56 SUMMIT ST - BUILDING INSPECTION K�
.: -PL*M*MT-eE f;L-E4�-APPROVED BY T+IE
1NSPECT.OR ,PRIDR TD A PERMIT BRING GRANTED
CITY OF SALEM
No. '�_ 'p Date
Is Property Located in Location of r
the Historic District? Yes_No_ Building
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, eroof, nstall Siding, Construct Deck, Shed, Pool,
Repair ep ace, Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name R9L 8;Alz? C T/EN�OU/�T
Address & Phone ASV M A4 tr- S�77: 7, � 712 3
Architect's Name
Address & Phone f
Mechanics Name �S
Address & Phone
What is the purpose of building?
Material of building? If a dwelling,for how many families?
Will building conform to law? Asbestos?
Estimated cost y'BO City License # N A State ' ense # 090 3el i
U,Q Home Lie. Improvement -Signature I latl9s3 X Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�rMt�rlC Dt-» c1f/ho�sn A ✓y /lm�/�lf/-«- ir/�u/ �OJs�LS/�,CG:
MAIL PERMIT TO: 4yzWa `%f4a 3 X g7E,LLA✓G_S Cff? 019 6o
No.. /Ie
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
2-Q
APP tOFD
INSPECTOR OF BUILDINGS
1
Client#: 13844 MELDS
CORD. CERTIFICATE OF LIABILITY INSURANCE 12107/OSDnyrrl
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
B.K. McCarthy Ins. Agcy. Inc. 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#
INSURED INSURERA. National Grange Mutual Insurance Co. 14788
Melos Construction LLC INSURER B: Liberty Mutual Insurance Company 23043
c/o Faustino Melo, 34 Jennings Circle INSURER C,
INSURER 0'.
Peabody, MA 01960 INsuRERE.
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 1"HE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN ADD' POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR NSR TYPE OF INSURANCE POLICY NUMBER Y
A GENERAL LIABILITY MPB23862 11/26/05 11/26/06 MOCCURREN� SIOIRENCE $500000
ENTED SSOO OOOX COLIYERCIAL GENERAL LIABILITY IrGLAIAIB MADE a OCCUR one person) S1 O OOOADV INJURY S500 000REGATE S1 000 000GEN'L AGGREGATE LIMIT APPLIES PER: GOA1PIOP AGG S1 OOO OOO
POLICY71
PRO LOC
A AUTOMOBILE LIABILITY M9H43926 09/21/05 09/21/06 COMBINED SINGLE LIMIT S
(Ed.c,idbnl)
ANY AUTO
ALL OWNED AUTOS BODILY INJURY S100,000
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS BODILY INJURY 5300,000 '
(Per eucldem)
X NON-OWNED AUTOS
PROPERTY DAMAGE S1OO,000
IF or acadenl;
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY. AGG 5
EXCESSNMBRELL LIABILITY EACH OCCURRENCE 5
�A I
OCCUR u CLAIMS MADE AGGREGATE 5
5
DEDUCTIBLE
RETENTION $ TH 5
B WORKERS COMPENSATION AND WC231S338762015 12/04/05 12/04/06 X TQFY WC
IIMIT FR
EMPLOYERS LIABILITY E.L.EACH ACCIDENT 1 51 OO 000
ANY PROPRIETOWPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE 5100,000
If yes,describe under E.L.DISEASE-POLICY LIMIT I S500000
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Peabody, Building DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN
Inspector NOTICE TO THE CERTIFICATE HOLDER NA TO THE LEFT,BUT FAILURE TO DO SO SHALL
City Hall, Lowell Street IMPOSE NO OBLIGATION OR LIABILITY F YKINDVPON THE INSURER,ITS AGENTS OR
Peabody , MA 01960 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001108)1 of 2 #M49578 LEG 0 ACORD CORPORATION 1988
uul c�lsnnw py I
096L0 vW '3Pogead
-'dIC S`DNINNAF 7C License or registration valid for iudividni use only
019yy ougsneS before the expiration date. If found return to:
NOLLO)Ad1SNOO 5.O13A Board of Building Regulations and Stnndards
One Ashburton Place Rill 1301
j uogeiodio0 3upgell pll -adAl Boston. Ma. 02108
900Z/9Z/9 .uopendx3
£9690L :uoileulsl608
8010H2llN001N3W3A08d W13WOH
spiepuelS pu¢ 5uippnfl yr p.ieofl 999000 __ 1
opvan�yzxoiy fn r y narniovuacoo �: .
Not valid without siguanl rc
�l
P
4
5'
iauoleslwwo0
I 096LO VW AO09V3d 00-35,000 cf enclosed space
31O211O SONINN3f K (MGO C.112 S.e0y
O13W N ONI1Sf1H3 to-Masonry only
00 ;pe»N78e2i 1 G-1 &2 Family Homes
Failure to possess a current edition of the
sit dx Massachusetts State Building Code
0 99 L6 :ou Jl LOOZILO/£0 I 3 is cause for revocation of this license.
996 L/LO/£O :01eP91j!8 1
£6£090 SO aagwnN p
iJOSIA83dIIS NOtion iSNOO :asuaoll ail
DIG SAFE CALL CENTER: (688) 344-7233 � J
S
{Q_
— 1
CITY OR SALEM, MASSACHUSETTS
• ' PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RD FLOOR
SALEM. MASSACHUSETTS 01970
STANLEV J. USMICE. JR. TELEPHONE: 978-745-9593 EXT. 3a0
MAYOR FAX: 978-740-9046
Salem Buildlna Densltrtmpn�
Debrla PfooW Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
(Location of Facility)��'/(//
Signature of Applicant
_3/ o
Date
The Commonwealth ofMcssaehusetts
Department of Industrial Accidents
O,o?ee ofln►restigadons
600 Washington Sired
Boston,MA 02111
www massjMVA a
Workers'Compensation Insurance Affidavit: BuBders/Contractors/Elect idans/Plnmbere
Awlicant Information Please Print Legibly
Address:_ n7`r•i//VAG C< m -- 7-r�y�.�,�
—.._
City/statemp: B 48w Phone# 979L
Are you in employer?Check the appropriate hoxt Type of project(required):
1.❑ I am a employer With 4. 12 I am a general contractor and I
employees(M and/or part-time).* have hued the sub=wnuaclors 6. ❑New oonstractioa
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
ship and have no employed These sub-contracron have S. ❑ Demolition
worl®g forme in a>qlcapacity.. wo comp,•ltultranc. 9. [�Building addition
[No workern'comp,insurance. 5. ElWe are a corporation and
nqutued ofliceca have exe rsod ilea 10.0 Eiectrical repairs or additions
3.❑ I am a homoowne=.doirlg all work right ofesemptiou per MGL' 11.�Plumbing repairs or addition
myself [No wodwW,comp c. 152,41(41 aid`are have ao 12.0 Roofrepaaf
iisumance requireQ t. employees "[PIo worlraa! ; 13.❑ Other
conga.inallrancx regniied j
;Any epptic®t thel cbecb box Mr rout plro all olt tqe eeWon below showing theu,worlyq�'omgKasEos➢eHoy inEoim�don;
t Homeowner.wbo submit eds�a6davit isdieitiog®ey em doing all work cod fim hiiaaitade melon mad such
tCoutrxlxs the cheek thb boi'mist efteched o edditiomt*test showing the tome 6fewsebanlVr<Yas end axle workers'cane,pohey intaterat n,
I am an employer dwt Is providing worksra'eompemokn b►swsuW for ary en yf0AL Below Is th policy aadjob sJAe
Informs"
Insurance Company Name: 9• k. Mc- LA oz 77t Y Te/5 SLY
Policy#or Self-au.Lic.# Ul L 31 S 3 3 R'7 4 2 a/ 5— Expiration Date:_
Job Site Add =- 5 L f/1&jL 5`l— - City/Statraip: ,Si9/-�f`—!
