sO&"C/ 6 - a(� 3 f
Construction Supervisor's Lic # CS D7y t'�9
Home Improvement Contractor#
Alccurrt:crn:NtaNIa;R INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CA►.CULA•rION
Estimated Cost x $11/$1,000 + $5.00=�/V 0?0 �
CONINIIiNrS
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the penalties o r'I
Signed GnM (owner) (agent)
APPROVED BY :
DATE APPROVED: t
CITY OF SALEM
�; PUBLIC PROPRERTY
a DEPARTMENT
.Ilnl: Nf I l"'JWIC.'I1
\I,:, a alrr lt, MA\SAI III it I ns0197^�
97sJ/5-9395 • his 9711-74C.'IS46
Workers' Compensation Insurance Affidavit: lfuilderVContractors/Electricians/Plumbers
\ l )licant information Please Print Leeihly
Viltlld lou.ute�yl)rganv;uinNlndtvdual is Ca�AS�C War 5(rCU«lYV ��C
ltldre,s: Pd Qoa /G `fS� oZd bi6P41" 57• Dupcgcray C)Q331
City,St:ua7ip' I'hunc
Ar�,e(sou an employer? Check the appropriate box: Type of Project (required):
I.,YJ I .,,it a employer with 4. ❑ 1 nm a genera)coulractor and ! /t. ❑ New construction
e mpluyccs.(full and,'ur part-time).• have hired the sub-contractors 7. JZRemodeling
2.❑ 1 mn a sole propricttx or partner• listed on the anachal ahcet.
ship and have no employees These sub-contractors have S. ❑ Demolition
working ror me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
No workers'cum 5. ❑ We are a corporation and its
P insurance officers have exercised their 10.0 Electrical repairs or additions
requited.) 1 1. Plumbin• repairs or additions
},❑ 1 am a homeowner doing all work right of exemption per have
n ❑ b P'
myself. IKo workers' comp. C. 152, j 1(i),and we hove no 12.❑ Rtwl'rcpain
insurance required.) f cinployecs. [No workers' 1}.❑ Other
comp. insurance required.?
•�m .ppbcant Ihur d:ccks bolt 01 Il,ust alas)it[Out Inc sectien twtuw shuwing their wurkai cumpcnsWiun pul icy udiumativa
' I6tmwwran who subnul this affidavit indicating rhuy are doina all. ork and then hire uutside cururmium must.uhroil a new affidavit indismng.ncA.
('onirwtun that shuck thn box mtwt mtxhed.m add,Iiun,I.Aeel.huwiug the n:unc of th.;suh-contraclun and their woAun'comp,policy mfumwnun.
/urn all employer that/s pruviding workers'eumpenvalian/nsurance fusty employers. Belasv is the•pu/ity arld jub.life
IIIfUrrllallr/n. �///���/eT ��a
Ir.,urance Company Vntne: l" �" .5'
I'olicv is ur Sclf-ins. Lic. n: // `��/U v�°2 Expirutlon Date:�q
Job Sit,: Address: 17 po*blse /?a1D LErt%lt /„p Clry;Slater"Lip:
Attach it Copy of Ibe workers' cumpcnsatiun policy declaration page (showing the policy number and expiration date).
Failure to x:cure coverage as required under Section 25:\ul'.\IGL c. 152 cart lead to the imposition ofcriminal penalties of a
tine up I.,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 till to S2So.o0 it day against lite violator. lie advi.icd that a copy of this statement may be lurwarded to the 011icc of
lol:..ngao.nu ul the DI,\ :or ro,urarcc .oscrayc wrilication.
/Ju hen•hy a anijv under drr pain.wl pe u/ •s rf prrj,,ry that the infurinullon provided above is true and correct.
crb�
U/)iciul use only. Do run irrite in this area. to be cunsple•ted by city or town a/jiriuL
('ilv or Town: __... _— Pcrmitll.iccnsc 0_
l%%uing.\ulhurily (circle one):
I. hoard of health 2. ISuildiu:; 0cpartuleul 1 y.'funn Clerk 4. Electrical Inipecfor i, plumbing luspcctor
6. Other
Conucl 1'Cnun: _. .. Phone tl:
Information and Instructions
%Ia�sachu.setts GCnerdl Laws chapter 152 teguire)all employers to provide workers' compensation for their employces.
Pursuant to this statute, an empluree is defined as "_.every person is rile service of another under any contract of hire,
cvpre»or implied, oral or written."
An empluyer is defined as "on individual, partnership,association, corporation or other legal entity, or any two or more
,'r the Glrcgooig engaged in a print emerpnse, and including the legal representatives of a deceased cnipluycr, or the
receiver or rru>tee of .tit Individual, par2nchlllp,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 huuse of another who employs persons to do maintcnunee, 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 02, $25C(6),also stales that'.'every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to uperafe a business or to construct buildings in the commonweultb for any
applicant whii.has licit produced acceptable evidence of compliance with the insurance coverage required."
Additionally. NIGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
corer into any contract for the performance uI puhlic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants -
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)namc(s), address(es)and phone nunlber(s) along with their cerrhficate(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 confinnnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be Mottled to the city or town that the application for the permit or license is being requested, not the Department of
Industrial ACCtdents. 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'rown Officials
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 fill out in the event the Office of Investigations lids to contact yiiu regarding the applicant.
