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16 PICKMAN ST - BUILDING INSPECTION (2) CrrY-HFS-ALE -- PUBLIC PROPERTY DEPARTMENT I:I�MFAIEY DRISI:ULL l �//y� a MAYOR -, 0 120 WASMNG ON STREET 4,SALF.Y,WAhsAcHLsLrM 01970 To-,978-735-959S*FAIL 976-740-98" 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 Address: J w ',CtLvvicth J+ , Sale- , Mqi- Ot -7 Property is located in a;Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: LlnklrA Address: I cc i c-k-m a✓1 5 Salo wl fil A O I 9 70 Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing a Renovation ✓ Number of Stories Renovated Change in Use New Demolition Existing oZ O0 Approximate year of �9G0 Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: I nsF-�1\ itie� e�sfi�rn rvlae�� �oo� PSaviele�� Mail Permit to: What is the current use of the Building? I«�ir16w ra I Material of Building? yr 'i C� If dwelling.how many units? —� ,n.) o Will the Building Conform to Law? Asbestos? ✓L o Architect's Name Address and Phone ( ) Mechanic's Name I I��I e Address and Phone < 34 ' s Cd Et i 9©S Construction Supervisors License# 9a So2o2 HIC Registration# /�/9 Z ZZ Estimated Cost of Pr $$may _ Permit Fee Cak elation Permit Fee$ccy" Estimated Cost X$7/51000 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 Z! N L "00 G 9 v: 20 � r V O 0 .� Y BOARD OF BUILDING REVISORS, '- STRUCTION SUPERPER License CON f> , c 092822 .it;S ,.., Number , } BirthdW. ©212 1979 i ( XPI 02d2812009 Tr no 92822 � Restoe� , RUSSEIL ONEIG 38 GROVE STREE7 t, 1� LYNN MA 01905 _, Commissioner . h ram. i N� CrrY OF $ALEm ' PUBLIC PROPERTY DEPARTMENT �•�• tmw�ear�ao�snsa•s.�yauo.xsr,:o»» Conshmedom Debris Disposal Affidavit (required AK aU de®oddom W movadom woM ddwStsss cat 111.11 Is aeeotdaooe wits►ebe>i>c�edidoe �780 a«da� OdN14 and dw p mvisiom o0AGL a 406 S 54 Bye rwmk A it land with the oonMom that dw de6rb resuWes Aoos Lids wort*ap be disposed of is a proparIY Ueamed waft dispoed&dft as defined by UM e 141.31=OA. Mw debris wiu be transpoeed by: 49, (OaOr dbrrlrr� The debris wiU be disposed*tin: (own of rftwd " CorfjV.e/'cI -I /(S'/rrH (wkkews of hem) ' Sivas"of pemur vojur dye CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT xnraERtEY ntuscou MAYOR 120 WAUM4GMN STRIM•SALEM,MASSACt1l75ET1S 01970 TEu 978-745-9595 a FAX-9M740.99" Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please—Print Legibly Name(Business/Organinoowindividualy. &Visoj 1 N Address•_� C-A coV-e— !�3+- , City/state/Zip: L_ � Ayi , 64 11- n 1 g O S Phone#: -7 8 I — `l 2-2--I B I S Are you an employer?Check the appropriate boa Type of project(required): 1.❑ I a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).• have hired the sub-conuacton 6' Cl construction 2. 1 am a sole proprietor or partner- listed on the attached sheet, t 7. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance, g, ❑gig addition [No workers' comp, insurance 5. ❑ We ate a corporation and its required.] officers have exercised their 10.0 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.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp•insimuses required.) *A ny Applicant ttm cheeks box el mtut also nu out the section below showing their work.a'Compensation Policy intormaae1, Nomeow`nn who suhmit ads tied"wdteadna awry m doing all work and dim tin t eke outalda eannaeten must submk a new at]ldavk iedkayng Jockaetom nt cheek this boa muse attached so sheet showing the name otd o sod d wk warlons'con*pouw ml onnolos, I an an employer that!s providing workers'compensadon Insurance for information my employees Below Is the policy and fob site Insurance Company Name: S vn Policy#or Self ins Lic.#: UOO Z 3 Expiration Date: 2 /G 4 7 Job Site Address:_ /ma c`j City/Statemp: cS� !4 W O/j 70 Attach A copy of the workers'compensation policy declaration page(Showing the policy number and expiration date)6 Failure to secure coverage as required under Section 25A of MGL c. I s2 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 S250.00 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. 