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1 PARKER CT - BUILDING INSPECTION ''• ���"'o� EITY8F� - PUBLIC PROPERTY DEPARTMENT Kl.%awJl1.6Y DRISCOLL MAYOR 130 WASMNGrON SMEEr 9 S"LLK NASsnaMsc-rls 01970 TEL 970-745.959S•FAx.w&740.9&M APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUC � OR BUILDIN 1.0 SITE INFORMATION Location Name: V ,ry- r r Building: Property Address: t Q)),-r C Property is located in a; Conservation Area YM N Historic Diatrlct YM n/ 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land " Name: + Address: lkQwrKr C-� Teleplxale: I.0j'+v- Li3CU • aq12 3.0 COMPLETE THIS SECTION FOR WORK IN 7ftVnes GS ONLY Addition g Renovation Number ated ,�Change in Use Demolition gApproximate year of Area per floor tedconstruction or renovationof existing building Brief Description of Proposed Work: (Lc,novwF� KAc4t— � ©w4�, ---------- Mail Permit to: b PC - What is the current use of the Building? Rcs Material of Building? r'neo A — if dwelling.how many units? Will the Building Conform to Law? Asbestos? prchiteas Name Address and Phone �7 Mechanic's Name 4 Q z4g9 Address and Phone a4��0 1385'`/0 Construction Supery rsors License# HIC Registration# Estimated Cost of Project S I �'� Permit Fes Calarlation Permit Fee S Estimated Cost X$7/$7000 Residential Estimated Cost X 511'$1000 Commercial An Additional $5.00 is added as an Administrative charge. 1 3 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 pelury /� P to .�3I O V Date 4CS I `. 96 at 01 y ` lh 7 L 3 F G� C6 c 4.._.- ----- CrI Y OF SALEM PUBLIC PROPERTY DEPARTMENT waaeasr nsamL HAvaa lm WAswNCMN SIW=•&USK MAneoa:s M 01970 TIM.97LU&M•FAS M740.9" Construction Debris Disposal Affidavit (required for.&H demolition sod renovation work) in accordance with the sixth edition of the Stats Buildins Code.780 CMB section 111.3 Debr*and the provisions of MGL a 40.8 3* Buildins Permit N is issued with the condition that the deluis resulting Brous this work shall be disposed of in s properly&Aused waste disposal EteiUty as defined by MCiL a 1 l 1.S 130A. no debris\wiU be transported by: r� • �C1nS'�+ ��+IM (rims achtaler) The debris wiU be disposed of in: (Hams of rAwity) (addma of heiliry) I� n V -� si pamut applicAA io '7 Al 0b dam .k6riar7,4,t CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOL L MAYOR 120 WASHINGTON STREET a SALEM,MASSACHUSETTS 01970 TEL-978-7459595 •FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PlumbersAauScant Information Please Print Le eiblv Name (BusinessHhganizatiowIndividual): dt-cJ� De514L C3ey NAA Address: ) q 94 a` 54 CS 64430„ hF City/State/Zip: haY uvrSi mk 0t9 t3 Phone #: (it-4 '4 3 i- zcig(� Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. Cl I am a general con7sheet. and I Pe of project(required): ployees(full and/or part-time).• have hired the subtors 6. El New construction 2. I am a sole proprietor or partner- listed on the attacht 7. Remodeling ship and have no employees These sub-contrace 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 required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4), and we have no 12.[] insurance insurance required.]t employees.[No workers' comp. insurance required.] 13.0 Other *Any applicant that checks box#1 must also fig out the section below showing their worker'compensation policy ittformatioa. Homeowners who submit this affidavit indicating they are doing all work and then hive outside cmttaeton must submit a new affidavit indicating such tConuactors that check this box most attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. p ' 11 Insurance Company Name: 6g3SoGS�eG d av5}n'�S a� LM�JS skv"S vu� dry c�ncc�j� Policy#or Self-ins. Lic.#: Rw< 1Al50c 3Q 11005 Expiration Date:_ %OS-10 6 Job Site Address: Qarl`er C} City/state/zip: Saler, Nlc,..0 11_ -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 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 5250.00 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. do hereby certify unser the ains and penalties of perfury that the information provided above is true and correct Signature- U All Dat /O/2t/p(, Phone#: r k4--: 33' 7994 F[Offlciadl7Health2. write in this area,to be completed by city or town oJJ9eiaL Permit/License# one): lding Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers Provide in the service workers' another enderunden for their employees. Pursuant to this statute,an employee is defined as"...every pe 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 erein,or the occupant of the owner of a dwelling hoose having not more r apartments construction od who resides rrepairwork on such dwelling house dwelling house of another who employs pe 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 construct ng agency ins he call ommonwealth the Issuance any r rate a