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2 TRADERS WAY - BUILDING INSPECTION (6)
What is the current use of the Buiidi ? }6UrC61t r.• Material of Building?Who �Yavw If dwelling,how many units? Will the Building Conform to Law? Asbestos? Architect's Name L m H F}ssocia-teP PA Address and saO0 -Me,v"dlw Plwv Dwl ,^tc ql�) SN'>`—Ood'7 Mechanic's Name Chic NA Address and PhoneeDh O I�U ) Construction Supervisors License# CS 9 9l0� HIC Registratbn# Estimated Cost of Project S q 13t 67 7 Permit Fee Calculation Permit Fee ll �� "'r ' Estimated Cost X$71S1000 Residential Estimated Cost $1141000 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 Pe to build to the abovesta specifications. Signed under penalty of perjury Date 's F� av y � o 0 � •• cti7 - s CITY OF SALEM I PUBLIC PROPRERTY iD Dom/ov DEPARTMENT \l.�fYn l?O Vt�A91INt,:JN S fBEET •SAUA1,5tMiNCi1l iL rl i;l197-. 'rn,978-745.9595 .F.":978a4F9846 Construction Debris Disposal Affidavit (required fur 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 vtGL c 40, S 54; Building Permit Al _ __ 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: -✓H h Qwt G �ct.S lQ __--- me of hauler) The debris will be disposed of in t -- (namr of facility) VV 'i ;a:rcie of fu':1,ty) a8 0? =� CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ;UxtI1::RLEY URBCOLL \I:avoR 120WASHINGIONS"rl(ELT*SALEM,MASSACIRSEI ,01970 lla_978-745-9595 •FAX:978-740-9846 Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers A i licant information Please Print Le ibly Name(13ucineWOrganizuion/Individual): ( G' Address: q dn� // City;State/Zip: I d� MOO Phone Arc to an employer?Check the appropriate box: 'Type of project(required): am a employer with C 4. ❑ I am a general contractor and I 6 New construction 1 c ployces(full and/or part-time).' have hired the sub-contractors ❑ 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ 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 10.0 Electrical repairs or additions required] officers have exercised their 3.0 1 ate a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workcrti comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required] t employees. [No workers' 13.0 Other comp. insurance required.] '.4vy applicant that chucks box rtl must also fill out the section twlow showing their workus'compensation policy information. 'I lomenwners who submit this affidavir indicating ihcy arc doing all work and then him outside contractors must submit a new af",davit indicting such. �Comracturs that check this box must attached an additional sheet showing the none of the sub-contractors and their workers'comp.policy information. l aar, on employer that is providing workers'cornpensation insurance far my employees. Below is the policy and jab site information. Policy 4 or Self-ins.Lic. 0: V Q .. .D ._ Expiration Date: d Job Site Address: I CityJState/Zip: SAPA Ma Dq l o Attach a copy of the workers'compensation olicy 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 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 may be forwarded to the Office of Invcsti�' ens u e Dirk for insurance coverage verification. l dr here n er t p tins and penalties of perjury that the information provided abov is trite and correct. See: ;use e: Date: Phone:;: Official use only. Do not write in this area,to be completed by city or town official. Cityor'Town: Permit/Licensed _.. .-._-- Issuing Authority(circle one): 1. Board of health 2. Building Department 3.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other _ Contact Person: Phone#: 1 Information and Instructions E 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 ;n ajoint 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 rill 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 contirnhation 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 Offlcials 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 till in the pennit/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;s obtaining a license or permit not related to any business or commercial venture (r.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I'hc 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-u5 www.mass.gov/tfia 'I ACORD CERTIFICATE OF LIABILITY INSURANCE CSR MW DATE(MWDDNYYY) CONSE-1 Ol 11 07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Homer T' Brown Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 298 Walnut Street HOLDER-THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 600613 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Newtonville MA 02460 Phone: 617-964-3355 Fax:617-796-8833 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A, The Travelers Property Casealt INSURER B: Commerce Insurance Co - Construction Services Group inc INSURER C: United States Liability 7 Lincoln Street #215 INSURER D: 1111mie Union imurance -AC8 Wakefield MA 01880 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. MON LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMID DATE l MMDIDIY1' LIMITS GENERAL LIABIUTY EACH OCCURRENCE $1,000,000 D X COMMERCIALGENERALLIABILITY G21983962002 01/12/07 01/12/08 PREMISES(Ea ecwrelrca) $50,000 CLAIMS MADE FX]OCCUR MED EXP(/Ny am person) $5,000 PERSONALS ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E2,000,000 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT B ANY AUTO MV3497 01/12/07 01/12/08 (Ea accident $1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per pan;an) $ X HIRED AUTOS BODILY INJURY NON-OWNEDAUTOS (Per accident $ PROPERTY DAMAGE $ (Per accident) GA RAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANYAUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLALIABILITY EACH OCCURRENCE E5,000,000 C X OCCUR CLAIMSMADE CUP1102646B 01/12/07 01/12/08 AGGREGATE s s DEDUCTIBLE $ X RETENTION $10,00O E WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIABILITY A ANY PROPRIETORIPARTNERIEXECURIVE 6RUB958X7960-07 01/08/07 01/08/08 EL EACH ACCIDENT EIOOOOOO OFFICERIMEMBER EXCLUDED? EL DISEASE-EA EMPLOYE $1000000 If yes,devsibe under E.L.DISEASE-POLICY LIMIT $1000000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS SampQ certificate 2007 CERTIFICATE HOLDER CANCELLATION SAMPCER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 DAYS VAUTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Sample Certificate IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108) ©ACORD CORPORATION 1988 R �/e �mnn<an.oealll o�✓l�o�oac�aaelC N Board of Building Regulations and Standards Construction Supervisor License License: CS 94964 Birthdate: 5/6/1971 Expiration: 5/6/2010 -"a Restriction: 00 CHARLES CANNON 7 JOSEPH ROAD FRAMINGHAM,MA 01701 Commissioner I .. ........ .. J (1 CITY OF-SaA3 L&E,1VIL -.- PUBLIC PROPERTY DEPARTMEINT �. O�ISCI)IJ. &m&K%l%ssmala:sasrm 01970 TM-M74S.9"S 9 FAX M740.9616 'FOR THE REPAIR. RENOVATION, CONSTRUCTION, DEMOLITION,OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: THp �,, Building: Property Addreax--- - 1 ra Berl Sa M Property Is located In a;Conservation Area YIN Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: �ouis 6 Ra�4P2±a MCu4dtj Cdly I�us�ceS Address: (, t o 0 la uiav r-, 20 04 :S e v, ,.}own PA 110(o Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN EX181ING BUILDINGS ONLY Addition 40 Existing Renovation q,,S Number of Stories Renovated Change in Use IV 0 New eD Demolition Existing 00400 Approximate year of Area per floor (sf) Renovated c construction or renovation of existing building New Sdd Description of Proposed Work: Ccnuev}'V j av\ ex,�{ "A5 6 -ou%,cj ROLAI ` Lkwh�� t�4lIS , flc) Gu I*/Ac S JrGct, I�Sli,45 u+��r� Sid S_pr%.,u<.-- l,eoAI re(aeJ�9 JPev Cc e IQyouF NcniJ Ce�I �yJ�(�laIT1� U-)&Lj �InokA Ct,nA oonn �Jeu) OAcL, c L e veP . F x� iw CQP4 S ')ro I v1G� PTIS Lot re awf fd '� Caw-Vt- -claoc�kik-f qWU li k1ih -- Mail Permit to: