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50 RAVENNA AVE - BUILDING INSPECTION A To \m M ' yr�t .If J ji et L,Y i J 11,E 1 .e1 / �•��tl. 1 ��II dvsi y 1 MZJ e ; t9 PVA j r1 r .+ • ea 1e e m iv . Irl «t . l 1tN N g ri tl ; rb; ■ ��:JL.^ J� . r� ?.��t■ - • ru�l� , ■ 1 4 ..1 i I e . rr � i t trt v-r t {'&!-� +ys 1 ■ 1 11 � e 2 ' of ef. 4i.1 UleeM 6►tn + WOOL ypo("a WOO) O am et • Wcrkera Campomiatfort i offMAVit meet be and gubmiteedwith his t . Fathao to pmvwo this d utlavit will Muh In the denW nit"Wam of Oho building POMIL SWW Affidavit Afteften Yoa .......... No....,,,, . C) Oli7r OWN1P�tA -OWMIAGANTOR i, - Y :Sr t .iMY as Owner of Oro N*Jtd pmp" audwdnGftC�. 9E"r— t 4 Aq A �—,w to to on my bc3raiF,M aU aratera rohdw to work Ohio buitdk%permit iinetion, Mel- 1 c3 s lY 7Dt OR A 7r to A NT EXC"1ARAT[OAi C&CM.a-- &dL A Apo husby deolero Aura On sbknwft and iffthrAdeft on the ayrldW4d"ana to and Accurate,to tie beat of my krgwAWV sad bWW N� 71 a ro+g. t ter.✓GJIG..,,, '' 1. An Owner AW ObWo a buildinS pook t0 do WOW own wort,to an owtYt an fact read in tha'Farw NAptavarrt C4060t(if1C)Program),wl41 taus Amer e or Ps"AM tmdor M 01.n. i42A. won Alw f{IC L (CSL)Out bo hf 110,R6 O.RS,tdra dda vaty. 2 Witen 069MWwork is p Ow k*fa*M below. Total fioaaa> a f8q Ft) o bit! de of nr pordt) ego"living am(4 FL) Htgitabhn toom oownt N of 5, Type w � ' 1. "Toad Pmjoot F~mty be Sbr*TOW Off^ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UIV www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information nn Please Print Legibly Name (Business/Organization/Individual): ZJ W T-0 E�. OVD f; S—r— Address: �� SAIJ 6�k tJ Z ox LyJ' a / f 3Z- 1�4101 City/State/Zip: O Phone#:c3o' Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with q 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp.insurance.'+ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.[ Other comp.insurance required.] I 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: —i�W Gb//6&'4> Expiration Date: 14114 20 10 Job Site Address: 5_0 ?AVEMAIR A✓F—NLF-- City/State/Zip: SUM t40� 0/�'70 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penQue`s`ofperjury that the information provided above is true and correct Signature: " "° Date• 3 jr & r— Nl. 6E$ AJ" ` Foe �SfXIrL M�NDdGc1 & SGatic� Phone#: I �p�� y,�2 ^l4(m / Official use only. Do not write in this area,to be completed by city or town offtciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Unofficial Property Record Card Page 1 of 1 Unofficial Property Record Card - Salem, MA General Property Data Parcel ID 08-0007-0 Account Number Prior Parcel ID 42-- Property Owner NOT AVAILABLE Property Location 50 RAVENNA AVENUE Property Use One Family Mailing Address Most Recent Sale Date 71111996 Legal Reference 69082.347 City Grantor JERMYN ANTHONY M Mailing State Zip Sale Price 186,000 ParcelZoning R1 Land Area 1.250 acres Current Property Assessment Xtra Features Card 1 Value Building Value 268,200 Value 0 Land Value 152,600 Total Value 420,800 Building Description Building Style Colonial Foundation Type Concrete Flooring Type Hardwood #of Living Units 1 Frame Type Wood Basement Floor Concrete Year Built 1986 Roof Structure Gambrel Heating Type Forced HIW Building Grade Average Roof Cover Asphalt Shgl Heating Fuel Oil Building Condition Average Siding Clapboard Air Conditioning 0% Finished Area(SF)2395.15 Interior Walls Drywall #of Bsmt Garages 2 Number Rooms 6 #of Bedrooms 3 #of Full Baths 2 #of 314 Baths 0 #of 112 Baths 1 #of Other Fixtures 0 Legal Description Narrative Description of Property This property contains 1.250 acres of land mainly classified as One Family with sin)Colonial style building,built about 1986,having Clapboard exterior and Asphalt Shgl roof cover,with 1 unit(s),6 room(s),3 bedroom)s),2 bath(s),1 half bath(s). Property Images 12 11 Disclaimer:This information is believed to be correct but is subject to change and is not warranteed. http://salem.patriotproperties.com/RecordCard.asp 3/31/2010 Massachusetts- Department of Puhlie Safa11 , Board of Building Regulations and Standards 1 Constructo:in Supervisor License License: CS 102828"1' _ P." .q2r RegttictedM 00_ _, t ERIC BENNETT 1 � .° 163 WEDE6EW06bLANE MANCHESTER, NHO3109 --` �'--i,, .. ' Expiration: 12/17/2012 (-tYfpiA6�NVflQP:,. a Tr#f. 102828 rti ••• ✓IfE 1�h�9# (f/2 ��{iJ¢.kf(tG Board of Butkltng Regulations and Standards HOME IMPROYEMENTCONTRACTOR �4 Registration: 154681 Explratioii: 3/2at2011 TyBri Supplement Card A TRI•STATE WINDOW&SIDING y ERIC BENNETT - a 47 SANBORN RD LONDONDERRY,NH 03M3 Administrator s f CITY OF SM.