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Fau7ure to weirs covens as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine trp to$1,500.00 and/or one-year imprisonment,as wen 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
Investigation of the DIA for insurance coverage verification.
1 do hereby rthspabna andpenabin ofpeya)`that the informadon pmvldcd above is anus and cornet
Phac#:
0,@feelal uta only. Do nor wrke In MY area,to be eoarpkted by eLy or ow ojk4L
City or Town: Permit/Idane#
Issuing Authority(circle one):
1.Bond of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector !.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
compensation for their employers.
Massachusetts General Laws chapter 152 requires an every P ea>s. �service
(Mother under any contract of Luc, .
Pursuant to this statute. an sa yrlrrya is defined "...every P . _. . . ,
or implied,oral or written."
An employ®is defined as"an individual,parmersb*association,corporation dr other legal entity,or any two or inure
m a pint enterprise, of a daceased employer,or tLa
asa including ate Meal gal a tity er . lo era. However..the
of the foregoing estgaged� . . association or oaten legal entity.empbyiog e� Y
receiver or trustee of an individual,partnership, and who resides therein,or ate oaatpa�of the "
owner of a dwelling house having not more than this aparrmals
dwelling house of another who employs persons to do maintenance+construction or repair work on such dwelling house
or on the Bounds or building a Jfteum
hereto shall not because of arch employment be deemed to be an employer.
MGL chapter 152,425C(61 also states that"every state or local licensing agency shall withhold the lasaanee Or
to t a bmdaess or to construct buildings V the commms"Mb for any
renewal a license or perms o� evidence of Compliance with the insurance coverage required
applicant who has not produced acceptable
Additionally,MGL chapter 152,4uC(7)states"Neither the coimnonwealth nor airy of its political subdivisions the insurance
span
enter into any contract for the Pace of public work until acceptable evidence of compliance with the insatance
enterequi into any of this chapter have been presented m 90 CO aracting apthonty"
Applicants
lion affidavit completely,by checking the boxes that apply 0 Your situation and,if
Please fiU,out the workers` ct*a)compensation with their ceitificate(s)of
��,,Rypply sop contcactoi(s)naune(s),addresses)and phone partners)along with no emploYees other than the
brorsuee; Limited Liability ComPaniee(LLQ or Limited Liabt7ny Partnerships(I I P)
members or parmas, are,not required in carry workers' compensation msmaua' If an I LC or Id p 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 bs sure to sign and date the atfldav& The affidavit should
for the permit or license is being Mptated,not the Department of
be returned to,the city or town that the application the law or if you an required to obtain a workers'
Industrial'AccideWa Should You
n the Department at the number
ouhave any questions iegardmB
to ljsted below. Self-inwred companies should enter there
compensatioapoltcy,P_.. ber on the `to
self-insuraaeelicense i
im
City or Town OffA Ws
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 p out tl saevent QOffice owbe used as a reference number. In addition,an applicant
tigations has in contact you regarding die aPPHCML
Please be sun it fill in the 1>�e app��in any given year need only submit one affidavit indicating current
that arast submit amifn pE1� the app&.M
policy information(if necessary)and under"Job Site Address" or insulted by thshould write
city "an locations be p o (he or
"A of the affidavit that has otf3ciaUy stamped the or town may be provided to the
town} copy or licenses A new affidavit nmstbe fidh�out each
applicant as proof that a valid affidavit is on file for future permits not rdesed;to arty business or oammercial venture
ear.When a borne owner or cid m is obtaWn s Bane or permit
y to burn leaves etc.)said person is NOT required to complete this affidavit
(i.es. a dog licemeotpermrt
The Office of Investigations would l&c to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to gin as a call.
The Departramrs address,telephone and fax numbs
The Commonwealth of Massachusetts
Department of Industrial.Accidents/
Office of Investigations
600 Washington Street
Boston,MA 021 It
Tel.#617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
pevised 5-26-05 wwwmws.gov/dia