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40 SUMMIT AVE - BUILDING INSPECTION (3) � , ' �L�1111�t1��w110 A/M�11011iD a11 ZiiE '" �•/�II mAl.i��yMq pMN'I�p CITY OF SALEM "°_�� . o.i. ' a o S'_ 1�L�L,� v � � � ,_.. ao�+w or.�a� e.�IMo�i pl�b r...p.. .t 1/�Ne� ��t ��P�Ip�aolyd 1� r / •' M�M��Iro11 Ma1 . tll��w V PMmR m: N�•a'�i Pl��A�l1.�.'A1qN IiOA. ��°y��PP�f� ��1�M 8idl�q,. COmbuot D�ok SINd. PooL 1�L�A@ A.L OYf'L�ffrL.Y i OOIMLl�.Y 1�0 AV�O�LAIIi M�IIOC�q TO THE �R OF�ILDWOB: ►. ��NPMd ��bp �PPM�� bt t pNnNt b bulld �oo0nf'hp,b tlr.foNowrq • / Ow�� tinM � �� iZ ' �ddiw l PhoiM �'�- Qs��wtn�t � tT {q-I 9� � � ;� 1 ArohM.a�. N.m. _�I`f�lni/a-�n 7 S� f� �iRP��r .�� / �ddiw l Pha» �2. CH-�tP_cH 5r—,S�t�w tM� 19�5 7G/�( - Ss`�7SsZ I�MdwMo� N�nr �fRUU�`2 CI�VI�; � �1d�lrw.a Phon. � � wti�e.A�d�p��t=Sn��t1�-s 11�Mtl d�p�► R��q,b►ho�r w�1�t�� b Irr'1 �� E�M� 7 � qr LiOor�__�UoN�• U ` �,� �� • = a � ��M �� noM o�wo�,c ro �e qo� °��`"""' _.�,✓��i�—� •n.�.=__.L�.�I�_�, �l„_,�/Isr,�,_ ��.�z_;,, /�! ' i ��f� �r� f�.�d121E- ��r-�'`'��_ � . � �� ._._ . ,. <, r IAR� IYG �� 1 . � � ' ,� � . �� Q � � � � '--,.� S � � � • �� . . � s � � �! � � �� . . � �. � I . - _ _ . .. . --~ - The Commonwealth ojMassachusetts �� . �` - Department of IndustrialAccidenls r� O/fle1 ql� .. ' 600 Washingron Street, f Floor Boston,Mass. 01I11 ! T'��Workers'Com eosatioo Iosurooce Arcdsvit: Buildio lumbin lectrical Contracton ..e,. n address: c�y staze: zio: ohone# work site locazion(PoII addressl: ❑ 1 am a homeowner performing all work myself. Project Type: ❑New ConsWction �Remodei ❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition :m.,- �❑ 1 am an employer providing workers' compensahon for my employees working on this�ob /' � .t� ;.! Yi�R e�.:a � _ � ayy. .;� comoanv mme: �r72C L/Y`�� ( C/11 5� �+ •c_9a4 F �, X ;�e'wr..��i i-�'j, � T-n-�"-�^ a 2 �5 ;�5. ' ' � � - � ., n:'" � ` , �d =�� : >n �'� i � .:c' °` ..' , > =.i .I M 1^^ nayy � �r^^ t�h': �Vv"/tY �'\�� k/'Y'��y ��'` tD�ll�,R�f��lFL ��'." ��5`��!"�� +,,.;��^-�� r �t.n� . ❑ f am a sole proprietor,general cootractoq or homeowner(ctrc%one)and have hired the conVactors listed below who have the following workers'compensation polices: comnanv name: - addresr cilv: � o600e Aa r � = y : . � s; �4: 1 .;. t�� .:, s.'d n � �" yax � .,. _ insu n x.,.t." �.Z' ++.�,; �:oeNCv'Iff ;°��"��.�`?l��"=i#�;?.4,�4; ,� •. : .,....�:., � -. ' - .. " .. ' � . . .�. . � . . . . , , . .. . , . . . , . ��'i��'kr 3 nw�u,�. cs'�Z'k+$�s*.fi�faiHY"siz�;'�"'�7�4.+�-.