98 SCHOOL ST - BUILDING INSPECTION PUBLIC PROPERTY
KI%MF81.EY DRISCOLL
MAYOR
1?0 WASlIINGi'ON SlxeEr 4 JAity,HA1SAd{(;36115 01970
TEL*978-745-9595*FAx 97&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
Location Name: Building:
Property Address: 98 `DG(r•oc' is ,-,-
MCC,
Property Is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land e
Name: CAVES ; N � \�O
Address:
Telephone:
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 (sO Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to: U njy`FIQI+ r,
r
v
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
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ H 5`0 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 A �'�►-� G�
Date
� d N
9
p i3 9 M
x
►.
C o, a _
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIINBF�l1.EY DRISCOLL
M.%YOa 120 WASFmvGTON STREET a SAt t MwanCtn,•s M 01970
TM-978-743-9595 a FAX 978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeffity
Name (mninesUOrgaaiatiovAndividual): nuy,�p i 90c)
Address: S 1 5- LO1,-e V1 tea- V
City/state/zip: >?Q CA- Phone#: a7(5- s i s= 6 6 ti 3 —
Are you an employer?Cheek the appropriate boat7mand
Type of project(required);
1. I am a employer with 4. 1 am ager and I 6.employees(full and/or part-time).• have hired thactora ❑New construction
2.❑ 1 am a sole proprietor or partneo- listed on the eet, t 7. D Remodeling
ship and have no employees These subcoave 8. 0 Demolition
wonting for ate in any capacity. workers' come. 9. Building addition
(No workers' comp. inn ranee 5. ❑ We am a corpd its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 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.C]Roof repairs
insurance required.)t employees. [No workers'
comp. insurance required) 13.0 Other
'Any applicant dut eleeb ban#t moat atao 90 out the section below showing their wod.m'
t Hcmeowome who submit this attldavit indicating they an doing all work and tho bin ot.Wde eaotrachn
tCo muq submit a pew aAidn y k ems,
nbaefon that cheek this ban mum aeaehed an additiattel sheet showing the name of subcontractors and their worbn•comp•policy atcamatlaa.
Ian an employer that is providing workers'compensation insurance jar my employees Below is the policy and Job tIN
information
Insurance Company Name: 2CA(k,
Policy#or Self ins Lic.M: 0,JOrb, Expiration Date: —1 —
Job Site Addressi
City/StatePLip:
Attach a copy ofthe workere'•comp asatiou- 4{"pe policy declaration page(showing the policy number and exphradoa 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 S 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
/do hereby n(d�er the pains ajn(d�pe tall des(ofperrfary that the injormadon provided above it tres and correct
Phone#: - S-3 -
[Okoonly Do not wilts in thi!area,to be completed by city or town aJJlciaL
n• Permit/Licenseority(circle one):Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
son• Phone#
DATE(MRIIDDlYYYY)
A_ ORRD,� ' CERTIFICATE OF LIABILITY INSURANCE o9/OE/20o6
aODucER 603) 883-5528 THIS CERTIFICATE IS-ISSUED AS A MATTER OF INFORMATION _
( ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
:ORRYVEAU INSURANCE AGENCY, INC. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
,15 MAIN ST
> 0 BOX 369 NAICv
IASHUA NH 0 30 61-03 6 9 INSURERS AFFORDING COVERAGE
INSURER A:NAUT ILUS
T5URED
:ONDONDERRY, MANCHESTER CONST SERV CORN INSURERB:AIG
)BA: OL)aAPIC INSURER 0:PROGRESSIVE
15 TANGUAY AVE __ msURERD: _, ..
RASHUA NH 03063— PISURERE'
COVERAGES
T EL
HE POLICIES OF INSURANCE US EOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD .NDICATED.NOTWI7HSTAlI01NPERTAIN,
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY
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 BY PAID CLAIMS, POLICY EFFECTIVE POLICY EXPIRATION LIMITS
NBR ACE'L TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YY) GATE IMMIODIYYI
LTR N RI g 4,000,000
A % GENERAL LIABILITY / / EACH OCCURRENCE
OAMAGE'I'0 RENTED 5 lOO,OD0
X COMMERCIAL GENb•MLLMBILITY PREMISES —I.-L.
