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4 PICKMAN ST - BUILDING INSPECTION ti 1 � 1 fL��11A��Efi�N�Mi19 AAIIONiD A>r�! ifil�p�ll ref 17p A`lS�OlMO fL11AM1�D � CITY OF SALEM No. ftd ft"n M NamN v LoovAd in Laatsm of M Pf"Nly LLsomd h ar aNrNaaon Awa9 . Y.t_No Pwmk to: OA11 141 Pw CAT APPLJ M F01% (chic wlddwm apply) Roof. Rnoof. Now 8mft OonoMuot Shad. Pool R�pMdRlpl�Oa. Orlor: �Anl��,� R P PLUM FILL ONr L.EMY A OOIMUM LY TO AVOO OKAVO N PROONr10 TO THE INSPECTOR OF BLaDDM- The undNaIV hmW oppLaa for a pannk to bold a000iftto tl�a.loNowiip Address a Pin Aboht nft Name �p . r� On�i M 14ci-A Addiw A Phone ► Qa R .Mc , n�fA �>,n��nC14 mR LAadmMp Name Ad*W A Phone j 1 momui d 4riof M a drw■i I for how=M IraaooI � wN hrldq oadoaa 10 wrr N IdWAN=d In S�Cb ua • mm uo a G5 0� ).55)j � ����� ti�a. Sgnatu f IlppYoork SIM11 LAfSN1 Will PWL L OP pona Y za—DUMPTMOF WQINL TO m om L NArcd.coqQ RHmP ov ,— 6ft.Cotc Door . L#% PEFOr11T TO:.,,*.. y ,I q w` The Commonwealth ojMassachusetts Department of Industrial Accidents Office of investigations Woo 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: C 0-�Oi OQ, :f_ bn�i m'ArL . Address: 7 gQ Q Mc t n - City/State/Zip: O 1 1i o Phone #: Are you an employer? Check the 6ppropriate box: Business Type(required): 1.el am a employer with 14 employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establisbment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl.real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. El Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] l2.FZ(Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. --if the cotpomte officen have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I an an employer that is providing workers'compensation insurance for nny employees. Below is the policy information. Insurance Company Name: IV)Ct_ Insurer's Address: Q-14 aa0 LcNA Q_Mn Ct:- A YQ_ City/State/Zip: QC (>,n >n 3r�81 N Policy#or Self-ins. Lic. # l 5/ 0 P�i 79 A - Oy Expiration Date: Q-01—C6 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 $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 ofGthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. S I do hereby certify,under the pains and penalties ofperjury that the informaton provided above is true and correct. Phone#: 97 � 5 i Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, " 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 owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, 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 152, §25C(6) also states that"every state or local licensing agency.shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any 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 contract 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 your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships (LLP)with no employees other than the members or parmers, 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. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of 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). A copy of the affidavit that has.been officially stamped or marked by the city or town may 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, 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 www.mass.gov/dia Form Revised 5-26-05 08/10/2006 THU 10:03 FAX 781 581 7200 BENEVENTO INS AGENCY 10001/001 ACORQ CERTIFICATE OF LIABILITY INSURANCE OPID DATE(MMIDOMT'Y) CAEIIN-1 OB 10 06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Benevento Ins. