7 RIVERWAY RD - BUILDING INSPECTION (2) EIT� --
`' PUBLIC PROPERTY
DEPr1RTbIENT
KIMBERLEY DYISCOLL
MAYOR d" / 120 WASHING"S-mEer*SnuM%LAzAcHL%j-rs 01970
TEL-978-745-959S*Fex:978-740-98"
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: A IJ Building:
Property Address:
c
A
Property is located in a; Conservation Area YJA Historic District YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
_ r ,c fR�tJfJ /
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN FYICT,Nrx 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 Description of,Prroposedl dWork:
f
Mail
What is the current use of the Building?
Material of Building? if dwelling, how many units?��_
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone ( )
Mechanic's Name A L)5T i o In L o
Address and Phone.
Construction Supervisors License# 0& 3 93 HIC Registrat on# /C7 cl 9S�
Estimated Cost of Pr ' $ + O 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 above stated
specifications. Signed under penalty of perjury
Datej-2 CJ�
I
OI
0
N
61
.r T
1y V
I -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
u�rca 1M'WA20WMS=W a SJUU4,MA%ACWmrM01970
'itt.9W45-M a FAX 9W40.9W
Workers' Compensation Inswanee AMdavW Bader /Contraetonmeetr(etaayplombers
Applicant Information Please print i albs.
Name( aw): COV-579cJC 1 t 0A1 c- L 6-
Address: 5' Al Nf��iUr%(1��
City/statemp:
Are you in employer?Check the appropriate be= —
1.❑ I am a employer with 4. [31 am a Sward conacW and I Type of iarelect(respired):
employs"(fall and/ar part-dme).e have hived the subeonpaetao 6' ❑New construction
2.❑ I am a sole propeiasor at partneo- listed an the attached=best t 7. ❑RemodeI
ship and have no employees These sub-Contractors have a. ❑Demolition
working far me in any capacity. workers'comp,WMMSM g.
'comp.insurance s. ❑ We are a corporation and its Building mop
ofRcera haw axeneised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work ruin of examption per IKGL I I.Q Plumbing repairs or additions
myself[No worlms,comp. a 152,¢1(4),and we have on
intluxaIICe required.]t employees.[No works=' 12.0 Raof repairs
Comp,insurance requite&] 13.Q Othes
'Aay W1100 err cbseb era et=W aW tm aut ere salon tdow reoeeaa ark w".6 esmpmmriaa Dakr leasenaa Hamosw who&A"aY SOW[kdieakeaeyawdais$9wokdamNm am"amams mast 06"a now afldwit
tCoeaeamm eat As*ale box snag amoded a addWonel start abwis of aeon area ssbaaaaeoaa asd ask wwskma'� kdiimrlea,
lowlowan ORMAYArrkm tr provlAlirs workers eawoaarodoa keereacalorM'9=00Yeea Below It ciaooUey as/Joi rlra
I
Insurance Company Name:_._. K. /P/C /14-- it/ -1 US
Policy N or self-ins.Lie
Expiration Date: /J_d y_ O z
. Job site Address 7 R f` Cityistuerlip:
Attach a ropy of the workers'compensation policy declaration page(showing the policy number and expiration dab)6
F"dum m secure coverage as reWired under section 25A of UGL e. l s2 can lead to&a of of criminal penalties ofa
fun up to g1 s00.00 aod/at one imprisoomem,as well AS civil penalties in die form of a STOP WORK ORDER and a Rno
of up to 3250.00 a day aaaimt the violator. Be advised that a copy of this statement maybe forwarded to the Oflkae of Investigation$of the D A for amaoee coverage verificadoo
f so kereby tern( mass,roe pelas and Pe rapt rlfwiaJormedow provldt/obaw br c►w awsronees
i law,
Phone M:
FBBasrd
msa oil/
Do not wrist in this areal m be complete/by CAY or maw oJ)fe/al
own: Permit/Lleense M
uthority(circle one):
of Health 2.Building Department 3.Cltyfrown Clerk 4. Electrical Inspector s.Plumbing Inspector
Contact Person: Phone 0. "
Information anchln-strucUuM
puseaa General Laws ehaPtae toprovide worvieakerso!'compcau'oather for their emploYese�
to this sperm.an emploYm is defined as"••.every Pin�the sac ano under any cam° olhire.
