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79 SUMMER ST - BUILDING INSPECTION (2) r , What is the current use of the Building? if dwelling.how many units? Material of Building? Asbestos? Will the Building Conform to Law? AU T I Architects Name Address and Phone 40 Mechank's Name iO ` 9'7r�' g 3/ Q R r! Address and Phone 3it �'y/Uru f i3 . o g953_ Construction Supervisors License# r7803�=HIC Registration#�----- Estmated Cost roj S / Permit Fes Cakulatlon Estimated Cost X$71$1000 Residential permit Fee$ v Estimated Cost X$111$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are property 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 C► Q L. M ''211 a o F» , a -111 y' OF PUBLIC PROPERTY DEPARTMEINT Ki.NFJU"Dv5UA1 MAY00 t 20 WASMNGTON 57RESr•-SALLK%Lk% ACHlSLI-rS Ot970 . TEL 978.74S-959S•FAx-978.740.9g" F APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDIN ° 1.0 SITE INFORMATION Location Name: Building: Property Address:: 7 / su)q t 6 Prop"is located In a; Conservation Area Y/N Historic District Y/N i 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land ` Name: A /01 Address: •79 < Telephone: AOA 7193iff3 6 S z t 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING` BUILDINGS ONLY 4 i Addition Existing Renovation Number of Stories Renovated Change in Use New_ Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation a of existing building New Brief Description of Proposed Work: r t " Mail Permit to: 141VOILVVD 10.vo rnn 010 o04 LLII 0 n mlbnll,nr {QJ vV IJ VVL F Y Y Ilen0:138" MELOS AACORD, CERTIFICATE OF LIABILITY INSURANCE 12TE11060mYYY) 12PoBf08 PRODUCER THIS CERTIFIGATE IB ISSUED AS A MATTER OF INFORMATION B.K.McCarthy Ins.Agcy.Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 10 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Peabody ,MA 01960 978 532.5445 INSURERS AFFORDING COVERAGE NAIC III INSURED INBURERA: NGM Insurance Compan 14788 Melon Construction LLC INSURER B: Liberty Mutual Insurance Company 23043 c/o Faustino Melo,34 Jennings Circle INSURER c: INSURER 0: Peabody,MA 01960 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- 11FRAW um TYPE OF INSURANCE POLICY NUMBER MUCYEtTEOOYE YEXPIRATION LIMITS L DATE IMK=fM DATE MMID01Y11 A GENERALLtANUTY MPS23062 11126/08 11/26/07 EACH OCCURRENCE E50000D X DAMAGE TO RENTED t 00,000 COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR MEO EXP(My LTIP Pry) E1 O 000 PERSON.-&ADVINJURY $50,000 GENERAL AGGREGATE $1 00O DDD GENT.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COIAIOP AGO $I DDD DDD POLICY PRO• LOC A AUTOMOBILE LMIBILM MOH43926 6121106 09/21/07 COMBINED SINGLE LIMIT $ (EA..tlmeml MY AUTO ALL OWNED AUTOS SODRY INJURY E100,000 PeIPaI) X SCHEOULEO AUTOS (PU X HI I)AUTOS BODILY INJURY $300,000 X NON-0WHEDAUTOS PROPERTY DAMAGE $100,000 (P�r acuUnnO AUTO ONLY-EA ACCIDENT E GARAGE LWBILNT EA ACC S ANY AUTO OTHER THAN AVTO ONLY:: AGO S EIOESSAAMIMA LIABILITY EACH OCCURRENCE, LL S OCCUR CLAIMS MADE AGGREGATE S E E DEDUCTIBLE f RETENTION E B . TATU• _ OT 12/D4/08 12/D407 XMOS K - PORKERS COMPENSATION AND WC2348338762016 EMPLOYERS'LU,BIUTY E.L.EACHACCIDENT E100000 ANNyaYFIPROPM SERE%NERI ECVTA'E E.L.DISEASE-EA EMPLOYEE E100000 3PECI OGAEX LUD EL DISEASE•POLICY LIMIT $500000 OTHEII DESCRIPTION OF OPERATIONS I LOCATIONS I VOUGLES I EXCLUSIONS ADOEO aY ENDORSEMENT I SPECIAL PROVISIONS 978535-3994 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Mica Construction LLC DATETNEREOF,THEISSUMSMURERwUL P.AYORWU-L jD_ DAYS MITTEN do Faustlno Melo,34 Jennings NOIWE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 90 BHA" Circle MPOSE No MUGATION OR UABLLRY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Peabody,MA 01960 REPRESENTATIVES. AVT pA2ED0.EPRESEN7ATiYE ACORD 25)20DIMO)1 of 2 952910 �7�YM,w.w 'T/J•• RBU ® ACORD CORPORATION 1998 2006-12-08 13:10 978 532 2217 Page 1 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT 12C tt(.%99N';:JN$;HEFT•$.