1 do hereby certify r tlu p ' Pena of /ary that the injormadan provided above L ban and correct SianaturewIX Z D Phone#: `J Z Of vial use only. Do not write in tktr area,to be completed by city or town ojJkiaL City or Town: Permit/Liceme# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other Contact Person• Phone#: Information and Instructions Massachusetts General Laws chapter I S2 requires all employers to provide workers' compensation for their contract of yce pursuant to this statute,an expbYee is defined as"...every person in the service of another under any him express or implied,oral or wntten." ,,)o r is defined as"an individual,Partnership, association.corporation or other legal entity.or any two a more of LA1Pl and including the legd representatives of a deceased employer,or the re the foregoing engaged in a joint enterprise. association or other legal entity,employing employees. However the receiver or dwells g o individual'Pip• and who resides therein.or the occupant of the owns of a dwelling barer having not yore than three apartments work on such dwelling house dwelling house of another who employs Persons to do maintenance,construction or repair deemed to be an employer-" or on the grounds or building appurtenant thereto shall not because of such employment also states that"every state or local licensing agency shall withhold the issuance or 6 for 25C ) wealth tiny 15 ( ninon ha 2.� VtMco MGL chapter buildings gs renewal o[a tloeatw or permit to operate a business or to construct » applicant who has ant prodaeed acceptable evideaee of comptlasee with the insurance coversgr required Additionally.MGL chapter 152,$25C(7)states"Neither the commonwealth nor any of its political subdivisions shall tract for the performance of public work until acceptable evidence of compliance with the insurance enter into any con have been presented to the contracting authority." requirements of this chapter Applicant tf Please fill out the workers'compensation affidavit completely,by checking the boxes that apply toys¢situation and, necessary,supply sub.conmwwr(s)name($),address(es)and phone number(s)along with their cerdficate(a)of insurance. Limited Liability Companies(LLG7 or Limited Liability Partnerships(LLP)with no employees other than the to carry workers' compensation inauranca. if an LLC or LLP does have member or policy i are not required sed that this affidavit may be submitted to the Department of Industrial employees a policy is ce9vited Also be sure to sign and date the alndavlt. The affidavit should Accidents for confirmation of insurance coverage. requested'not Department o[ be returned to the city or town that the application for the permit or license is being r eq Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' their compensation policy,please call the DepsruncUt at the number listed below. Self-insured companies should enter self-insurance license number on the a line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space ou regarding atthe bottom of the affidavit for you to fill out t/H ensse umbber the event the 0which will be used as a rffice of investigations reeference to nuumct yber addition,an applicant Please be rue to fill in the perms applications in any given year.need only submit one affidavit indicating current that must submit multiple perms)and n policy information(if necessary)and under"Job Site Address"the applicant should write"all location in_(city or or marked by the city or town may be provided to the town)."A copy of the affidavit that has been of for IIy stamped licenses. A new afndavir must be filled out each applicant as proof that a valid affidavit is on file for future permits or license or permit not related to any business or commercial venture year.Where a home owner or titian is obtaining a aired complete thin affidavit (i.e. a dog license or permit to burn leaves ctc.)said person is NOT required to The Office of investigation would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Depactrnent's address,telephone and fax number: The Commonwealth of Massachusetb Depalwem of Industrial Accident O®ce of Invaliptions 600 wa Ming& oa Street Boston,Mw 02111 Tel. #617-727-4900 wd 406 or 1-977-MASSAFE Fax#617-727-7749 Revised 5-26-05 www mass,govlai Russell O'Neill & James Galland Custom Solutions 38 Grove St. Lynn, MA 01905 781-599-6925 781-922-1515 November 21, 2006 Lloyd Ternes 16 Pickman St. Salem, MA 01970 Dear Lloyd, We are pleased to provide a quotation of three thousand one hundred twelve DOLLARS ($ 3,112.00) to install a new front door with side lights and elliptical transom. The scope of work consists of- Remove and dispose of existing door unit. Remove and dispose of existing roof overhang. Apply fast drying oil based primer to all surfaces of new door unit. Install new custom made Spanish cedar entry unit, including side lights and transom (to match existing). Install any necessary transition trim. Provide and install flashing pan under threshold. Door unit to be fastened with corrosion resistant masonry screws. Install new door latch and deadbolt lockset provided by owner. Door unit and all trim to be paid for by owner. This quote does NOT include painting. Terms of payment are $3,112.00 upon completion. We thank you for the opportunity to be of service. Sincerely, Approved: Russell O'Neill Date: