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73 SCHOOL ST - BUILDING INSPECTION ' PUBLIC PROPERTY ' DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASHINOTON STREET•SM E.0 MA.SSACHLSLI-M 01970 TFL-978-74S-9595 FAx: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: Building: Property Address: 73 Sc� - cd Property is located in a; Conservation Area YIN _Historic District YIN 2.0 OWNERSHIP INFORMATION 2.4 owner of Land Name: P2obow g ,rust b O - &JJ7 1,Je2 Address: P T 6a1c 3545 poae,oc MPS of9b)-35vv Telephone: 97ow— 532- 9ll/ gi1L 4,jtj9Y4Vb 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 Bdd Description of Proposed Work: Mail Permit to: _ What is the current use of the Building? RE-5 ID rnr�+L Iua.d f�+.,-e 3 Material of Building? ,q I�n«t4 U�x S /t,l If dwelling, how many units? Will the Building Conform to Law? YE-S Asbestos? ES- [9n 58arE tfEirTi S Architect's Name Address and Phone Mechanic's Name Address and Phone pga66 Construction Supervisors License# a66 04 HIC Registration# Estimated Cost f Pr �t060 d Permit Fee Calculation Permit Fee$-% `L� 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 Date 4 °?� D !� �I Ct O q\ o0 � � o F � y oIN C7 abi u IN u Q CONSTRUCTHONT SERVICES GROUP,M. Wayne Tarr ` Operations Manager 7 Lincoln Street, Suite215 Wakefield,MA 018803021 781 246 9432 Fax 781 246 9771 Cell 617 548 0179 wayne@constructionservicesgroupinc.com CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASHINGTON STREET ♦SALEM,MASSACHUSETTS 01970 TEL:978-745-9595 ♦FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information y/����� //q��P_lea�se Print Legibly Name (Business/Organization/Individual): - `�Y� Address: 7 City/State/Zip: /14 /fie Phone #: 78 1 d `f 6-,ni N a Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. _ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El 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' 13.0 Other comp. insurance required.] Any applicant that checks box#1 most 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 most attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Q Insurance Company Name: p v 06 I • g Policy#or Self-ins.Lic.#: �/ U� 7�8 It 7r� Expiration Date: Job Site Address:73- �✓�i�.�.�r City/State/Zip: 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 penalties ofperjury that the information provided above is true and correct. !r— Signature �( P } Date: dJA 6 Phone#: 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. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)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 permit/license 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 future permits or licenses. A new affidavit;nest 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 Revised 5-26-05 WWW.maSS.$OVldla ACORD CERTIFICATE OF LIABILITY INSURANCE CSR MW DATE(MMIDDIVYVY) . CONS E-1 01/18/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Homer T Brown Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 298 Walnut Street HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 600613 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Newtonville MA 02460 Phone: 617-964-3355 Fax: 617-796-8833 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: iuinois union Ins a e ACE INSURER B: United States_Liability Construction Services Group Inc IN c. Commerce Insurance Co 7 Lincoln Street #215 INSURER D. The Travelers Propertl Casua1L Wakefield MA 01880 ---- - -- —__- -- INSURER E'. COVERAGES TPIE POi ICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY GEO IIIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PE PI-IN TI IE 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 BY PAID CLAIMS. INSR ADD POLICY EFFECTIVE I POLICY EXPIRATION - -� - LTRINSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE IMMIDDIYYI LIMITS GENERAL LIABILITY I EACH OCCURRENCE $ 1 , 000, 000 I ;-DAMAGE-rOLIENrED - , 50 ,000 A X COMMERCIAL GENERAVL LIABILITY G21983962001 01/12/06 01/12/07 PREMISES IRK occuleoce) CLAIMS MADE J OCCUR MED EXP(Any one person) _ $ 5, 000 PERSONAL a ADv wduav IS 1 ,000,000 _ GENERAL AGGREGATE III $ 2 ,000, 000 GENT AGCREGA'1'C LIMN APPLIES PER PRODUCTS-COMPIOP AGO $ 2 , 000 , 000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 C ANY AUTO - MV3497 01/12/06 01/12/07 1 (Ee ecprdem( ALL OWNED AUTOS BODILYINJURV X SCHEDULED AUTOS (Perpe,seD) X HIRED AUTOS BODILY INJURY NON-OWNFU AUTOS (Per accident) $ PROPERTY DAMAGE . (PBr,ICCidIa'm) $ GARAGE LIABILITY AUTOONLY-EAACCIDENT ANY AD10 EAACC 5 OTHER THAN _ _—_.---_ ._— __.. AUTO ONLY: AGO EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ 2,000,000 B OCCUR ' CLAIMS MADE CUP-1102646A 01/12/06 01/12/07 AGGREGATE II $ 2,000,000 ; $ DEDUCTIBLE _ _- $ X RETENTION $10,000 $ WORKERS COMPENSATION AND XITORY LIMITS ER EMPLOYERS'LIABILITY D ANY PROPRIErORIPARTNER/EXECUTIVE 6KUB958X7960-06 D1/.08/06 01/08/07 EL EACH AGGIDENI ___$ SDDDDD OFFID ERAIEMBER EXCLUDED? I E L.DISEASE-EA EMPLOYEE $ 500000 11 es descnde under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT I $ 500000 OTHER I DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SAMPLEC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION SAMPLE CERTIFICATE ISSUED DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN FOR NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL CONSTRUCTION SERVICES GROUP IMPOSE NO LI TIONOR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR INC / WAKEFIELD MA 01880 REPR A AUT R E TATIVE ACORD 25(2001/08) _ 9 ACORD CORPORATION 1988