12/09/2005 12/09/2006 MEDEXP can MIa u,l S 5,000
CLAIMSMADE OCCUR NC502722 4,000,000
PERSONAL&GRE INJURY $
GENERAL AGGREGATE $ 4,000,000
PRODUCTS•COMP/OP AGG 5 4,000,000
GOWL AGGREGATE LIMIT APPLIES PER: / / / /
POLICY JpECT_, %71 LOC -
35190760 05/11/2006 05/11/2007 COMBINED SINGLE LIMIT 5 1�000,000
C X AUTOMOBILE LUU3ILITY (Ea accldwi)
X ANY AUTO
/ / I I BODILY INJURY 5
ALL OWNED AUTOS (Pee Pa160n)
X SCHEDULED AUTOS
BODILY INJURY 5
X HIRFDAU1'05 - (Per acclddnD
X NON.OWNED AUTOS / / / / PROPERTY DAMAGE
$
(Par eccldrnq
AUTO ONLY-EA ACCIDENT 5
GARAGE LUURLDY
I / OTHER THAN EA ACC 5
ANY AUTO AUTO ONLY: AGG 5
EACH OCCURRENCE S
EXCESSR)MBRELLALUURLITY AGGREGATE S
OCCUR CIAIMA MADE g
DEDUCTIBLE W y S
RETENTION S 09/25/2006 09/25/2007 X TO Y MRS % ER
B WORKERS COMPENSAM AND WC2791321 (NASS) _ _ _ 500,000.
EMPLOYERS'LIABILITY - .. . .. . - - - - E.L.EACH.ACCIOENT S
ANY PROPRIETORIPARTNERIEXECUYIVE / / / E,L,DISEASE•EA EMPLOYEE S 50D,000
OFFICERIMEMBER EXCLUDED'? NOT EXCLUDED 500,000
If,ea•desalbe Vr100e - - - - E.L.DISEASE•POLICY LIMIT 5
SPECIAL PROVISIONS below - - 01/13/2006 Ol/13/2007 -
A OTHER INLAND MARINE IHB 113963 � 190,000
DESCRIPTION OF OPERATONSILOCAMONSIVENCLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PRONSIONS
CANCELLATION
CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
( ) _EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30, DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO'INE LEFT,BUT
F UK 0 GO SD SHALL IMPOSE NO OBDGATIDN OR LIABILITY OF ANY qND UPON THE
INSURER AGENTS OR REPRESENTATIVES.
AUTOO D. EPRESEMMTIVE-
ID ACOROCORPORATION1988'.
ACORD 25(2001108). . . Paga,az
ti
INS0251D10B).05 ELECTRONIC LASER FORMS, .-(Bpp}e27D545 _ .
TO MnHA nH7ni?U4n'l FZCCPRR6R9 R7.:PT 9HG(7,/RR/50
rtfl � ,
C✓�Ce �anv�na-.r<ceai/l o�,/�auor/veeda: -
BOARD OF BUILDING REGULATIONS
- License: CONSTRUCTION SUPERVISOR
Number. CS 080145 -
Birthdate: 10/26/1963
Expires: 10/2612007 Tr. no: 8042.0 :.
Restricted: 00 -
GEORGE VASILIADES
. 515LOWELLST G'„� .�
PEABODY, MA 01960 Commissioner
..
- � Board of BuildingRegulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 124356 -
Expiration: 6/12/2007
Type: Private Corporation
- Olympic Painting/George Co., Inc
George Vasillado
_ 515 Lowell st. _,
InPeabody,MA 01960. Administrator -