&M, NWSACHUSETTS BL'IIDLNG DFP.JLM.LENT 120 WASHNGTON STREET,3' FLOOR c� TEL (978) 745-9595 FAX(978) 740-9846 KI\tBERLEY DRISCOLL MAYOR T Homa ST.Pm m DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris,and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name eop,of�facility) (address of facility) signalarc of permit applicant 31l A0 date dcbn.wfT.dw ACORD CERTIFICATE OF LIABILITY INSURANCE 3DATE WOD /31/20 0' PRODUCER (603)432-6414 FAX: (603)432-3852 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Financial Insurance Services Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 950 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Derry NH 03038 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A.Peerless Insurance Cc Tri-State Window & Siding Cc Inc. INSURER B:Guard PO BOX 1028 INSURER C: INSURER D. Londonderry NH 03053 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. MAY HAVE SEE q REDUCED BY PAID INSR ADD'L POLICY EFFECTWE POLICY EXPIRATION 1.11L um TYPEOFINSURANCE POLICY NUMBER DATE MWDDIYY DATE MMIDDIYY LIMITS GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISE Ea o=nnence $ 50,000 A CLAIMS MADE ❑OCCUR CCP8419722 4/16/2009 9/16/2010 MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY IS 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY JPEC LOD AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea aoaaent) $ 1,000,000 A ALL OWNED AUTOS BA8413223 4/16/2009 4/16/2010 BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HI RED AUTOS BODILY INJURY X NONAWNED AUTOS (Per accieen0 $ PROPERTY DAMAGE $ (Per amtlen0 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. AGG $ EXCESSNMBRELIA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION - Is B WORKERS COMPENSATION AND WCSTATU- OTH- EMPLOYERS'LIABILITY LIMIT ANY PROPRIETORIPARTNEWEXECUTIVE EL EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? TRWC011600 4/4/2009 4/4/2010 E.L.DISEASE-EA EMPLOYEES 100,000 It yes.4esenbe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER A Inland Marine IM9827743 11/25/2008 11/25/2009 Llmit: $196,630 A Inland Marine IIM9827743 1 11/25/2009 11/25/2010 Limit: $196,630 DESCRIPTION OF OPER nONSILOCATIONSIVEHICUWEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION (603)218-7780 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Tony Jermyn EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 50 Ravenna Avenue 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Salem, MA 01970 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Sam Fragala/PAT ACORD 25(2001/08) ©ACORD CORPORATION 1988 IMIQMA,n o,no., oena 1 11 ACORD CERTIFICATE OF LIABILITY INSURANCE 3/31/20 0' PRODUCER (603)432-6414 FAX: (603)432-3852 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Financial Insurance Services Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 950 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Derry NH 03038 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Peerless Insurance Cc Tri-State Window & Siding Co Inc. INSURER B:Guard PO BOX 1028 INSURER C: INSURER D: Londonderry NH 03053 INSURER E. POVERAGES 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. IE WN MAY HAVE SEE A EEQUQED BY PAID CLAIMS INSR ADD'L TYPE OF INSURANCE POLICY NUMBER DAM MMNDIYYE PDATE(EXPIRATION MIOD) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED SO,000 PREMISE Ea occunence $ A CLAIMS MADE F OCCUR CCP8419722 4/16/2009 4/16/2010 ME EXP(Any oneperson) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL A GR EGATE $ 2,000,000 GEN'L AGGREGATE U MIT APPLI ES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY F JEC LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea aWdent) $ 1,000,000 A ALL OWNED AUTOS BA8413223 4/16/2009 4/16/2010 BODILY INJURY X SCHEDULEDAUTOS (Per parson) $ X HIREDAUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Peraccitlenp GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY ER ANY PROPRIETORIPARTNER/EXECUTIVE E L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED'r TRWC011600 4/4/2009 4/4/2010 E.L.DISEASE-EA EMPLOYEE$ 100,000 H yes,describe under SPECIALALPROVISIONS below E.L.DISEABE-POLICY LIMIT $ 500,000 OTHER A Inland Marine IM9827743 11/25/2008 11/25/2009 LI t: $196,630 A Inland Marine IM9827743 11/25/2009 11/25/2010 Liaut: $196,630 DESCRIPTION OF OPEMMONSILOCAMONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Salem, Massachusetts EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 93 Washington Street 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Salem, MA 01970 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Sam Fragala/PAT ACORD 25(2001108) ©ACORD CORPORATION 1988 IMCA9A mina,na.. P.„a 1 nry