96 SWAMPSCOTT RD - BUILDING INSPECTION (5) "' °�'� �� PUBLIC PROPERTY
�"� DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STRFzr•SALEK%iAS&AGHLsLr S 0i970
T'EL-978-745-9595 • 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 ti
Location Name: 9 Building:
Property Address: qG S,,,�,aMp5cott
,IOm Mini, (-)K IT �
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: WoSCA 12C CC.
Address: A .
hY t"r_ q
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN OfISTtNG BUILDINGS ONLY
Addition U`A. Existing
Renovation ✓ Number of Stories Renovated /
Change in Use New .MA
Demolition N Existing q0Cq
Approximate year of Area per floor (so Renovated SA09-
construction or renovation
of existing building J ® New
Brief Description of Proposed Work: // / '' 1
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(I)S'P"-A 2060 SOtc - 8 3y®6 s,61104
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Mail Permit to: nn l n
What is the current use of the B ilding? / + 16
Material of Building If dwelling, how many units? A
Will the Building Conform to Law? /���` Asbestos?
Architect's Name J Pic, q
Address and Phone ( j-1� - r a�Z'-2-
Mechanic's Name
Address and Phone % °
Construction Supervisors License# yGG HIC Registration#
Estimated Cost of Project$ Permit Fee Calculation
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 X —
Date
y t
—- - - - _ -- o- \ -- _ a — - --- ----- -- -
CITY OF SALEM
` PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET ♦ SALEM,MASSACHUSETTS 01970
TEL:978-745-9595 ♦FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information r/f Please Print Leeibly
Name (Business/Organimtion/Individual): Gy `]D1 !c- n� (�
Address: ( I Xil\n I ���1 l T QST M �ry1
4 . W`l(3�) �
City/State/Zip: Y �', Phone M 60-567— E� C]I
Are you an employer?Check the appropriate box: Type of project(required):
1.VI am a employer with 4�20 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. _ ?• [21 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
required.] officers have exercised their 10. lectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.ETPlumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.[_1 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► T //�•
Insurance Company Name: / t !^ ad I Cl. I IJ
Policy#or Self-ins. Lic.#: o Expiration Date:
���'
Job Site Address: % V •I ity/State/Zip: 111/(EJ►1 /f 1!T
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 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$250.00 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 7cer�d 'Zundee;oi a ena s of rjuty that the information provided ab a is ue and correctSi nature: Date:
/1` G�
Phone#:
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
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."
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 commonealth 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 on file for 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 burn 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
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
Weaw.au.yhats ' %twsancH�sEM01970
�/AYot l�Wtiwmc'rcu+S�[wFbT 0 SuE�4' .
To:973-74S-9595• FAIL 978-740-9946
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 MGM c 40.S 54.
Building Permit M is issued with the condition drat the debris resulting from
erly licensed waste disposal facility as defused by MGL c
this work shall be disposed of in a prop
111,S 150A.
The debris will be trans/ported by:
Z"/V��
(same of liwler)
The debris will be disposed of in:
(name of fxility)
drcaa of facility)
s of pemlit applicant
"
DES ANCTIS INS Fax:7819335645 Sep 18 2006 13:28 P. 01
OP ID L DATE(MMIDDmm�
ACORD_ CERTIFICATE OF LIABILITY INSURANCE GVNIN-1 09/18 06
pnooucER T
HISERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
AND CONFERS NO RIGHTS UPON THE CERTIFICATE
DeSancti.S Snsu]Caf10E+ AgCy, Inc. ER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
De CTatis l Park THE COVERAGE AFFORDED BY THE POLICIES BELOW.
MA 01801 NAIC 0
Phone: 781-935-6480 Fax:781-933-5645 RS AFFORDING COVERAGEINSURED I Acadia Insurance C any
B: ^^= L IndoettY TA-. Co.
C:G.V.W. , Inc.
120E HSostongtOn NIX 02128et D:E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWfTHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN.THE INSUMNce 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.
INSIR LTR NS TYPE OF INSVRANC6
POLICY NUMBER DATE M D GATE M LIMITS
EACH OCCURRENCE $ 1 000,000
GENERAL LIABILITY
A X COMMERCIAL GENERAL LIABLOY CPA009215913 06118106 06/10/07 PREMISES(Ea S250 000
CLAIMS MADE XQ OCCUR MED E)IP(0-y m PeI=i) E 5,000
PERSONAL&ADVINJURY $ 1,000 000
GENERAL AGGREGATE 52.000 000
2 000
GENL AGGREGATE LBAITPPPLIES PER PRODUCTS.COMPlOP AGO 000
POUCY X W Lam'
AUTOMOBILE LIAWLT/ COMBINED SINGLE LIMIT I;I O',00,000
(F�aoddw*
ANY AUTO
All OWNED AUTOS BODILY INJURY S
A X SCHEDULED AUTOS HAA009213813 06/18/06 06/18/07 (Pa'P" )
X HIRED AUTOS BODILY INJURY S
(Pa amdA M)
X NONAWNEDAUTOS
PROPERTY DAMAGE S
(Pv am -t)
AUTO ONLY-EAACCIDENT 6
GARAGE LIABILITY FA ACC S 1
ANY AUTO OTHER
AGO 6
EACH OCCURRENCE $5,000,000
E(CESSHIMBRELLN UABILRY
A X OCCUR � CwMSMADE CUAO09216213 06/18/06 06/18/07 AGGREGATE s5,000,000
S
S '
DEDUCTIBLE
S
RETENNDN $ -
X TORY LIMITS ER
WORKERS COMPENSATION AND
B EMPLOYEWLIASILIn WC5310004 07/18/06 07/18/07 E-L.EACHACGIDENT SSOO,000
O PROPR OORIPM LNERw=UTNE 2 E.L DISEASE-EA EMPL 5500,000
ICERfMCkARFR IT yyeesS OawT4a�naeT E.L.DISEASE-POLICY LIMIT s500.000
SPECIAL PROVL410NS Delve"
OTNER
DESMPTION OF OPERATIONS LOCATIONS VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
PROJECT: 96 Swampscott Road, Salem, MA - Unit #9 .
CERTIFICATE HOLDER CANCELLATION
71ig
F THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EID'IRATI
,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITSEN
CERTIFlCATE HOLDER NAMED TO THE LEFT,BUT FAILURE TD DO SO$HAL
L
Grossman UOATON OR LIABILITY OF ANY MIND UPON THE INSUREIy ITS AGENTS OR
mpscott Road Unit #9
MA 01970 P ENTATIVE
10 ACORD CORPORATION 11