25 SHORE AVE - BUILDING INSPECTION EITY-OFSALE
PUBLIC PROPERTY
DEPARTMENT
K1%Q1FJLLEY DRI5C0LL
MAYOR 120 WASHINGTON S REEr•SME AN-AAQ1l; I-M 01970
TEL-978-745-959S*FAx:97&740-9846
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:
62 5- -541,z
eo
Property is located in a; Conservation Area Y/N Historic District Y/N </
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
[Name: �ress:phone: 2do- / — / 7
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use U�/U �� 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:
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 d�� `�"+—y QG Me 5
Address and Phone J` 5!1�r2n S i ( ) S7f
Mechanic's Name
Address and Phone s a Cd.Y S� 9�� ' 77% 0
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ c/z"u 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 x
Date
N
y
o� U N ' u
- d uN
C6--
QTY40F SALEM
PUBLIC PROPRERTY
DEPARTMENT
xntat:ata,r caacou
atr►roa uo�vpsmac,oN sra¢ar.su�lt.�[wStpatvmrrs o1970
TM--97t-743-9M a FAX 978.740.9W
Workers' Compensation Insurance APHdavit: Boildet•s/ContractorsMet:Ml
Anolicant Information cans/Plnmbm
Pleans print Legibly
Name i . .ten: �2���n�e �• /�-
Address:- 3
City/Statemp:_ 426uvv ems- /'9. 01s-7 Phone# 9 71 - 7
Are yob=employer:Caeak the appropriate bons 'lbw of Project(raga r*&.
1. I am a employer with 4. 01 am a Sawa(contractor and 1
employees(1hB and/or part-time).• have hired the subconaactats 6 ❑New construction2. I am foie proprietor ar mpartser• listed on the attached shaft t 7. Remodeling
ship and have no employees These have 8. ❑Demolition
working for an in any capacity. workers,comp.insurance. 9.
[No worker ce'comp.insurance 3. 0 We a a corporation and its
m°8 addition
required] officers have exorcised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs at additions
myself.(No workers'comp. a 152, ¢1(41 and we have no 12,CJ Raofrep repairs
insurance required]t employees.[No works s- 13.0 Other
come.insunum required]
;Any VPlkmW*9 dab ban at amat ako aU ore ice secdas twow thdtwakm-oompassanoa peft
ttamaowam wkf albeit nit man sk AW so fi Eby m&ft&a took ad er wre aew&eomnrxew mnae submit a am amen*ieNaWia saoL
tCoetraeattt the e6edc dte but aaW ateebad m ad&dwA abut ahmiaNNNNNNNNNEMM� a dw alma of de=&cuomamtm sod duk wattea'aomR PomY htfbmatlaa
!am an employer that!s Pro vfdlns workers'compeneasiam lmrwrawe4 joi wry ento%yeea Below is do
In policy,awefob sip
Information
InsuranceCompanyName: G/t til-I e S7,/a /e
Policy M or Self-ins.Lic. ?d PdP rq 20 Expiration Date: G 7
Job Site Address o2 S it oz¢ /, Ir_ City/State/Zip: s��.�
Attach a copy of t workers'eompensadon policy declaration pap(showing the policy number and expiration date)6
Failure m secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of mmind
fine up to S 1.300.00 and/or one-year imprisonment,as well as civil pities of a
of up to 32S0.00 a day against the viola w. Be advised that a c of thihis ar �n form ben STOP WORK ORDER and a fife
Investigations of the DIA for insurance coverage verification COPY statemem may be Forwarded to the Office of
f do kerrAY ce/r�dO under the point and pewaldn ojperJwry tket the InfOrmadon provided above is trw and correct
Simmafarf:_C h (.� t✓' ��J'e, Date,
Phone At: 476 - 77Y - o Zr' ,
O,Q'lelat ate only. Do not write lw this arse,to be completed by cult o►pow agk&L
City or Town: PermiULicease M
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Ctly/Towa Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone M:
Information and Instructions
ir erepleyeeL
Massachusens General Laws chapter 152 requites all eaiployeu to service oofde sanother�oeny cfor otiact of hire.
