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9 PLEASANT ST - BUILDING INSPECTION EITY-OF`�LE1G PUBLIC PROPERTY DEPARTMENT Ki.%op LEY DRLSCOLL MAYOR i?0 WASHING nN S'IREEr•SAt E.0 ,XA.SSACHM-1-IS 01970 TFI-,978-745-9595*FAx:978-740-9M APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION. DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION n Location Name: ! 0 e R: Building: Property Address: S i 9 Pler4sarl -� T Property is located in a; Conservation Area Y/N Historic District Y/N _ 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: Telephone: r g --7LIY 15137 3.0 COMPLETE THIS SECTION /FOR WORK IN EXISTING 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 New Brief Descriripption of Proposed Work: CA C 10 i 2 r} ��e_K0`J cJ �J2e.'17- - t- 2 y / $e-+ b,;kck- Ft-o rn Mail Permit to: What is the current use of the Building? Material of Building? W®© r_1 If dwelling, how many units? Will the Building Conform to Law? Y 2 5 Asbestos? Architect's Name Address and Phone ) Mechanic's Name Address and Phone Construction Supervisors License# I 2 J HIC Registration# 1 4 Z lD Q 7 Estimated Cos Pect$ 3 CO• °a Permit Fee Calculation Permit Fee$ _ Estimated Cost X$7/$1000 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 ab e s ed specifications. Signed under penalty of perjury X Date of N 9 a Q r CT, a9i p i CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KAIBERIEY DRLtiCOLL MAYOR 120 WASHO'=ON STREET a SALEM,MASSACHUSEM 01970 TEL:-978.745.9595 a FAx:9M740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lenibly Name(Business/Organizadowbdividual): o y L" l r J r P 1¢ i1 Address: 2,1 b Y Iq y p City/State/Zip: x/2 �/ V1� l4 Phone#: "1 7 8 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with 4. Q I am a general contractor and I 6. [j New construction employees(full and/or part-time).• have hired the sub-contractors 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. Q Demolition working for me in any capacity. workers'comp. insurance. [No workers' comp.insurance 5. Q We are a corporation and its 9' Building addition required.] officers have exercised their 10.Q Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself.[No workers'comp, c. 152, §1(4),and we have no 12.Q Roof repairs insurance required.)t employees.[No workers' comp. insurance required.] 13.Q Other DeC� *Any applicant nut cheeks hoe#1 must also fill out the section below showing their woekar'c,mpgasation policy infannstloa. t Homeowners who submit this affidavit indicants they an dour all work and duet hies outside contractors must submit a new affidavit iadicattug such. tContneton that check this boa must attached an additional sheet showing die name of the sub-eontractoes and their worker'comp,policy bdbnnmiaa. I am an employer that Is providing workers'compensadon insurance for my employees Below is the policy and Job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach aeo �;1m. , an"d______.._._. - pyaEcee=workers'-trti�penaation policy declaration page(showing the policy number and exptraHoa data). 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 fore of up to$250.00 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. I do hereby rt/ and t paint and na/t' ojperJury that the injormaton provided above it due and correct Sin p t �I Za O b - - Phone#: q-2 ,r `�� l 0,07cial use only. Do not write in this area,to be completed by city or town official, City or Town: Permil/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions m , F 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 employe. 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 sub-contractors)name(s),addresses)and phone number(s)along with their certificates)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. 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 Permittlicense 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 town may be provided to the applicant as proof that a valid affidavit is on file_for_funre•permits.or licenses._A new af3davir must be fined 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 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. i , The Commonwealth of Massachusetts. Department of Industrial Accidents �>h Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax Al 617-727-7749 Revised 5-26-05 www.mass.gov/dia �Q pFAONS+RO PATRONS MUTUAL INSURANCE COMPANY of CONNECTICUT GLASTONBURY, CONNECTICUT = ARTISAN CONTRACTORS POLICY DECLARATIONS NT.G I01 Policy Number: CTR0007625 ENDORSEMENT Effective date: O'I/13/06 NAMED INSURED AGENT 6504 ....................................... . ROY E CURRAN II INSURANCE SERVICES OF NE, LLC- TK DBA RAR BUILDING & REMODELING C/O HOFFMAN INS SRVS 16 HALE STREET UNIT 4 PO BOX 9002 BEVERLY, MA 01915 WELLESLEY, MA 02482-9002 (508)947-3497 Policy Period: from 01/13/06 to 01/13/07 12:01 a.m. Standard Time at your mailing address shown above. Insured is: INDIVIDUAL Business Classification: CARPENTRY- RESIDENTIAL Code: 10030 LIABILITY COVERAGE COVERAGES LIMITS OF INSURANCE L. Bodily Injury and Property Damage Liability $500:000 Per Occurrence $1,000,000 Aggregate _ M. Medical Payments $5,000 Per Person N. Products/Completed Work $500,000 Per Occurrence $1,000,000 Aggregate 0. Fire Legal Liability $50,000 Per Occurrence P. Personal and Advertising Injury Liability $500,000 Per Occurrence PROPERTY COVERAGE DESCRIPTION AND LOCATION OF PROPERTY Loc. 1: 16 HALE STREET UNIT 4 BEVERLY, MA 01915 COVERAGES LIMITS OF INSURANCE Loc. # Building# Limit ACV A. Building B. Business Personal Property 1 1 $2,500 C. Loss of Income ACTUAL LOSS SUSTAINED, NOT TO EXCEED 12 MONTHS. WAITING PERIOD: 72 HOURS Increased Property Off Premises: Automatic Increase—Coverages A &B: 0% ANNUALLY Property Deductible: $500 ........ SUBJECT TO THE:FOLLOWING FORMS AND ENDORSEMENTS AP-100 Ed. 2.0 AP 0611 01 99 AP 0643 12 99 AP 0432 12 03 GL-895 Ed. 2.0 PG 5521 0605 AP 0700 12 02 AP 0740 12 02 AP 0688 06 02 AP 0690 06 02 AP 0692 06 02 PREMIUM AND:BILLING INFORMATION ANNUAL POLICY PREMIUM: $518 $500 Minimum Earned Premium Regardless of Term ENDORSEMENT PREMIUM: $0 BILL TO: Direct Bill To The Insured TERRORISM PREMIUM: $11 NON-CERT TERRORISM PREMIUM: $0 MORTGAGEES PRINTED: 09/26/06 AGENT COPY THIS IS NOT A BILL