1 SEWALL ST - BPA-05-685 STOREFRONT ENCLOSURE -PL*NSIMIST-BEfiL{G-AfJD APPROVED $Y T*IE
UNSPEGJpR .PIWR TP A.PEHMIT BEING GRANTED
CITY OF SALEM
a;
No� •�" 'v �\ Date
MIIVB
Is Property Located In Location of
the Historic District? Yes_No tz Building
Is Property Located in
the Conservation Area? Yak_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: Se_-6--A t».
PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name
Address & Phone l 5r--W
Architect's Name W1ly� ° -
Address & Phone 2Da ESM:CC i f OZ 744737
Mechanics Name _�- 3V3 �� ✓A
Address & Phone 6,41t�l ` (/�� ) 91,7, 7
What is the purpose of building? vs�^
Material of building? If a dwelling,for how many families?
Will building conform to law? �I e-- Asbestos? AFD
Estimated cost dop VCV City License # N P' Slate License # t'S 22
Bove :mprovesent x
Lic. Signature ofpp cant
SIGNED UN ER HE PE ALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
rev<e
h
p p �
MAIL PERMIT T0:
a':-Alt
No. J,�—�
APPLICATION FOR
PERMIT TO
LOCATF
PERMIT GRANTED
PJIyo4 2-0
AP liOVFD
INSPECTOR OF BUILDINGS
J
C
The Commonwealth of Massachusetts
-_ --'' Department of Industrial Accidents
office ofinvesugHuons
600 Washington Street, 7h Floor
Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit: Buildin lumbmg/Electncal Contractors
Aophcant informatton:.,w=. - �. :, please PRINT h:ei6iv - '"
name: C._eph-8 0y)
address:
city state: fir zip: 6) phone# 2e3
work site location(full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ 1 am a sole pl2prietor and have no one workin in an capacit ❑Buildin Addition
I am an employer providing workers' compensation for my employees working on this job
cpm UI name: " n
address: v 1�7 .. f
r e f
City: ohone:#.
e
insu nce co. policy#
❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address: ,-. .- ... .
city: . ohone#:• - " '
"}
insurance co. otic #
M ,
0 Vital
company name:
address: sa,�lr"W SQAr:ro^ Cr'.ro
r-
city. - - " .. _ phoned!
ter._
insurance co. _ lie #
_.
Failure to secure coverage as required under Section 25A of MGL 152 cap lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a
copy of this statement may be forwaMed to a Omce of Investi ations of the DLA for coverage verification.
I do hereby ce tify a the pains d pe [ties of perjury at the information provided above is true and correct.
Signature Date -2 —169
Print name Phone#
7-1.1
use only do not write in this area to be completed by city or town official
city or town: permit license# 7
[]Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
ae,ised Sepi.3003)
Y
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the`law",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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
w
.,e _m .m 77-
The
.._The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Imesggatiens
600 Washington Street,7h Floor
Boston, Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406
STPAUL
' ro TRAVELERS
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GKUB-3973618-1 -04)
NEW-04
INSURER: THE TRAVELERS INDEMNITY COMPANY
1. NCCI CO CODE: 11347
INSURED: PRODUCER:
WJJ PLANNING & CONSTRUCTION
LLC MCLAUGHLIN INS AGENCY
828 LYNN FELLS PARKWAY
64 HAVERHILL STREET MELROSE MA 02176
READING MA 01867
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedUle(s) attached.
2. The policy period is from 11 -25-04 to 11 -25-05 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
o
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits Of our liability under Part Two are:
Bodily Injury by Accident: $ 500000 Each Accident
Bodily Injury by Disease: $ 500000 policy Limit
Bodily Injury by Disease: $ 500000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
a�
SEE ENDORSEMENT WC 20 03 06
m
tiM.—
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o�
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
�= Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 12-30-04 TR
OFFICE: ORLANDO INDUS AFF 161 ST ASSIGN: MA
PRODUCER: MCLAUGHLIN INS AGENCY 28TGH
008202
X01 CITY OF SALEM, MASSACHUSETTS
�! PUBLIC PROPERTY DEPARTMENT
s s 120 WASHINGTON STREET, 3RD FLOOR
lA SALEM, MA O 1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGI,c 40 S34 I acknowledge that as a condition
P , g n
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S150A.
The debris will be disposed of at: A
Location of Facility
t).' L'a— i 1— AQ 10
Signature of a 't Appli Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any
Address, City & State
The above statute requires that debris from the demolition, renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
_ -�e
Board of Building Reqqulations
One Ashburton Prace, Ism 1301
w, Boston, Ma 02108-1618
License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 06/25/1948
Number: CS 062246 Expires: 06/25/2005 Restricted To: 00
WILLIAM J JENNINGS JR
64 HAVERHILL ST
READING, MA 01867
Tr. no: 11429
Keep top for receipt and change of address notification.
�/ze�on�mvruuca� n�'✓��is:wacf+,uuv.!!a
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
_ Number: CS 062246
Birthdate: 06/25/1948
Expires: 06/25/2005 Tr. no: 11429
---- Restricted: 00
WILLIAM J JENNINGS JR
64 HAVERHILL STs..a-e
READING, MA 01867
Administrator