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2 PARALLEL ST WEST - BUILDING INSPECTION What is the current use of the Building? t.T—r Material of Building?"�oD Elf dwelling.how many units? ? `lS Asbestos? ►20 ' i Co nform to Law Witi the Building Architect's Name l"t'�. Address and Phone ( ) Mechanic's Name o ? ART L A N yl N Address and Phone 74 S 7 ��63 Construction Supervisors License# ©0 2 6 8� HIC Registration# A r g f D F Estimated Cost of Project Permit ee Cale Won sue._ Permit Fee: �U Estimated Cost X$71i1000 Residential Estimated Cost X$11141000 C4mmemla4-- ---- - _. An Additional$6.00 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 built to the above stated specifications. Signed under penally of perjury X_A44 6�!�--A, Date { h N O L L E- ,off G � 'a ►. a -IN - 4 ClTrop-SAIEM -- -- PUBLIC PROPERTY DEPARTMENT Z412ep ICI?OtFJIhY DlISCOLL NAVM 130WA9dNG'R7N!'MM•S•�%LUSACI?.StY[S 01970 Tn.9767ii9M•FAX 976-740."* APPLICATION FOR THE REPAIR. RENOVATION. CONSTRUCTION DEMOLITION. OR CHANGE OF USE OR OCO ANCY FOR ANY FMSTIlNC,�, STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: auilding: - -- property,gddreas:---------- -- ----------- - - -- -- ------- -- . . _ _ _---- - Property Is located In a;Conservation Ares Y/N Historic OlsMct Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: D J £ ( v 19 f Address: r— wfq s %� Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISI'm a BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building I New Brief Description of Proposed Work: �4 / �,E-EILL S ��i W r cJ I Vj K I '1—c H—C, � CT9 �/Nr�Ts -1-U Y�Cc i4 (Sc/Qfl-N Tr-- ---- ----Mail Permit to:. 1 A ,o 2m 81&A F-R'I- 4t C-6Vt 0 77S DRL si !'0 A-NDWF-R W\A ©I SYS- r CITY OF JALEM PUBLIC PROPRERTY DEPARTMENT r.�arat.r m..•t► \t.►►►� I tl I.�N::Jt+i ittT ilk A4vgt:w.Y►1a::9 1ti1:ti7►fai+tnl!•the 97W�G•'MN Ar— Construeden Debris Disposat Affidavit (required for all d mmAn toe and renovation work) In=onkum with the sixth edition of the Stets Suildiss Code.7SO CNIS section It 1.S Debris.and the provisions of MtQ.c 40.S Sk. guy W r,g pm p _ _ is issued with the eoadtdoe that the debris rea+ltinS fors this wok shall be disposed of in a property liceased waste disposal facility as defined by MOL.e IIt.Sts" The debris will be transported by: y� T -muck _. tdom..u'hauled fhedcbds will be disposed orin : nt;utve m•racttny) ,rirfs�ta,,f Cr:t.ty) ...r� CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT �1v/aruar etatawu xvrcta ue rnan,vrsresr•t+t tste,>tulsrw a m„x o tsxl Thi P&M-9111a6 a F.vx:9)iF74&%* Workers'Compteasatloa Insuraaee Afftavir 8u1(denlC6n&Wten/Eleev1d0R&1hmbpn .Applieaat Information �¢ Please s.t • a .etwti niness NO(nC tMtOrtri:atimvl"VKb.l):R06� LA'NGE VI 0 tg/.D G A &F—m 6 Asldroasa Z2 ' City/statrizip: 0 o- iw D o V t;R NnA-(.kooe Iw 9 7? ,s i 'a do -7 Are you as emPbyart Cheek the approprleb Dolt t0l a eruPklyer with ♦. ❑ 1 am a gaaursi contraetor and i ha�pro�aet(� � uyvims(full amyor pun-erase).• have hired the suh cuserectors 6' Now BOO a sole proprietor or Penises, listed oe the attached shoat t 7. 0 Remodeling and have no anployoea Them a hero g. 0 Omwitioe ing for rtra in arty capacity. workpa'ownR inaurrtca 9. serltew'COMP.in umnea J. 0 We am a corporation teal its ❑��addition oflloen have exerciaod their 10.0 Sleetried repaid or additionsa heroeowner doing all worst right of exasnptlan per MGL I t.0 Plumbing repair%or arkditiemf.(t,e workcn'comp. C 132,((I(6x sadws bve tto 12,0 Ruof mprtianoe require&) r cmployeea.