��5?ti,�`�'�s'^�.rr�r�a»i% comoaov name: � � � . . _ _. . _ . t*r«� 4 i�a .t,�.<'z�y+x;}�.'& i�:, e.,,,.'r' . �;i eddRst• ��`� r` � . � . . , . . �"; . [IM � � O Of.M! � ,• F !1 a�. . x � ^S t � '�'Y i�...�Y.� 4�.'�i . . _ 1 ' ;Y... 1 ! � �' - r :►1NFSe Failurc to securc coven�e u required uoder Sectko 35A of NGL i51 can kad lo t6e Impoaitbu of criminal peoaltia of�Me op to 51,300.00 inNor one yeen'imprisonment u well oe eivil peonitin lo the form o!a STOP WORK ORDER aod a Ilne of SI00.00 a d�y agoiust me. 1 uodentaod Ihat• cupy of thu smlemeot mny be forwarded la Ihe Otllce o(InvatiQatiom of 16t DfA for covw;e veriilutbn. /da hereby cn�ify under the pains qd pe raftia ojperjury that the injormalton provJded above ia lrue and corred. - Signamre � Date � Print n� Phone k oRicial ux only do nol write io t6u area to be completM by city or lowo ollicid city or towo: permiNlcenx N OBuildlog Departmeot ❑Ucemiog Boord ❑cArck if immediale responx iv required �Selcetmen's 011ice ❑Healfh Departmeol contact persoo: p600e k; �Ot6er � �«vuW SeP�'upl . I AC��2E�'., pT /'� /i, pqp [ 5p � [�� p��'+� - -- -- - ��R 1 �F�l.if1�� L�/'1La�L.0 ��-. � ��tl1'�/Yltl4r� onrel�,+inioon`�,v� 03/11/2005 PRO�UCER (g00)333-7234 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION EASTERN, INSURANCE GROUP LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE � 233 WEST CENTRAL STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NATICK, MA 01760 INSURERS AFFORDING COVERAGE NAIC# - INSURED Groom Construction Co. , Inc. wsuRean: Acadia lnsurance Company 324 Essex Street iNsuRERe: Swampscott, MA 01907 �Nsuaeac INSURER D: MSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN � 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 DD' rypE OF INSURANCE POLICV NUMBER P�LICY EFFECTIVE POUCY EXPIRATION UMITS �I GENERALLIABILITY CPA009695111 O3�LO�ZOOS O3�LO�ZOOG EACHOCCVRRENCE 8 � 1�000�000 X COMMERGIAI GENER4L LIABILITV - DAMAGE TO REN7ED E SO�OOO CLAIMS MADE O OCCUR MED EXP(Any ane person) E 15��OQ A PERSONAL 8 ADV INJURY S 1�OOO�OOO II GENERAL AGGREGATE E 2�OOO�OOO GEN'1.AGGREGATE LIMIT APPLIES PER: PRODUCTS�COMP/OP AGCa E Z�OOO�OOO ' POLICY X PRP � JECT LOC AUTOM061LELIABILITY MAA009695211 O3�LO�IOOS OB�LO�ZOOG COMBINEDSINGLELIMIT ANV AUTO . (Ea acciCenl) a 1,000,000 ALL OWNEO AUTOS BOOILVINJURY a A X SGHEDULEDAUTOS (Perperson) X HIREDAUTOS BODILV INJURY $ X NON-OWNEDAUTOS (Peraccidenl) ' PROPERTVDAMAGE $ (Peraccitlenp GARAGELIABILITY NUTOONLV-EAACqDENT S I FNVAVTO OTHERTHAN �ACC $ � AUTOONLV: qGG E EXCESSIUM62ELtALiABILITY CUA009695311 �3�10�2�05 �3�Z��z0�6 EqCHOCCURRENCE E LQ�QQQ�QQQ X OCCUR �CLAIMS MADE AGGREGATE $ ZO�OOO�OOO A $ I DEDUCTIBLE E X REfENTION E LO�OO E �' WORKERSCOMPENSATIONAND WCA009695511 03/10/2005 O3�ZO�ZOOG X WCSTATU- OTH- EMPLOYERS'LIABILITY /� ANY PROPRIETOR/PARTNEfLEJ(ECUTNE E.L EACH ACCIDENT $ I�OOO�OOO OFFICEWMEMBEREXCLU�ED? E.LDISEASE-EAEMPLOVE E Z�OOO�OOO � SPECIALSPROVISIONS belaw E.L.DISEASE-POLICV LIMIT E 1 OOO�OOO OTHER OE$CRIPTION OF OPERATIONS I LOCqTIONS/VEH�CLES/E%CLUSIONS ADDEO Rv FunORSEMENT/SPECIqL PROVISIONS � ' IFIC T OLDER AN E L SMOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E%PIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOH TO MAI� 3O DAVSWRITTENNOTICETOTNECERTIFICATEHOLOERNAMEDTOTHELEiT, R _ BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NOOBLIGATION OR LIABILIN OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. � AUTHORIZED REPRESENTATNE �� Rosemar Fulham/PMA ACORD 25(2001108) OO ACORD CORPORATION 1988 � CITY OF SALEM� MASSACHUSETTS ° �. PUBLIC PROPERTY DEPARTMENT � � 120 WASMINGTON STREET, 3RD FIOOR SAIEM, MA OI 970 ' �� TE�. (978)745-9595 Ex7. 380 FnX (978) 740-9846 �TANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, 534,I aclmowledge that as a condirion of Building Permit# , all debris resulting from the construction activity govemed by tlris Building Permit shali be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, S I SOA. The debris will be disposed of at: �`�`�� Location of Facility , G'l �_ igiature Permit Applicant Da FULLY complete the following infocmation: (PLEASE PRINT CLEARL� Name of Permii Applicant Firm Name, if any Address, City & State 1'he above statute requires that debris from the demolition, renovation, rehab or other alteration of building or struchue be disposed in a properly-licensed solid-waste disposal facility as deSned by MGL cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. L ` � �/ G � ' - 1sPPR0 D '• _ � Subject to appsov�i: y ' y'cLaez authoriLy h��vi,�g ju_�-as3ic�aca. CdT�'og 92�..EIl•�,i"3A.tiu. BARR F��D ��9��,�� _ �.� � PLt::� ?� R0�''7SG.'�L`(FO<ID' T7 :G`..i--'.t�� 1'"F:'. '� ;;.t AC Q: Fi"' 4i-73rCGTiufi C�;:�_o. � . � l; 3�YcCTiL� ^ 1!' �U3 c;i"'i0 A �/ '�YEi AP:DINSP'::i10 �-VF'ninF�FTECC::i:'J� R E S I D E N C E � -,ld1T.7HE EIRECUDF.. , � . � � � ` SALEM, MASSACHUSETTS 24 1„C,4fi`C� 2 ��5 P & � WA�DLE� l �c��cTs �.c � � , 32 CHURCH ST. � � SALEM, MA 01970 . , -� 978 - 744 - 8982 �X ( S�' 11�1C� i EXISTIt.ICs SQUARE FOOTAGE a�° -.R . � � FIRBT FLOOR 1048 SQ.FT. � `n � .. . BEGOND FLOOR Bb4 BLi FT. �/ � 8UUS-TOTAL 1899 BCi F?. �.