pursuant to this statute.an e=*Yee is defined as"...every Person m the
express or implied.oral or written"
as"an individual,parrestai P.association.corporation or other legal entity.or any two tt mote
An easployp is defined the legal repcesentanva of a deceased empinYOw v the
of the foregoing engaged in a joint enterprise. association other[l rep entity. ves of io I employees However the
receiver Or trustee of m individual,partsersliiR who resides therein.or the Occupant of the
owner of a dwelling house having not"ante than three apattrnenta or weak oti sired dwelling home
dwelling boners of another who employs Persons to do net bens se f such a ipl be deemed to be an employer."
or on the grounds er building appurtenant thereto shall net bcauaO of such employmem
MGL chapter 152,42SQ6)also states that"Ovary state or legal ace Laing sgeaey>dar withhold rho WOanee Or
ss o a business w to construct buildings in the commonwealth for tiny
renewal of•lleew or permk Ponta coverap required.
applicant who has out produced acceptable evtdeneo of a common with the In y of it a visions shall
Ppddidam lty,MGL chapter 152,125C()states"Neither the commonwealth nor any of its political w a Wmmnoe
cramaer for the Performance of public work until acceptable evidence of comPh8000
enter of this chapter have been lamented to the contracting atitherity'
rW
ApplIpppll eanb
fill out the proakers'compensation affidavit completely.by checking&a boxes that apply to Your situation and,if
Pleaumber(s)along with their cardficsts(s)Of
necessary.suPP1Y sub-contractor(s)name(a).a Liability a(es)and phone npartnerships(LLP)with employees ode than the
insurancO. Limited Liabilitynet rMolr� carry insurance. If an LLC or L.LP does have
members or psrtsers, to workers'compensation
employees,a policy is regtred Be advised that this affidavit may be submitted m the Department of Industrial
Accidents far olicy is requ re insurance coverage AIM be son to sign and date the affidavit. The affidavit should
application for the permit a license is being requested,not the Department of
be retiw to the city or twvtr that any 4iiaenoOs regarding the law or if you are required to obtain a workers'
Industrial Acridents. Should youthe number lined below. Self-insutad componiaa should enter[hair
compensation policy.please call the Deparmamst at
self-insurance license mtmber on the
City or Town Omdsd
The Deperanent has provided a space at the bottom
Please be aura that the affidavit is complete and printed legibly.
of the affidavit for you to fin out in the event the Office of Investigations has to contact you regarding the apPlioaDL
Please be sure to fill in the perm Micense number which will be used as a reference number. in addition,an applicant
that must submit multiple permidilcense applicatioaa in any given year.need only submit one affidavit indreating current
policy infonnadon(if necewry)and under"Job Site Address"the applicant should write"an locations fa__(city or
or marked by the city or town may be provided m the
town)."A copy of the affidavit that has been offtciallY stamped or ticensea Anew afrrdrvir must be filled tout each
applicant as proof that a valid affidavit is on file far license
figure o permits
year.Where a home owner or citizen is obtaining a 1p aw is NOTpermit not related o any ethis
business or commercial vemme
to burn leaves etc. said is NOT required to complete this iit8daviR
(i.e. a dog license er Permit ) person
ns would like to k you in advance for your cooperation and should you have any questions,
The Office o4lnveatigatio give
us a c�
shoo
please do not hesitate to
The Departments address.telephone and fax number.
The Commonwealth of Massachusetts
Department of IndtlsaW Accidence
Of&*d Invadtlitku
600 WL*0PS Street
BoM%MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Revised 5-26-05 wVyp/.maMz0V/till
CrIY OP SmmA
PUBLIC PR+OPElTY
DEPAXrUI T
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(rind hr an ammum"a ciewados Wade
is WOMWma wide dw IQ.s+4 t O � a�780 C!d sedim 1113
odWWj rd dw p wAWk ar _
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The debrb*12beVompod dbp
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The ddxls will be dispomd of is:
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PaflDucm TINS CERTffICATB TO
A$A MAT TEROFINFORRIRnum
Dan HTArley Ineurense Agency ONLY AND CONFERS NO RIGHTS UP19W THE Nn,EXTCATE
END
Chestnut Green, Suite 24 MOLDER_THI$CERTiFIGATE DOESN�-iAMEND EXTEND O
ALTER THE COVERAGE AAFOImED I!s' THE POLictES BELOW.