(ivlo workers' co,tep .nsuranaat rcgtuttxi j 13.0 Other. •Nq 4pbo"Mr eltleka has ai art Am as out aw aeplat tutsw Aaw*lkair twkq' PWW,iearnatiow'1¢ ffl nin d wM aik dia d1bbm sflm ao Is w m a ley rs Jul"as wait ale"trbs so,"assusam amar aubedt a Cave aladalrit Lx miaa a1wk. ('anrx+uas ttw ekaak this bat mat arudW w adlW'=W AM.Mwms of mar Of the alh.sauxtma Md itim lsW*M. OOAF P•'Ikr lase ua eiapfoya that bt prot•ld/ay workers'cosrpemadoa lnsaraaaejor my emp/oyeea Bdory I:rbe puHar i Inurarue Company Vora Nnlicy a at salr--ins. Lie.M _ .. Eapinuton Data: Job Site Address: Cityrstatazip: Attack a cupy of the workers'compeasatlua pulley declaralles page(sbowing the Polley number and rxpiratiue date) Failure w secure coverage as required under Section 25A ofMGL c. 132 can lead to the imposition of criminal penalties eta tin.up nt 50.0 0a d and/or one-yst the yr .imprison, as well as civil penakiar in the form ota STOP WORK ORDER sad_a Gas of up us 5330.00 a Jay agriost the violator. Ile rtdviscd that a cupy or this suurrtom may be turwarded to the Oi ice or h1�..hgauolts ul'the DIA for axurarce covcrap vcrifecation. /Jo hereby e.ni/�,yn Inc unafs u�prr�aq rkW r/N In onraypA (/Vi1l l pr+eruA•sl above is trry unJ cornet �ir�r r �4n rh1 era a. F 2F c CC)-7 I)/Jkia/ap an/jt /Jo naV adii/w tbG alto,to dr toarp/erd bJ'ryy a/olsrs 0Qls/al City or rowna. PormiNUeease 1 __ _ Issuing Aulburity (circle aim): 1. Iloard of Ilralth 2. awiding I)cPart,11cr.t ).Cit)•/fowo Clerk t Electrical Inspector S. Plumbing Inspector 6. Other C.nitact Person: I'honc p: Information and Instructions ltapter 1 s2 requires all employers to provide workers' canpensation far their cisoloy"L .tassxduseus General sate Laws c a 06, a a ee..Aveey pew is this service or another Y 1'uestratd to this ataant.as ear/�ne' e.prser oruripfied'ool tic wrnoss" or two or man awodadm wpwatias tx odftir kpttl entity. asY ,y�dytdr b ddtllasd i!dh"daab�aapttosw'-Z tcpl representatives of a deceased employer•or the of the foregoing engaged ;nd at kept�•�°yinS pep' waver the receiver as tttawte of s i livid err�arterott who resides thereit►or the ooetfpsm otths o bases of who drys persons m do maiamsaace•umsa+aaa o err repair work as such dweltiai lwtw or on the grounds � or iding apptmaaa@s thaesa shed set became of steak detpioyona be dsemsd to be an employs. MGL chapter 1 S2.42x(6)also states the"evarY seer«K lead Mosselsig aasq shad wlehb"the banana or neew@t of a fi eatis w Mkt is sparate a sn�as er a autrwd bet~In the c@o wesw*d*ter ne' epNteaet who hss rat prod ad aeapeaele ovNosa of arnpdssee with tie@ leasing"eoverais regatred• AdditioWlY.MOL chapter 152.;2SCt'/)atatds"PNidter the comtnontstahh�om t pl w osubdMa inn seem Low my contract ter the performance of pudic week until aeeeptab requirements of ibis chapter have has presented to die contracting arrhotlt e"' Appliesse tion afildsvit completely.by checking the boxes that apply to your situation an4 if Pleas@ fill me the� nan*s�address(es)erns phone number(«)along with their cartitkaals)of necessary,srPP1Y (LLC)or Limited Liabt'IHy Pettwrships(I with s employees other rhea dt@ insurance, Limited Lisbilltyt carryuired to w�terve if as LLC or LLP done he" members a pew• so advised drat�b afitdsvlt tmtiy l>t wbmitred te the Depstment of Industrial employees.•polity is o coveraN, Also be tun to sip sad date the aQldaviL 71r atYldavit should Accidents for confirmation that insurance co% atiaa fM the permit er license is being requested,nor the Department Of be ret timed to rho city or town the law or if you era required to obtain a workers' Industrial Accidents. Should you have any goeuioas regardias lea should enter their compensation policy.pieties call the Department at numbs Used below. Self-iusursd COMFes self-inwranca Brent number on elf@ City or r 1r. .own Ofiltaate PI-asc he so it tht_.at the affidavit is wtnplele and p"cited► logibly: The Depsatarm had Provided a space at tla.hottoat _. lit of the affidavit for you to fill out in the event the Office of Investigations has to contact you regording rye aMartt._ Please be sure to fill is the purnritllicetuw number which will i e n ed anyear,ne eedf o� numsubmit one affidavit indicating current that must submit multiple permit/licaass applications is any y policy information(if necessary)and under"fob Site Address"the applicant should wrier"all Locations in city car town)»A copy of the aftldsvit that bad bean officially sarnped or marked by the city or town may