111aase be sure to fllf in the pennit/license number which will be used as 3 reference number. In addition, an applicant
that must submit multiple pcnmitlliceitse 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 1 le'city or town inay'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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I IlK line to thank you in advance fur your touperai ion aad should you have :my questions,
please du nut hesitate to give us a call
The Uepartincnt',address, telephone and fax number
"The Commonwealth of Massachusetts.
Department of Industrial Accidents .
4 ofAce of(nvesdl atlo u )
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
ACORD CERTIFICATE OF LIABILITY INSURANCE 2si20 e"'
PRODUCER (781)681-6656 FAX: (781)681-6686 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
The Driscoll Agency, Inca ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, PYTEND OR
93 LonaRfater CirCle ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW-
P.O. Sox 9120
Norwell MA 02061 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA:Travelers Indemnit
Coastal Construction Corporation INSURER B:Charter Oak Fire
22 Depot Street INSURER C:Travelers Property
P.O. Sox 1644 INSURER D:Travelers Indomity Co.
Duxbury MA 02331 INSURER E:Illinois Onion Insurance 78978
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 SHO MAYMAVIES159 REDUCED BY PAID CLAIMS,INSR DD'L TYPE OFINSURANCE POLICY NUMBER PDgTEYrAhY GmYE PRATELey
MXP,I Dry N LIMITS
GENERAL UAR)"" 3 11000,000
X COMMERCIAL DA
AL GENERAL LIAB
ILITY MAGE TORENrEO $ 800,000
A CWIMSMAOE ❑X OCCUR OTC0101OL7671HIf08 9/24/2008 9/24/2009 MFQFX S 51000
F R N $ 11000,000
GENERALAMIREGATE $ 21000,000
GEN'L AGGREGATE LIMIT APPLIES PER' S 2,000,000
POLICY FX7 P LOC
AUTONOBWE WABWTY COMBINED SINGLE LIMIT $ 11000,000
X ANY AUTO (Ee uods w)
B ALL OWNED AUTOS OTA08YOS680B62000s08 9/24/2008 9/24/2009 BODILY INJURY
SCHECULEDAUTOS (Perparoon) y
X HIREDAUTOS BODILY INJURY $
X
(PerA Idem)NON-0V.NEO AUTOS
PROPERTY DAMAGE $
(Pa,aulden8
GARAGE NABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN A A C S
P
AUTO ONLY: A
EXCESSRJMBRELLA LIABWTY DTSbCU9S6B08712sILOS 9/24/2008 9/24/2009 s 10,000,000
X OCCURCLAIMS MADE AGGREGATE $ Y0,000,000
y
C DEMCTIB40 $
X RETENTION S10,000
D WORKERS COM NSATWN AND CTEDB5660B62008 9/24/2008 9/24/2009 XI-MUM
EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNER)EXECUTIVE E.L.EACH ACCIDENT S 500,000
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE S 500,000
If Yea,desadlw mdw
f Al. R SIGN hdow E.L.DISEASE-POLICY LIMIT 5 500,000
E OTHeL pollution Liability CIPYG230987430OZ 9/24/2008 9/24/2009 each Dowr=a+.e.. $1,000,000
7
xggre8at $2,000,000
DESCRIPTION OF OPERATIONVLOGLTIONSMEHICLESIEXCLUSNINS ADDED BY ENDORSEMENTISPEC AL PROVISIONS
Evidsnoe Of insurance for work psrformsd within the Insureds scope of normal business operations. Notice of
am llaiion provision is 30 days, awcept YO days applies for won-payment of premium.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
-- EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAR.
30 DAYS WRITTEN NOME TO THE CERTIRCATE HOLDER NAMED TO THE LEFT,BUT
FALLURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UAMUTY OF ANY WHO UPON THE
INSURER,ITS AGENTS OR REPRESENTATIVE&
AUTHORIZED REPRESENTATIVE
B. Dr18C011/PD3
ACORD 26(2001108) ACORD CORPORATION 1988
IwaAgr, -. e.....,.sn
10 loud NOI1DnlUSNOD -C1SVOO 9989bE6T8LT L1:60 800Z/TE/OT
CITY OF SALEM
PUBLIC PROPRERTY
DEPAIZ"I'VIENT
. . I
III •i'S.-4;. i;.,; I �\ 'i'9 'J_ ;L•
construction Debris Disposal Affidavit
(rcyuited fur all demolition and RIDU1'IIUUn \%'otk)
of the State Building Code, 7S0 ChIR suction 1 1 1.5
Ill aaurdancu \%ith tile sixth edition
Wit is, and the provisions of MGL e 40, S 54;
Building Permit it- is issued with the condition that the debris resulting front
operly licensed waste disposal I'acility as defined by MGL c
this work shall he disposed of in a pr
I t 1. S 150A.
The debris will be 11ansported by:
0s ���ora�� I2utc�►N�
(name it hauler)
I he debris will be disposed of in
t nainr ur Ixihly) .
I.0 It tress it, lacih t,I
a natuic Ott perm t n
LO - 31 - 0 �
,late