Seven Federal Street
Danvers 2�L 01923-3620 ;NpIC tl
phone= 878-7192394 Fax:97S-777-3306 INSURERS AFFORDING COVE RAGE
INEUNERA: Preferred HHutual...,...
NsuRERIi _Granite State__Inau:Kance I --____._.
le Brothers Construction WURFR0
art�aOlomex Kiley DAR .__.__......_._._.... �__
Danvers MR001923 RuvAERD.
COVERAGES
I NE POLICIES Of NSURANCE LMTFO I tLOW HAVE BEEN ISSUED TO TF1F INWR:D NAMEDABOVE FOR THE POLICV PERI00 NDICAIED NO WMI C TANDING
ANY REOVR"ENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DODUI DENT WTH IitSPECT TO\JHICH THIS CERTIFICATE MAY RF ISSUI OR
MAY PCRTAN.THE BISLIRANCtlV-WflOEO OY TII[PDL!CL BOEBCP:BEO MEREII MSUW=TO ALLTNF TERMS,EXCLUSIONSANDCOHDRIONE C'.f BUD"
PINICLES ACUREGATE LIMITS SHOM MAY IHAVL BEEN REDUCED BY PAID CLAB S � pp�Dy _ ..
' PDLiCY NUMBER DpT NMAWnY! DATE/815V00 �i�
LTR TYPEOFINSURANGE EIwHOCTU',iRF.NCE 4 30D000
GENERAL UAVAM 'C RENTED
A II x COMMERCIAL GENERAL LIAM ITY I CPP0130564252 10/16/06 i 10/16/07 PR6MISE$1'.o..�neAoels50000
1C NVIMADF iOCLVRI -MmEJCP1:'Lrya+APArsAAj 65000
r PERSONA..•':ADV WURY
—� O - ...•-I s 300000
GENERAL:L MEGATF S60
. 111 GG1i600000
GENLAGGRCGATF I gqWM�IT APPLIES PER. --
'$ POLICY ECf I IOC -
AUTOMOBILE LIABILITY GOMBIHEC BNGLE UMIT $
ALLCVMCD AUTO$ I I BODRYKII.RY S
SGHEOUI FO WTOS -
1 IHIREDAUTOS I BODILY IA.J.RY $
(for acua�o.i .
-PAOPEFrVt)AIAm*.
iGARAGELiABIUTY AUTO ONI,)_EAACCIDENT
ANYAUTO OTFERTIil4 EA ACC $
— AUTOOM.1 —AOC I$._
EXCI;SSIVMBRKLA LWINI.IYY EACH OCIA;RRENCE
I
CCCRi CLAWS MADE
I IOF.DIX:RmE $
RETENTIONWOMUR
IMPLOY Rs,LmN6ATIDN AM TM L''Mit,4' ER I _
EDPLOYER9'UABR)TY
8 WC2782020 I 06/20/06 06/20/07 [EL
EACHA:CIDENT $100000
I ANY PROPRICIORIPANINERIEX[fAJTIVF ---
'OFfHCERW NIRL4t=LUDED, ( �` ATTACHED NC PE DISU'F',=-FA 94-LOYEM$1000 DO
nya EBBWBfe uNAr ..-._�. .
SYd:IAL eRDVISIDNsIrem«, RA DISEAEi:-POLICY LIT $500000 '
I OYRfiR I -
I _
DESCRIPTION of OPERATWN$f LOCATNNLB f VEMIGLEe f EXa.USNN9 ADDED BY E NORBEYi]lTr EPECW.tNNP/s10N8
As per policies.
CEFMF4CATE HOLDER CANCELLATION
PDI:INFO $NOYLUANY OF THE ASDVE DESCRVLED POLICIR M CANCELLED BEFORE THE EXPIRATION
DAn THEREOP.TN MSMGROSMRMBLLSNI;i AVORMUML SO DAYSWmRF.R
For inEOrmation purposes only, NOTICE TO THE CIUMMATE HOLDIM NAMED T;)ME LEFT,BUS FAILURE TO DO SO$NALL
Please ual cat agency ficE,t for IMPMENOOBUGARMORLNBILITYDFANYRIADDPONTNBMSURERIMAGEm M
individual certificate.
REPRESENTATIVES.
AVMm♦tgs REBEflTATM
Daniel J � is
ACORD 25(2p011MO8) ®ACORO CORPORATION 1900