be provided to the it be filled dech applicant as proof that a valid affidavit is on file for tirttrr@ permits t licenses.not related to say b ioess�ommercial venttr'e yea. What a horse ownsr or cidzca is obtaining a license or pen t i.e.a�g license or permit ro burn leaves ate.)said Person is NOT required to compke this atYidnvit ['he 01111:c of fuvestiyatiuns would at to thank you in advance for yow cooperation and should you have any questions. Icase du not hesitate to give us a call. The pcpanmrnt's address.telephone and fax number: The Commonwealth of Manachtlsetts DepetMVAA of Indltstrid Accidents omee st la►wsdpow 600 wsshh*M Shed Botlton.MA 02111 Tele N 617-7274900 ext 406 of 1-977-iMASSAFE Fax N 617-727-7749 2:vi>cd i-26-03 wtyw.man.gov/&& 11/28/2007 12:13 9786894425 PAGE 01/01 A0I .. DATE GERTt�ICz1TE �f._'INNS;[JRA�1�1'CEwsr:''�;: �<� ; . _ . . �I - 11 7 PRODUCER THIS CERTIFlCATE HS-999EMAS A AATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS OR Hays InsLmarR:e Age ALTER THE COVERAGE CAFFORDED TE DOESBYY THE POLICIES BOT AMEND E OL W ncy 36-Hawdw m AVG. W COMPANIES AFFORDING COVERAGE Methuen, Ma. 01844 COMPANY - -.-.—.-------._._......... __.._... . . . —.. ...__.. ........... . . .._..__,..._ A Norfolk & Dedh�n_Mutua�Eire_xDsurarlce...Co...... _ INSURED ... COMPANY Robert Largevin B Robert D -- _..._........ ...... .-- ,. ....,.----...- ---.. , {, I.anL�P.V1n COMPANY 795 Dale St. North k*Ver, Ma. 01845 COMPANY__.._.._..---_ ......—.... �. D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REOUIREMENT,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.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. co Y'/PE OF INSURANCE POLICY NUMBER TKO'POIJOYEPPECTIVE POLICY EXPIRA N1 . . lYR GATE(MN708m1 DATE(MMIDDIW) I• UMNS GENERAL uaBILm ' GEN ERN.AGGREGATE 52 .OW 000 COMMERCIAL GENERAL UABILm PRODUCTS.COMPOG A X. R0514 7A t0/25/07 10/25/� IP AG S .INJURY _ ...2,000,000. . x CLANS MADE �OCCUR� PERSONALS AOv INJURY S OWNER'S A CONT PROT EACH OCCURRENCE $1 ! I FIRE DAMAGE(My elm nrA) S 50 ......—__�—__-....— MEO EXP(My eM pnnron) S AUTOMOBILE LIABILITY ~- •, ••T"` —'• } __. ANY AUTO COMBINED SINGLE LIMIT S 4 ALL OWNED ALTOS INJURY N BODILY INJURY S SCHEDULED AUTOS (Pn P�) HIRED AUTOS I BODILY INJURY.. .. .... . NON-OWNED AUTOS (Pn/AcctlanU IS .. . II PROPERTY DAMAGE i S ......_......_.._..GARAGE ------_ .......�...�.._L._.__ —_.---._._�..._._...__. � __.._ _..... .. .� UABI4N I j AUTOONLY-ER ACCIDENT I.5. . .. ... N A ......_. I .., .._.. . . .. AHV AUTO I OTHER THAN AUTO ONLY: EACHACCIOENT I .. ...... AGGREGATE..Ls.. .. . .. . . . EXCESS UAIIun EACI4000URRENCE._..,, .IS UMBRELLA FORM ! AGGREGATE I S OTHER THAN UMBRELLA FORM S WORKERS COMPENSATION AND I.-AV-....... LIMITS,....... .. EMIPI.OYFJiS'LIABILITY EACH ACCIDENT S .... ST __..i_.'._.:.:. ... . THEPROPRIETOR/ NiCI - OLR -- POLICY UOMR S XEC PARTNERSIEUTN -- E -. DIESE______—__. .. ... ..... . OFFICERS ARE: EXCL DIBBABE-EACH EMPLOYEE i OTNEP 1 1 DESCRiPRpN OF OPERATIONS'LOCATIONSNEMICLESSP CIAL READ y. �� - Ca'W ty CERTIFICATE HOLDER i 'i''i.'?.CANCELU 31ION. :. City Of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BER= THE 120148Shington St. EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL .Salon, Ma. 01970 .30_DAYS WRITTEN NOTICE TO THE CERTIRCATB HOLDER NAMm Tb THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR UAMUrY OF ANY FUND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. A V I acoaD zs-S(alssl •. -:,: SEES' ,.� . . �:...� „,�: ,,,.,-.::::. �„ 0aCORD:CDRPORa'iWN:1889 BOARD'OF BUILDING REGULATIONS- License CONSTRUCTION SUPERVISOR �NUmber C 002685' Blrtbd�te 02/24/1947 r I 8 Tr.no: 15095 ROBERT M Re3jrlMd � } ., 795 DALE S�NGV1Nx4 7.,c/ - t NANDOVER, MA 018455-�` i��- Comm(asloner f lee '(�ammemwira�x a�./�.000ar/sudella p� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration 111990 Expiration =2/1.1/2009 Tr# 126605 Type: DBA ROBERT LANGEVIN BLDG&REMOLDING ROBERT LANGEVIN 795 DALE ST -dw"G�-°""� N ANDOVER, MA 01845 Administrator