3 SUNSET RD - BUILDING INSPECTION yy EITY OF S-AL --
PUBLIC PROPERTY
\ � DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET•S Atr.Iu.MAisAait;Sr=1-rs 01970 8.
TEL-978-745-9595♦FAX 97&740.9W
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: k>Z . 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: 7
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING. BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: Pe roor
Mail Permit to
r �
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
Address and Phone
� 61G
Mechanic's Name
Address and Phone
Construction Supervisors License
#*� ee '-6F 'GwOIC Registration#
Estimated Cost of Project$ Permit Fee Calculation
Permit Fee $ a 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 7 113lot.;
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KMBERLEY DRISCOLL
MAYOR 120 WASHNGTON STREET ♦SALEM,MASSACHUSETTS 01970
TEL:978-745-9595 ♦FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly l^�
Name (Business/Organization/Individual): nlu FN lam/
Address: � / l
City/State/Zip: L hone #: J7 — CT
9
Are yo employer?Check the appropriate box: Type of project(required):
1. am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).` have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t �• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.❑ Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work right of exemption per MGL I LE] PI bing repairs or additions
myself [No workers' comp. c. 152, §1(4),and we have no 12. oof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box most attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. n -� _
Insurance Company Name: l D rr i V e-aA =, InV f Ct ci2--.
Policy#or Self-ins. Lic. #: Mc 5�0 a 24;L Expiration Date: ��
Job Site Address: c� DV/l gd City/State/Zip: �Z_ehp-2, �� 01,97a
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 MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjuty that the information provided above is true and correct
mature: Z !/ L Date:
Phone# 0 7&aa;m1-/_3
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
i. . .z
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 hue,
express or implied,oral or written."
An 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,partnership,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."
MGL 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,MGL 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(s), 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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"(ili file O ur future permits or licenses. A new affidavit must be filled 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for 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-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/dia
ACaMP. CERTIFICATE of LlAbILl i Y iNOurvANUr os 29/2006
PRODUCER (603) 8B3-5528 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
CORRIVEA[1 INSURANCE AGENCY, INC. HOLDER. THIS CERTIFICATE DOESNOT' MEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
1tS MAIN ST
P p BOX :)69
NASHUA NH 03061-0369 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURE A:NAUTILUS
LONDONDERRY, MANCHESTER CONST SERV CORP INsuRERB:AIG
DBA: OLYI4PIC WsuRERc:PROGRESSIVE
15 TANGUAY AVE INSURE D:
NASHUA NH 03063— INSUREa E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REOUIREMEAR,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, POUC EFFECTIVE POLICY EXPIRATION
INSR ADO'L TYPE OF INSURANCE POLICY NUMBER DATE MMA?DM' DATE MM OUNY LIMITS
A R GWIERAL LIABIIDY / / / EACH OCCURRENCE S 4,000,000
DAMAO TO RENTED S 100,000
X COMMERCIAL GENERAL LIABILITY PR-MIS E c'nam.
12/09/2005 12/04/2006 MUD EXP An one arson S 5,000
CLAIMS MADE OOCCUR KC502722 4,000,000
PERE NAL A ADV INJURY S
GENERAL AGGREGATE S. 4,000,000
GEITL AGGREGATE LIMIT APPLIES PER: PROWCTS-COMP/OP AGG S 4,000,000
X POUCr ims F7 LOC
A X AU"OMOBILE LIABILITY 05/11/2006 05/11/2007 COMBINED SINGLE LIMIT $ 1,000,00p
(Es acclden)
ANYAUTO
ALL OWNED AUTOS / / / / (Pefpe on) F
(Par person)
X SCHEDULEDAUTOS
X HIREDAIITOG / / / / BODILY INJURY S
(Per accident)
X NON-OWNED AUTOS
PROPERTY DAMAGE F
(Per accident)
GA VAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANYAUTO / / / / OTHERTHAN EAAOC S
AUTO ONLY: AGO $
EXOES9(UMBR,ELLA LLAaUTV / / / / EACH OCCURRENCE S
DOCCUR ❑'CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE / / / / $
RETENTION S S
g WORXERIi COMPENSATION AND NC2791321 09/25/2005 09/25/2006 X TORRYLIMl q X
EMPLOYERS'LIABILITY 100,000
ANY PROIRiIETOWPARTNERIFXECUNVE E.L EACH ACCIDENT F
OFFICEMAEMBER EXCLUDED? mss / / / / EL.DISEASE-EA rMPLOYG9 S 100,000
fly",dandhe undel S00,000
SPECIAL QOV19IONS DEIUW EL DISEASE POLICY LIMB S
A OTNER ];NLAND MARINE OL/13/200,_ Dl/ /2007
%13/ 190,000
DESCRIPTION OF OPERATIONSA.00ATIONSNEHICLES/EXCLUSIONS ADDED BY ENOORSEMENT(SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
( ) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT
FAILURE TO DO SO SHALL IMP09E NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER,ITS AGENTS OR REPRESENTATIV S.
AVTWWED REPRES TI
d
%CORD 25(5001/08) (b ACORD CORPORATION 199)
�TM INS026 mlo8)m ELECTRONIC LASER FORMS.INC.-(800) .0545 Pn¢c I of
�/re {omrmaanme¢l!/ q�✓�aaaa�uaeCG
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 080145
Birthdate: 10/2611963
Expires: 10/26/2007 Tr. no: 8042.0
Restricted: 00
GEORGE VASILIADES
515 LOWELL ST
PEABODY, MA 01960 commissioner
i pp
�/te.yfarirmovuaea�i.o`✓tfaaat�u<Ae� I
>. .� Board of Building Regulations and Standards
t UP. HOME IMPROVEMENT CONTRACTOR
1 Registration: 124356
Expiration: 6/12/2007
Type: Private Corporation
Olympic Painting/George Co., Inc
George Vasiliado
515 Lowell St. ,.
m Peabody,MA 01960 Administrator
CITY OF SALEM
l• PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR - 120 WASHINGrON SmEjEr•SALF-K MAssACHLSEm 01970
1'Ei 978-745-9595 0 FAx:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
1n accordance with the sixth edition of the
State Building Code,780 CMR section 111.5
Debris,and the provisions of MGL c 40, 3
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,
l
lame of hauler)
The debris will be disposed of in :
(na a of facility)
5715— U xA)L / cc�(—
(address of faclluy)
signature of permit applicant
Jrluisal7.due