\t 04, .LIl1:19/C TF.t:97t:74>9S9! •F.i`t:978.74G9846 Construction. Debris Disposal Affidavit (required for all demolition atui renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.3 Debris, and the provisions of v1GL c 40, S 54; Building Permit # _ _ _ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111. S ISOA. The debris will be transported by: — — (name of hauler) I'he debris will be disposed of in (nlme of Iacillty) tom/ /t//1J i mldrCSa .ff C:1Ct LCY1 . �i_lAlbi: )I :�Clll:C +(]i7.IC1dC CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT :J]IURIEY DRtSL:ULL M. Ay st MC WA$iINGTONSTREET*SALe-w,MASSAC1n ui"1'1S01979 'ref:978-7454595 •FAx:978.740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers Applicant Information Please Print Leribly NaMe lBusiixsygrganizatioNlndividunl): /VLLo CS C©/V ST, GLC Address: �3 �"� t/Nr'yrS City/SrarG'zip: /) /9 C`1 Phone #: c'78 S Are you an employer?Check the appropriate box: 'type of project(required): L❑ 1 um a employer with 4. Q I am a general contractor and 1 6. Q New construction employees(full and/or part-tine)." have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : 7• ❑ Remodeling ship and have no employees These sub-contractors have V. ❑ Demolition working for me in any capacity, workers' comp. insurance. 9_ Q Building addition (No workers'comp. insurance 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions required.] officers have exercised their 3.0 1 am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions myself. [No workers comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.j t employees. (No workers' 13.0 Other comp. insurance required.) 'Ally upplicunt drat checks box n1 must also fill out the saeuon hcluw showing their workua'cumpenwtion policy inhamution. , I lomvuwnan who submit this affidavit indicating they are doing all work and than him outside contraetons must aututtit a new affidavit indicting such. �C,mtmior;that chttk this box most attachad an additional hm sbowing the name ortha wb-comraaors and their workers comp.policy infumation. I fun an employer that La providing workers'compenxadon insurance for toy employees. Below is the policy and job site information. Insurance Company Name: 3-x Policy N or Self ins. Lie. tt: Wr_ _C0..2-..O/.)o Expiration Date: 40 — o y— O7 Job Site Address: S7-Ilw lz,e ..5 CityiS1ate/zip: 5d1,.it2 `'/-,e O P7J 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.'vIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of , Intasngaliuns al'thc DIA for insurance covcra,,c verification. 7 do,hereby certify under the pains and pen�uhficr/olif perjury that the information provided above is true and correct. Si,,jwure Datc: 7 , official use only. Do not write is this area,to be completed by city or town official City or Town: Pcrmittl.iccnse p_ Issuing Authority (circle one): 1. Board of Ilcalth 2. Building Department 3.Cityffown Clerk a. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: __ _ _ _ _ . Phone N: J 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." Art 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,patmership,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." biGL 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, bIGL 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-contractor(s)name($),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 employees,a policy is required. Be advised that this affidavit 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. 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 till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pci nitilicense 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 affidavit must be tilled 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 burn leaves etc.)said person is NOT required to complete this affidavit. l'hc Oitice of Investigations would like to thank you in advance fur 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-N ASSAFE Fax#617-727-7749 Revised i-26-05 www.mass.gov/dia