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18 SPRING ST - BUILDING INSPECTION -- �' '�� 9�-Q,/' PUBLIC PROPERTY '�"^ I DEPARTMENT KIMBERI.EY DRISCOLL MAYOR 1'V WASHINGTON STREET S A'`}\lA.ssAcxt;sr=I-rs 01970 1VL 978-745-959S• 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: /r s j Building: Property Address: Property is located in a; Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: — Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EVIS1I ur_ BUILDINGS ONLY Addition Existing Renovation t/2v f/ Number of Stories Renovated Change in Use s'O-A' 4z New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: C /V Mail Permit to: �/e What is the current use of the Building? f�cJ�r • .. , Material of Building? If dwelling, how many units? Will the Building Conform to Law? P Asbestos? Bib Architect's Name �os.e U' r' �-7 f� ii s� c�� 9�� pia Address and Phone o Mechanic's Name 2 Address and Phone.mil ov�<� S /�r�vLp/ �%• �l5' Construction Supervisors License# HIC Registration# �a Estimated Cost of Project$a y Permit Fee Calculation 5;I y Permit Fee$ _ 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 Date � oI N O 0 a i CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KIAOWALEY DWSCOLL MAYOR 120wtiH1NGroN STREET•SALEM NIAZACHLSEM 01970 1Vli 978-745-9595•FAX:978.740-9M Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111,S 150A. The debris will be transported by: o<o ce, (/o.Ly (nama of hauler) The d ebri s will be disposed of in : sfd j a (— A/t �y — (name of f—hty, (address of facility) sigttatu4ofrn applicant date ,Iebri>a17.duC ' 4 ACORD CERTIFICATE OF LIABILITY INSURANCE CSR JL DATE(MM/DD/YYYY) KILEYBR 06 21 06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dan Hurley Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Chestnut .Green, Suite 24 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Seven'Federal Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Danvers MA 01923-3620 Phone: 978-777-9394 Fax:978-777-3306 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Preferred Mutual 15024 INSURER B: Granite State Insurance Kiley Brothers Construction INSURER C: Bartholomew Kiley DBA 56 Conant Street INSURER D: Danvers MA 01923 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/UD/YY DATE MM/DDm LIMITS GENERAL LIABILITY EACH OCCURRENCE s300000 A X COMMERCIAL GENERAL LIABILITY CPP0130564252 10/16/05 10/16/06 P REMISES(Ea occurence) $50000 CLAIMSMADE 7XIOCCUR MED EXP(Any one Person) $5000 PERSONAL B ADV INJURY s300000 GENERAL AGGREGATE $ 600000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 600000 X POLICY PRO LOC ECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 71 OCCUR CLAIMS MADE AGGREGATE $ $ I DEDUCTIBLE I $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS f ER B EMPLOYERS'LIABILITY WC2781020 06/20/06 06/20/07 E.L.EACH ACCIDENT $ 100000 ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? SEE ATTACHED NOTE E.L.DISEASE-EA EMPLOYEE $ 100000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT s500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS AS per policies. CERTIFICATE HOLDER CANCELLATION FORINFO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN For information purposes Only. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Please contact agency for IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR individual certificate. - REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Daniel J Hurley ACORD 25(2001/08) ©ACORD CORPORATION 1988