Pursuant
enpcess or implied.oral or wetted"
assoeiacen.Corpentiaa or other legd rangy.or�nMO err mme
as"ate Wavidud,Partnersh�ip•�,,,1i,,� .or the
An s+rployo mOd m alb and ineludioz the L-W representatives,of a deceased ���
re the foregoing engaged md'viduai.pt�p• or odsar le�rho red employing
i tha ooeup�
sndwbsresideetheni4 of the
receives a data not man thin than apartmema house
owner of•dwetliot bona hsvntt arsaus to do mainoemaa.ce�tuctke or tePair wadi an such daeliiD{
dwalUng botno of amothar who 4 thwetm shall net because of a"employ�be deemed to be as emPI%W-
ar on the grounds at building aPt�°Oiet INCY_.ruhhold iwnanee or
MGL chaptar 15%12$C(6)also sates there"every state M teed liaaiK ergs a<a aaa set btsiWnp M a is tnseawa*fat NW
reMwel a!a Iles*"W Pu"fo epeefa a bnfllW
wMh tY Insuraeee eeverap rt�"
applicant
p naoaIly�MCIL cbsp b"not w i� Mass"Nei w the can= atlth�Of its pull"of compliance vr�dmaunou
enter into anY� c far the n b mane of mm',o work mad saceptable
de cotmraet[nt awd�Y•"
regW—fta oldds cbsPter haw hem peesmted
APPd afildavit •by checking the boxes that apply to Your dmstiaa Maul.if
Pica"fill out the wodw ace a).Wdseas(a)and Phone mtmber(s)slant with their eatifiede(s)of
necessary.: su Nib or Limited Liability Partnerships C»wig no °�than the
insuraea• Limited Liability ComPIMM .e insurance. if m LLC or LLp does bsve
not required m carry the of Indusaiat
members or
�is Be advised that this affidsvis be submitted toAculd
employs confirmation of insurance covvaata. Ale be Me to sip and date the affidavit the affidavit d Of
fits the permit a license is being requested,
not the Depatneet
be remrned to the city or mtisa that the application the law or if you an required to obtain a workers'
Irtdrwnal Aecideofs. Should you have any questionslisted below. Self-inataed companies should came thek
compensation policy.plow call the DaPattmmt fine.
self-in man"lkmse tntmbor on the
City sr Tswa Melon psas at the bottom
Please be me that the affidavit is comPieas and Dilated legibly. The Dns bas o c has provided a sding
of the affidavit for you m fill out in the even the office of lnvestigaaowt m m contact you regarding the n applicant
mamba which will be used as a retamee number. ht addition,an BPP
Please be me m fill in the pamittliceae applications in any glum yea,need only submit one affidavit indlearing cotraat
that mud submit multiple paudulkease app
information(if necessary)and under Jab Site Addrase the applicant should write"all locatione is __1he or
Policy or marked by the city or town may be provided m the
town)."A copy Of the affidavit that lose hem ofi!kie&stamped a licenses.-A new afu&vu mud be filled out escb
applicant as proof that a valid affidavit is m filo tar fiutue permits net mlaad m my business a cemmac�vse°tea
ea.Where a bows owner a eitizm is obtainingp. s i license at Permit
yu NDT required m complete this afQdavit.
(i.e. a dog liease at pamtt m burn leaves cap.)said person
advance for your Cooperation and should you have any questions.
The Ofike of investitaaone would like to thank you.m
please do not hesitate m give us a csiL
The Department's addtesk telephone and&a number.