business or " renews!of a license or permit to operate 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 contact 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-contractors)name(,),address(es)and phone numbers)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. for besure to a licgenseas beingd date trequested mint thehe affidavit. eDaepartmeat of shoulddavit be returned to the city or town that the app permit 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 tows may t provided to t the applicant as proof that a valid affidavit is on the for future permits or licenses. A new aflid4 E 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. you in advance for our cooperation and should you have any questions, The Office of Investigations would like to thank y Y Pe 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 .• t' BOARD OF BUILDIN REGULATIONS. ` License: CONSTRUCTION'SUPERVISOR r Numbsr;tC. 08477 . r Birthd_"--08[QgH968 �, ' E�xpkres:oeldu2b Tr.no: 270.0 - - - - - • -Rests Q JEFF BIRD: 10 PAGE ST_ DANVERS; NA 0192 4 . Commiubrie[,. . WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts NCCI NO 26158 (800)876-2765 , POLICY No. I AWC 7015093012005 PRIOR NO. I AWC 7015093012004 ITEM 1. The Insured Jeff Bird dba Bird Design&Construction Mailing Address: 10 Page Street Danvers MA 01923 (Na Sneb Town«City Cwmty slam Zip colla ® individual ❑ Partnership ❑ Corporation ❑ Other FEIN 35-2210544 Other workplaces not shown above: 2. The policy period is iroml'12W005 to 11252006 12:01 a.m.standard time at the insureds mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ - 100,000 eachaccident Bodily Injury by Disease $ 500,000 policylimit Bodily Injury by Disease $ 100,000 each employee C. Other States Insuranca:Coverage Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rales and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Estimated Per$100 Esumalea Code Tow M d Mnual RaummaW, Remunerd6m Premium INTRA 200642 SEE NSION OF INFORI 4ATION PAGE Minimum premium$ 500.00 Total Estimated Annual Premium $ 1,420.00 As indicated,interim adjustments of premium shall be made: Deposit Premium $ 1,470.00 ® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg. $1,132.00 X 4.4000% $50.00 This policy,including all endorsements,is hereby countersigned by &e-eX 11/012005 AuOioraed Siipu Date GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE I CHECK GROUP Cassidy Associates Ins Inc 70 High Strut MA 5651 705 8 Danvers,MA 01923 WC 00 00 01 A(11-88) htl des mpydgNod maledai of ire Naiio,at Cour m Compe„sati InSura,rce, usetl�tiU As pemistian. ,YGUlAL UUNTHAU` UM 1JUJ1Nr'bbUyG4m1(A YvL11-1 LlacGl.l Dino ate'^ Commerce Insurance ime Commerce Insurance company Cw Citation insurance Ccmpanr — 211 Main Street,Webster,Massachusetts 01570-0758(508)993-9000 POLICY NO. XZ7247 AMENDED DECLARATION ISSUED BY THE COMMERCE INSURANCE COMPANY EFFECTIVE 2/06/06 POLICY PERIOD FROM 2/06/06 TO 2/06/07 AT 12:01 AM STANDARD TIME AGENT T96 NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: JEFF BIRD CASSIDY ASSOCIATES INS. AGCY. , INC DBA BIRD DESIGN AND CONSTR 70 HIGH STREET 10 PAGE STREET DANVERS MA 01923 DANVERS MA 019232825 IN RETURN FOR THE PAYMENT OF THE PREMIUM AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. FORM OF BUSINESS: Individual SECT. I PROPERTY DED. AMOUNT: $500 SECT I OPT COV & GLASS DED AMT: $500 --------------------------------PROPERTY LIMITS------------------------------- REFER TO ATTACHED SCHEDULE FOR PROPERTY/LOCATION INFORMATION. ------------------------LIABILITY AND MEDICAL PAYMENTS------------------------ EXCEPT FOR FIRE LEGAL LIABILITY, EACH PAID CLAIM FOR THE FOLLOWING COVERAGES REDUCES THE AMOUNT OF INSURANCE WE PROVIDE DURING THE APPLICABLE ANNUAL PERIOD. PLEASE REFER TO SECTION II , PARAGRAPH D.4 . OF THE BUSINESSOWNERS COVERAGE FORM. COVERAGE LIMITS OF INSURANCE PREMIUM -------- ------------------- ------- LIABILITY AND MEDICAL EXPENSES $1,000, 000 (INCL. ) MEDICAL EXPENSES $5, 000 PER PERSON (INCL. ) FIRE LEGAL LIABILITY $100,000 ANY ONE FIRE OR EXPLOSION (INCL. ) CONTRACTOR POLICY -- CLASS: 91340 RATE: $43 .71 PAYROLL: $36,000 -----------------------POLICY LEVEL COVERAGEE--------------------------------- COVERAGE LIMITS OF INSURANCE PREMIUM -------- ------------------- ------- EMPLOYEE DISHONESTY $10,000 (INCL. ) MONEY AND SECURITIES $10, 000 INSIDE THE PREMISES (INCL. ) $5, 000 OUTSIDE THE PREMISES CERTIFIED TERRORISM $25 FORM NUMBER COVERAGE LIMITS OF INSURANCE PREMIUM BP-0515 01-03 TERRORISM DISCLOSURE MANDATORY FORMS AND ENDORSEMENTS: BP-0003 07-02;BP-0108 07-02;BP-0501 07-02 BP-0514 01-03;C-068 07-05 BP-0704 07-02 SECT II PROP DED: $500 pBP-0417 07-02;BP-0419 07-02 6 TOTAL ADVANCED ANNUAL PREM: $1 ,715.00 ADD'L/RETURN PREM: $517. 00- AUTHORIZED REPRESENTATIVE: 125 3/09/06 PAGE 1