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6-8 SHORE AVE - BUILDING INSPECTION EIS-OF SAL PUBLIC PROPERTY DEPARTMENT a MBEs sY ORISC OLL MAYOR 120 WASHINGTON STREET EAIt2/,%4A.ISACHI,'St11S 01970 TF1--979-745-9595 • FAx:97&740-9U6 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:5(�ore- of -�e- Property is located in a; Conservation Area YIN P Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.4 Owner of Land Name: Address: / S" 0,v� Telephone: 17 8 - -7 NAi - 7 Lf`'^ -t 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing 3 Renovation Number of Stories Renovated Change in Use New Demolition Existing iZ� lam Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: Mail Permit to: '� / J What is the current use of the Building? Material of Building? v-100d If dwelling, how many units? 2 Will the Building Conform to Law? �IZ� Asbestos? �o Architect's Name Iti� Address and Phone Mechanic's Name Address and Phone Construction Supervisors License#CSOB 1166 8 -HIC Registration# Estimated Cost of Project$ 1O_000 Permit Fee Calculation Permit Fee$ 70 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 Of specifications. Signed under penalty of perjury Date of tic w N L 7y 1 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 Please Print Leeibly Tc d2 ssal� CO r0J7n Name (Business/Organization/Individual): �✓`.e ev- t„n L Address: G Slutlre- a VP, City/State/Zip: S'otlewt wto. U t' 70 Phone #: `%7g _7�- 7 LtSLf- Are ou an employer? Check the appropriate box: Type of project(required): 1. I am a employer with .-C- 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. t 7• ❑ 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.❑ 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 12.2 Roof repairs insurance required.] re t employees. [No workers' , L q ] comp. insurance required.] 13. Other C'No� can�n�Ze�fro °mil *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 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. Insurance Company Name: e r Policy#or Self-ins.Lic. #: 7-63 86 OS Expiration Date: g 11 d Job Site Address: 6-6 st,oty— c,vw- City/State/Zip: Salem.,, MA C211170 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 cecerrtiffyyyunder the pains and penalties ofperjury that the information provided above is true and correct. ure:Si gnat u®.lL Date: 9/R/Oy Phone#: 017g 74y 7 9sy 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-contractors)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 t affidavit may be submitted to the Department of Industrial employees,a policy is required. Be advised that this a y p P 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 aiiivavivuiust'oe 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 bum 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.gov/dia CITY OF SALEM r� PUBLIC PROPERTY DEPARTMENT Klsm i"M I scm %{,�f}1lSEM 01970 Nar a 130 Wwswt+crtwr$11F1it•c•,ck Ri 97a.74S-9595•Fnx:97/-740.9846 Construction Debris Disposal Affidavit (required for.all demolition and renovation work) la accordance with the sixth edition of the State Building Code,780 CMR section 111.5 Debris,and the Provisions of MGL a 40, Building Permit 0iss issued with the condition that the debris resulting from this work shall be disposed of in a properlY Umsed waste disposal facility as defined by MGL c 111,3150A. The debris will be transported by: • ..f G V,f 5 I( C. r t� The debris will be disposed of in �—� / (name of facility) (address of facility) i���jlwt+ve:of permit applicant 9�r��o6 dare ACORD CERTIFICATE OF LIABILITY INSURANCE o9ii2 os PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rose Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA.PENN—ANERICA INSURANCE J.C. Russell Carpentry Co. , Inc. INSURER B:The Hartford 6 Shore Avenue INSURER C. 'SURER D' Salem NA 01970— INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDI ) DATE(MMMOIY LIMITS GENERAL LIABILITY / / / / EACH OCCURRENCE $ 500,000 DAMAGE TO D X COMMERCIAL GENERAL LIABILITY '° PREMISES E.Eacc.. $ 50,000 CLAIMS MADE ❑OCCUR PAC6522579 08/10/2006 08/10/2007 MEOEXP(AnYore Aeon) S 5,000 PERSONAL S ADV INJURY $ 500,000 GENERAL AGGREGATE 6 1,000,000 GEN'LAGGREG LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 1,000-000 Poucv ATE PRO-ECT LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $ ANY AUTO (Ea accicierd) ALL OWNED AUTOS / / / / BODILY INJURY (Per Penton) S SCHEDULED AUTOS HIREDAUTOS / / / / BODILYINJURY (Per a¢iEerrt) $ NON-OWNED AUTOS PROPERTY DAMAGE (Per accitleM) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSNMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ S DEDUCTIBLE / / / / $ RETENTION $ $ $ WORKERS COMPENSATION AND 3638B75905 09/11/2006 09/11/2007 X TORYLIMITS WLIMI - OR ER EMPLOYERS'LIABILITY _ 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? .. _� _ / / / / E.L.DISEASE-EA EMPLOYEE $ 100,000 If Yes,Uescdt,e under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATN)NSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 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 THE LEFT,BUT City of Salem Building Dept FAILURE TO 00 SO SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHOR R PRESENTATNE Wv— O ACORD 25(2001/08) ©ACORD CORPORATION 1988 *,M INS026(010).05 ELECTRONIC LASER FORMS,INC.-(S00),T2Y05,t5 Page 1 W 2 Date: _ To: Salem Building Department I allow Jeffrey Russell of JC Russell Carpentry Co, Inc to act as my agent for the purpose of obtaining any and all building permits needed for work at my residence. Property Address: dl9 70 Si d: rint) 3 CAUSSE1 L JC Russell Carpentry Co Inc Estimate ' ' 6 Shore Ave Salem, MA 01970 DATE ESTIMATE# ,•> ;%% 978-745-7454 978-745-7454 7/30/2006 1039 NAME/ADDRESS Kathy Bruin 8 Shore Ave Salem, MA 01970 PROJECT 3rd FI Deck Replacement DESCRIPTION Estimate for Work Proposed: Demolition Remove hand rails and Decking Remove siding and trim as needed Remove fascia boards Remove deck framing back to outside wall of house Remove privacy partition Remove rubber roof membrane Remove roofing as needed for repair Disposal of debris Installation Repair subfloor edge Install new rim joist Install new rubber membrane Install new sleepers Install new decking Install new handrails Install new PVC trim boards Install new flashing Replace siding Repair roofing � ♦ .� A :i " yl•,. , y. •.Y'•J1y�^i �r%'VBYr{ . '..,r �t? � %.'.'•-f ��� 4�.��°Yy �` ,•A �*.ti .` ` ? �J�. -`. �tl'. 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