IU c4mmWWt! M Of Mtl7Sf use"
DepeltmeM of bALI d Amdetntil
Oflsa of vyedISR nos
600 WL*02"S>t d
Bod^MA 02111
TeL #617-727-4900 cd 406 Of 1-877-MASS'Fg
Fox 0 617-727-7749
Reviscd 5-2"S Www.IIta LPL/din
I4(v0j'vv0 IJ.vo rnn 010 Jut 4LII o n mbbnn inr wjvvl/VVL
lient#:138" MELDS
ACORD. CERTIFICATE OF LIABILITY INSURANCE CAM(Mwoonrrq
12/Oef08
PRODUCER THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION
B.K.McCarthy Ins.Agcy.Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
10 Centennial Dro e, , -. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Peabody ,MA 01960
978 5325445 INSURERS AFFORDING COVERAGE NAIC i
NBOMOT WuuAEIR A: NGM Insurance Compan 14788
Melos Construction LLC INSURER e: Liberty Mutual Insurance Company 23043
clo Foustino Melo,34 Jennings Circle INSURER C _
' INSURER O:
Peabody,MA 01960 INSURERS:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFIGATE 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 BEEN REDUCED aY PAID CLAIMS.
ppLIOY�FECnYEPOLICYEXPIRATION LIMITS
1119w am L TYPE OFNSURANCE POLICY NUMBEROATS mmmDrjm
A Gtt1ER M ALLBIurY MP023862 11/26/08 11/26/07 EACHOCCIIRRENCE $500,000
DAMAGE To RENTED a500 00
X COMMERCIAL GENERAL LIABILITY g'
CLAIMS MADE EA OCCUR MED EXP(MY ma vvn l 410.000
PERBtXTAL S ADV INJURY $500000
GENERAL AGGREGATE $1000000
GENL AGGREGATE LWIT APPLIES PER: PRODUCTS-COMP/OP AGO a1 OOO OOO
POLICY PRO. LaC
A AUTOMDBILELURBRITY M9H43928 09/21106 09/21/07 COMBINEDSINGLE LIMIT f
ANYAUTO
ALLOWNEDAUTOS SomyimuRY f100,000
(Der porNnl
X SCHEOMEO AUTOS
X HIRED AUTOS BODILY INJURY s300,000
<Per 9m q
X NDNi1WNED AUTOS
PROPERTY DAMAGE ON000
(Mracdden0
AUTO ONLY-EA ACCIDENT a
GARAGE LIABILITY
ANY AUTO AOTHER WOO YN EA ADD S
AVTO OIar: AGO
EACH OCCURRENCE S
EKCEBBNM r,NLLA LIABILITY
OCCUR �CLAIMS MAOE AGGREGATE a
b
i
DEDUCTIBLE
f
RETENTION f vA;STATu OTH-
B WORKERS COMPEN9ATION AND WC2345338762016 12104MG 12/04/07 -
�WYERS'LNBILITT' E.L.EACH ACCIDENT 1100000
ANY PROPMET0PA'ARTNERIEXECUTWE el.DISEASE-EAEMPLOYFE a100020
OyFyFICERAAEMBER EXCLUDED9
SPEC E.L
IONS heiw E.L DISEASE•POLICY LIMIT $500000
OTHER
DESCR PTION OF OPERATIONS I LOCATIONS I V@XCLFA I E,cLusms ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
978-535-3904
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE MMMBSO POLICEEB BE CANCELLED BEFORE THE EXPIRATION
Melon COnatrUOtlon LLC DATETHEREOF,THRMSUNGMUPJERwuL EAVORTOMML 10 DAY9WRITTEN
do Faustlno Meio,34 Jennings HOME TO TWE CERTIFICATE HOLOER NAMED TO THE LEFT,BUT FAILURE TO 00 SO 81EALL
Circle MPOBE NO OBLIGATION OR UASRM OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Peabody,MA 01960 REPRESENTATIVES.
gyRHpBrr:o REvRESENTArnE
ACORD 25(2001100)1 of 2 852910 RBU 0 ACORD CORPORATION 1988
2006-12-08 13:10 976 532 2217 Page 1
CrrY of SAmm
PUBLIC PROPERTY
DEPARTMENT
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