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 497 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Swampscott, Imo. 01907- Phone: 781-599-3411 Fax:761-581-7200 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA PREMIER INSURANCE Al Cabinetry Unlimited Ent INSURER B! RTFORD INS. GROUP e INSURERC:Pater Bagarella president EA rise _ 122 Resr Mayy n SIE INSURER D: Peabody MA p1960 INSURER E' COVERAGES 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 SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. V. -IrE LTR NS TYPE OF INSURANCE POLICYNUMBER DATE mMlDDm) GATE IMAVIOIM LIMITS GENERALLNBILITY EACHEMUM OCCURRENCE $ 1,GOO,QQQ A X COMMERCIAL GENERALLIABILRY 1-680-4753B409-TCT 10/21/OS 10/21/06 PREMISES IEe acauence) $300 QOQ _ CLAIMS MADE � OCCUR MED EXP(Any one pBraord 1 $5 000 —, PERSONALAADV INJURY S 1,000,000 GENERALAGGREGATE §2,000 000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCT§-COMP/OP AGG $2 000 000 JPRO- POLICY LOC AUTOMOBILE UABRITY COMBINED ANY AUTO Ea accident)ANGLE LIMIT S ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Perpytsm) $ HIRED AUTOS NON-OWNED AUTOS (PefL sve nt) $ TO •---_ PROPERTY DAMAGE § (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EA ACC $ AUTO ONLY: ACC $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS WOE AGGREGATE $ S DEDUCTIBLE a RETENTION $ $ WORKERS COMPENSATION AND X TORV EMPLOYERS'LIABILITY LIAll MITS ER B ANY PROPRIETORR'ARTNER/EXECUTNE 6SGUB-7963A75-A-04 10/21/05 10/21/06 E,L•EACH ACCIDENT _ $ 100000 OFFICERIMEM13ER EXCLUDED? E.L.DISEASE-EA EMPLOYEE § SOOOOO 11 yaCIALPe8aROVISder EL DISEASE-POLICY LIMIT $ SQQQQQ SPECIAL PROVISIONS Ielaai OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIN DATE THEREOF,THE ISSUING INSURER WILL ENDEAVORTO MAIL 20 DAYS WRITTEN City Salem NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO BO SKAL 120 Washington St IMPOSE NOOSLIGATION OR LIABILfTYOF ANY KIND UPON THE INSURER ITS AGENTS OR Salem NA 01970 REPRESENTATIVIRL AUTHORD:ED REPRESENTATIVE ANTHONY BENEVENTO ACORD 25(2001108) 0 ACORD CORPORATION 194 PUBUO PROPERTY DEPARTMENT 120 WASHINGTON STRZWn $no FLOOR . SALaM,MA OI&70 TCL(276)74"595 EST.380 FAx (976) 740-964s STANLa:Y J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In aceoidance with the pmvisiona of MGL c 40,S34,I of BmldinS Permit 0 .all debris ac dw cadge thiat as a &jty, iaa Sm caned by this BWk&g Permit shaft be . posed gin a the ��disposed of in a pr+opaly licensed solid-aaaft disposal fsci7i'ty.,as defined by MC$,a I>;SISOA. The debris will be disposed of atIJc, A n / LacaIIon of Fammy � m r— '— atrir� eDsLe, (PLEASE PRINT CLEARLY) ,p-N(-.�o r-cl 110� Name of Panait Agplrica� Firm Name, ifany Addexs,G�ty&State The above statute requires that debti fi»m the demolition, renovation,rehab or other alteration of building or atr wtum be disposed in a facility as defined by MQ p rilitg or soli Mare disposal indica the location of the facihci 'tyl SOA, and the building permits or licenses are to ' 4a • "� � �Q�ytOa! i t s 60AD OF �Uq,Dll ION$ I V PC"": CONSTRUCTION SUPERVISOR NumbtLCI\ 087554 L BI 965 1 I 7 Tr. no: 87554 fi PETER BA- - 28 MARLBORO SALEM, MA 01970 Addsw m oner I . f �e a Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement .Contractor Registration �..