- � \J � . . . � . � �.�� PORCHEB /BTAI� bm 8Q-FT. � � � � . tOTAL � 1949 BQ.F?. � f n M-N�— ��/ U � � aEDRoori � c� _____�_______ ___" - I]'-9•x 1m��9" � � /� . i___-�__ �� . . � "i . � � � i � �� '- B. e . . � �� I c saTyRooM c � � T ��,a . ,.�„ pp � . m � m . . II N 1 . � � . , i m � � m - ' p ' �k _ � � A�'A 1 � I � � � � B9DROOM � `______________�_____- ____ ��..0��x Va�.9�. � 24 MARGN 2mm5 � 7e,_i� � � rr�� u�� ARGHIT�G7S LLC 32 CHURCN ST. SALEM, MA (d1970,.. a SECONp �LOOP PL�4N 9�8 -�4� - 8982 82 SCALE: I/8" = I,_m" I � � � . �XfS�' f1�lC� Exisrirt� sauar� Foora� �-�-8. FiRaT �ooR i�aa sc.fr. � � .. . BEGOPID FLA7R 8S4 8GL FT. . � . SUB-TOtAL 1899 9Q FT. � . . � � � �� h� � � � PORGHEB/8TAIR8 80 8Q FT. � �. � 'h�" I I I - TOtAL � 1949 9Q.FT. � . , _ ' � , � � � � ; :� � ; � � ;; � �\ � . � . DIN,MG j,.ROOM . . _ � 1 \ (� a-aF � , . _� _ KITGFIEN � • � � ` � •,, i�._�.:n,.m„ � — m ++ � � � � � , mIBRARg - p � � � C� - �6� � c � ��;_�,�_,�«-, �el��s`f�� r s �r C � �R \'/ a � 24 MARGI—I 2m�5 zB,_i,� P f T1"r r41�1 � UJ,4RD L E Y ARGHITECTS LLG 32 CNURCH ST. SALEM, MA m19�0 a �IRS7 FLOOR PLAN 9�8 -�44 - 8982 Asl gCALE: I/8" = I'-�" � � � � �� - ff- � � � � � � � U � � � � - � � � � tl_�_i - --------------------------- � , h � � Q m � 0� ao �4 �AR�� 2m�5 ----------------------- - ao --- i�( Ti��4N � UJ��'DL��' ARGH17ECt9 LLG 32 CNURCN ST. SALEM, MA 019'10 a �RONt ELEVAtION 9�8 -�44 - 8982 �3 SGALE: I/8" = 1'-�° � � � , �-�--� � � � �— ll�l � � i � � �C � � � � � � � � � � � � ------------------------------ ll9.t �I�II1_IL�11JI�I � �'^ � � . I�I � � m . V/ �0.J11 e^p/ � . . . . . . i-F�— , '""""__'___"__"""'___""'___ . . � . . �IWII � �� .. I�I �� 24 MARGN 2mm5 -�1-� �� ----------------------- ----- �f Tl"� � U1�4i�'D L��' i � ARGHItEGTB �LG 32 GNURCN ST. SALEM, MA m1970 a S I D E E L E 1/A 7 f ON 9'18 -'144 - 8982 SCAL�: 1/8" = I'-�" . � � � _ �--�-� � � � �- �9J � � � � � � � � � � � � � � � V�l ' -------------------------- �..1--I. �(p/�C� _ � N �Y/ 'Q m � � � 24 MARGN 2�m5 --------------------- ------ � �' f Tl"��N � - UJ��'DL�Y � � aRc�fi7�crs LLc 32 GNURCµ S7. ' SALEM, MA (d1910 a B,4CK ELEV�,�'ION 9�8 -�44 - 8982 B5 SCALE: I/8" _ !'-�" � � � ( y � � c� . �— 1�- llIl1 � � � 3 I � � � � � � � � — � � � � .:: . , 9.U1 - -------------------- h � •^ -v �7� m i-l- � '___"'_""__________ . . _ k,. � I I 24 MARCN 2��5 �--------------- --- }� f Tl"C,��l � l�J�i�'D L�1� ' ARGHITECTS LLG 32 GNURCH St. SALEM, MA fd19�0 ,a SIDE ELEVATfON 9�8 -�44 - 8982 SGALE: 1/8" = i'-�° � � �