- Registration: 131846 R Type: Private Corporation CARPENTRY UNLIMITED ENTERPR(SESI1't- Expiration: s/zs/zoos PETER BAGARELLA ?: 122 REAR MAIN ST. P EABODY, MA 01960 Update Address and return card. Mark reason for change. Address Renewal C Employment , Lost Card zl9Y- __._ 363p��60 w 9� V 49 % 35 4R ' 355 � '"r1 ...x` •s ° Q a%�r E.• ^° 35 05 5 a 364Q1$56 35-(1 4 2 a aU4� - 35-Q�51 ��5 35 2 1 CO 35z -�7� �9 w. j35ao�oo62 � 5-V45 0 2ro^ o y 3561. .RF ?e � 1 �, �, ,C 35i9 P4 * m s . °.' 4`y 4�s' 35-, 7 �5,' o d35i 91 _ 2 -* 35Sr6 '°8 s 35-055e,. s v o aeaa 35-�i575 s 35a _ N 35-PA64 ,+t ...;� 35'=•• 9 .3590� `� 3555 �� �• ` yQ 35 �465 ' .35y( 7. 354031i4 35s0 ev3s' 1 '3N141 56 n 9ya, 3 , ry s 35-QA72 - ��, $i � je.,�s a '•t °5 .a�a 35i�566 �. s 4 - ` n G p 3%RA70 O S\s 4 " 4. ° 3529 6a8$ ` s35 35s� 6' •. $ 9s,�� a .n 79117' t 3SzQs�9 .� O ti K ' 3 , ► 35 n2 3 �d67� 4n : 35 .�15 35-sN87 5 35066 3268 77 e�s11 ;r o' :. 5- 7 a 35 531 5=�1414" 3596 ° • N s z �P+ n(i7 , (J1 • za 2 4gs� ' _ 3 71 '� 1`�3. "6q r+' 35-'zQ5�68 g yu 35a�4b'° ' 3Q' 4 Q�85 F 35 � z� _�5��84 �� `ti5 <` r' ti^• � "�' a: 35aed�3�,` n Y w y,., � ,.i35a�sb `.; 0 �q .,. N h �/ 304M .n. zdssr 35ss1r12 i'��v- e o 5 7 `,�.p;�A i0m 35W4".a 65a�Q°o'1a0J3,.r�' L. 35s�°�6er Na Qt. p �.° 1� u.. ' Y 2 y� P 100.5 r r 3 .rno l �N. ns :�3,5aQ�8 'o - 352 5336 5s 11423 Wi ,- 10 35 yam, ' 4 s, a,. 254 8 t 5-q•106 m e r `"36A107 35-�O-9 EXTERIOR INFORMATION BATH FEATURES COMMENTS SKETCH 13 -Multi-Garden 1 1, a INSPECTED FFL ONLY. 27 3 3 Story I I Oki,— Retin 3 94—84k,T— Rafn Aves a SFI- f6dridebod 3 BdcVStone ;A30Bth R Is FFL 4_ p me 1 Wood rn.-B-Al RaBn 9hdT Piltakwall 08 -Brick Veneer— ;WHBta (480) 'Sec Wall 1 1% RESIDENTIAL GRID Food 02 -Hip OTHER FEATURES 01 -Asphalt Shgl 1 w -a n ryTWOR b1offt .1 1 :3 Rating.jAverage f BRICK erg' gge Ratln§'Average A 2 01 GENERAL INFORMATION IWSFN lRatind ix�C -Averse ORMATION ouet CONDO INIF TFL Y *.'1806 NEff-W-01ii. u 5FL kxbuc�— .AfrAt*11 �TRIVI�JQ �,Bk!�13 36 FFL 32 j K 1 0 1 166 REMODELING RES BREAKDOWN BMT %OW& No UmIF JRMS S! -��FIJ,I LUmWAO Indo(&, 1 3 41 1� M , OS ,f,,' -Name INTERIOR INFORMATION DEPRECIATION Addition', P�Conf;AV - % TFL Ift-,irrin(Wel 02 -Plaster a % 7 - SFL 4 IT S 'Jilt I I %FEco 21 7 C28) V! Psirli�T Typica % 4 Electric: I Special: — Pdrinflofti 03 Hardwood Override; % !Hi 31 121 3 SUB AREA SUB AREA DETAIL See Floors'14 Carpet 1 351- %prrpanwpl: a a] Code 12 Concrete I CALC SUMMARY COMPARABLE SALES - P, D wdr�9g SFI- Second Floor 1,494 100.4401 150,058 1 1 ype. BMT Basement 1,41613 25.110 36,811 3 Typical 9 0.75 W,,,&Size Aj, FFL First Floor 1,466 100.440 147,246 46d0oristAdl, 1.01586 TFL Third Floor 1,008 100.440 101,244, SO:100.441 1 Oil *-Goi t 1.00 03 -Forced HM Featimas;69000— Nka77 �Jrvi]Val]0 "1.00 w 100 C Facitb� NJ6($WoWAFew15A34 �- Tvoial] 435,359! a Su Fin;86.44 3968[Grosskeal 5434[f,mAreal 1969 Derdratvk MT.MW Adj Tata(504360 A nq,'I.� epreclation�161395 Spacial ---tdresjo VaYSu Ne 63.12 �De_a_p_ =41M Vo IMAGE Patriot Properties,Inc prectaled Total:342965 W@?AFma1 d8b343000 VaVSIj Wit 86.44 ess -nnA7.n TIR % RPoIRCEL ID C*�W�Dapod*n,.g&jiy/S C [:tfePT11'L0CffFaoi�,NB�Mry ME k� RIM wimlyycpoa�.Ky uJift%*wDfS ftJuds.VaIue,.W, 03 Garage 0 Y 1-40011. AV FR. 1945, 1 14.88 T 50, 105 3,000! 3,0001 35 0067 0 1 of 1 Residential TOTAL ASSESSED:483,800 Map Lot Suffix CARD Salem 14035! PROPERTY LOCATION IN PROCESS APPRAISAL SUMMARY T • Nb011 r:ia�t piredtivnBtre.el/Ci np p;:Use Code, Builtl' 'Vafue " 1'aM Items iE= :Land Size'^ "e nd Value= -";.�7ofa4Vaht9 .. >t 91Le IDeBCriptiO 4 PICKMAN STREET,SALEM v 105 - 343,000 3000 0159 137,800 483,800 v I` OWNERSHIP _TG�SRef' `v ,0inert:GASTON UAYMREGINA --- --- --- - --- --- 343,000 3,000 AS m `3' Y� "__,'� ... 5q �SourceMarketAdl34C3o0s0t 0 .:++io3fa0l0V0a lueperS I gI S 0159 137,800 483,800 ,800 483,8000159 3 OR t Patriot � 0� n / ad Properfleshw. SALEM 05/10/00 USER DEFINED PREVIOUS ASSESSMENT Parcel ID 3500670 W MA d-... flwn iTex;YrBUse CaT ld Value: 1,La- LendVaNe=TbtelVafue}t4ss'addValue:F':" N Q : `'-m0aten�... PrW4d v P�01970 2006 105 FV .. 343000 3000 .159 137800 483800 483800 year end 1212812005 'Pdotld# '. PREVIOUS OWNER 2005 105 FV 328,900 3000 159 12760 1.0 459,500 459,SOO year end roll 11612005 PRINTa �•Prier!d 3; 2004 105 FV 305 200 3000 1te " T[p1e p ON41�`1,3 159 118200 426400 426400ro11 1I2012004 Pr10fId#1S 2003 105 CV 305 200 3000 08/07/06 11:57:37 i7wmef3i .159 118200 426400 426400conversion - 1(/12004 Prior ld#2 Strpett 2003 105 FV 172,700 3000 .159 133200 308,900 308,900 Year End 17712003 LAST REV Prior,ld.#3: m T �• 2002 105 FV 159,200_ 3000 .159 104000 _. 11412002 d2tei .Tlroe,Y.Frior,01 ff SUPrdv' Ctl 2002- 105 T8 159 200-3000--- 59 104,000 266,200 121412001 10/26/00 13:41:16 ,PnOr Id#21 2001 105� 10''. 0 .14400 LA10 11/2012000- t?t sfial; 59 24 apro Pnor Id#3' NARRATIVE DESCRIPTION SA ES INFOWCAlal, PAT ACCT. 4035 ASR Map; t'u�iV 1,�'` T ,L al SN a 1?t;.. 0at6 n' SeleCode:'1" SaIEPIfiCe '�V' iaf'.`.VHir ASs4CP1JL° aIUA a ram' x�" NOkea -4 _;. This Parcel contains.159 Acres of land mainly classified Fgc1 Dtsi Three Fam.with a(n)Multi-Garden Building Built ab t 1806 OCONNOR I E 3121421 111/1900 No No Having Primarily Brick Veneer Exterior and Asph t Shgl Root Cover,with 3 Units,3 Baths,0 HalfBaths,13/4 aths,l2\ Rooms,and 3 Bdrms. _ �I:andtteason OTHER ASSESSMENTS zBldReasw o?<:_. ':Amamm:.'. r� BUILDING PERMITS ACTIVITY INFORMATION DakB ar' Oases r t"`C70t .LastVstEedCotle 'F. I .`°' mneM =x Oats = T }� =''Res_q _ :., Iferd-"Code re CIAB$ ' \ ' 5110I2000 Measllnspect .. 283 esd �'�, 9G�'?tterci°.;Cdde .o'ixl - -- - 2 ..R2 RES TWO F 100 S!1r=< __. _.. .. __. .......... _. ... _. u, Exml>il t0: 1 T -1 Level .r1 Sfree ....... ._ _. ....... .._ _.. N Use OC cri .„LSIOa bEU •, apt ` ilnftT aj kT ELT'_.i$dsej::United `rAd'Ti� i a4e5h'N* °ti' 'sa''4.t�"'"w°: "-'x. .;+' u.'A... ISed C, NL u '$pec� -",L a J. �-5„r.- Faa „ua�PriceUMs= d.ype 1 Nelgh, in81 % --.1n172 h,%�Irdl3 '% ,s„ .% xFact Use Value �. -"rNoles r 4k+t.a. .,,,n: , n,u„ .�. FaCfefYaklB�,a,,, e..=V „ ' .' IDflu Mod:�{ u;, : �.f-' .`�tr �,. .. e VaN1e'"' ' Ctassa 105 Three Fam 6920 !,Sq.Ft Site 0 10.96 1.817 FA 11.00 004: 137,833 `n137,800', 105 Three Fam. 140I '.Front Ft Site 0 EA1.00 004: ToYaIAC%t{A•0.158861 6920.00 Par'--- 105 Three Fam. ,Prime N DDesc EA R 4 Tofa1: 137,833 Credit 1rNa 137,800 Disclaimer:This Information is believed to be correct but is subject to change and is not warranteed. Database:FY2006 apro 2007