1 VINNIN ST - BUILDING INSPECTION CITY OF S I-A M
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APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
JINIPORTANT: ,%pplicants must complete all items on this page
SITE INFORM ttTION ,+�.�yr,
.� _ Y
Location Name �"Al (dl `7' Building d57rM s'K / tc7/�1/.�l��' Hcm
Properly Address -
Located in: Conservation Area / Historic district
APPLICATION DATE L 2` S^` 0
Use Groups
(check one)
Group Homes 123 IZd_
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) Al _
New Building_ Assembly (restaur:mts & clubs) A2r_A2nc_
Addition Assembly (churches) Al _ -
Alteration Business B
Repair/Replacement_ Educational E_
Demolition Factory (moderate hazard) FI
Muve/Relocate Factory(low hazard) F2_ O
Foundation Only High Hazard H_ Qi
Accessory Building Institutional (residential care) 11
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile N4 _
Storage SI _Moderate Hazard W
Storage S2 Low Hazard
Ivo snot, 114PA,e �_
ON'NI•'RSIIIP INFORMATION(Please t E or Print Clearly) `rte
OWNER Name nur�v�e,. �'jt=
Address-
Telephone
ddressTelephone 1
Signature
DESCRIPTION OF WORK TO BE PERFORMED
�L
FS I'IMATED CONSTRUCTION Cost
-- - d
CONTRACr014 INFORMATION
Name jt yaA.- TV tTt�&
Address t46q SUNc1i 1t 5 AoT ¢I 1 /3057]Jn�dtFt OZ/2�
Telephone 617 5-94 8632
Construction Supervisor's Lic # R T3 8
Home Improvement Contractor # 1,;-9 -Z 3
:\RCI11'rl'UPENGINEER INFORMATION
Name
Address
Telephone'
Mass. Registration #
,t <
PEIRMIT FEE CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
CODIMENTS
The undersigned applicant oes hereby attest that all information stated above is trete to the best of my kilo Wedge
render the penaltie perju
Signed (owner) (a,cnt)
APPROVED BY :
n
DATE APPROVED:
F "
eN
CITY OF SALEM
,,. 1 `i PUBLIC I'ROPRERTY
/ DEPARTMENT
\Lt n at f2C WASHING I o.N Sfxet:'I' 4 S.tu:aa,MASSACUI .In Is 01970
Th.t:778-745-9595 Ir FAX:978-74C'1846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anllicant Information Please Print Leeibl
Name(nu<iucss/Oro.anizVinNlndivldual): R '^"p/ T- / v v
Address: LAMSurylt- LS .V) "T-107J
CityiScatei/.ip:NT-PN wtA p21 2P ('hone ;': 1-7
Ara you an employer' Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ i am a general contractor and I 6. E] New construction
am ylo 'ccs 1"all ans.Vor art-time).' have hired the sub-contractors
,�( l 7 ( P' 7. ❑ Remodeling
�. `LJ' I am a sole proprietor or partner- listed on she attached sheet. t
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
iKo workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exarlscd their
3.EJI am it homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myselff, iKo workers' comp. c. 152, y 1(4), and we have no 12.❑,�,1RRuofrepairs
insurance required.] t employees. iKo workers' i3.�Other /\"G'fLp-AT7Ot'
comp. insurance required.)
-.Any applicant that checks box hl must also sill out the suction wow showing their workuY cumpcnwtion Bulky infurmatium
' 1 Wmatwners who submit Ihis affidavir indicating they ore doing all.vork and Ihcn hire outside cuntrxtors must auhmit a new affidavit indicating snch.
Contract,,,,that c)seek thus box must anxhod an additional chin showing the name of flso sub-contractors and their workers'comp.policy information.
I am an employer that 5-.x providing worAers'cumpen.cntion insuranceJor my employees. Below is the policy and job site
information.
Insurance Company Name: 3b�(-N
Policy a or Self-ins. Lic. *: __...___ ... _____ Expiration Date:
Job Site Acltlzk;ss; /0 VilJ i/W 5'T� $A'�-�r'Vl ✓✓t 14 CilyiStatei"Lip: S• / m A�
Attach Is copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to,ccurc Covertge as required under Section 25A of J1GL 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 5250.00 it day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
luve,tigalions ul the DIA for insurance coverage verification.
I tit)hereby c,. under the 6rtsa )enaltics ajperjary,that the information provided above is true and correct.
Sie:ruure: _..—N,k /�� 2 p Dat r /7, /Z 8
ofjicial use only. Do not sprite in this area, to be completed by city or totem oJjic•ial.
C•ifv or 7-own: —_--... Permit/License x ..._..__.. . .___ .. _ .
Issuing:\W purify (circle one):
1. Board of Health 2. Building, Department 3.City4own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Pcrsoa:, _-_ ...----- Phone it:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplgvee 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 tither 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 :m Individual,parmership,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, NIGL 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-contractors) name(s),address(es)and phone nuinber(s)along with their ccrtificate(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 not in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pennitllicense 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
n 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.c. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Office ut 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-NIASSAFE
Fax # 617-727-7749
aoviscd 5-26-05 www.mass.gov/iiia
Board of Building Regulations and Standards
- HOME IMPROVEMENT CONTRACTOR )1
Registration: 154723
=Expiration: 4/2/2009 Tr# 254776
r Typo: Jndividual p
RYAN J.TUTTLE
} RYAN TUTTLE - -
91 VETERANS RD APT 206:
WINTHROP,MA 02152 Administrator
gRYAANN
d of Building Regulations and Standards
nstruction Supervisor License
Licei se:,CS 97387
Birthdate: 6/28/1980
Expiration:: 6/28/2011Trk 97387
estriction: 00
T.206. 2152fX—.
Commissiouer
„ •ACPRQ. CERTIFICATE OF LIABILITY INSURANCEDATE(MMIOD/YVYY)
12/11/2008
PRODUCER (617) 846-8600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
John M. Biggio Ins Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
399 Winthrop Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
WinthropMA 02152- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:Harleysville Insurance
Tuttle, Ryaan INSURER B:
469 Sumner Street INSURER C:
INSURER D'.
East Boston MA 02128- 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.
INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YV) DATE(MM/DDIW) LIMITS
A GENERAL LIABILITY EACH OCCURRENCE $ 300,000
X COMMERCIAL GENERAL LIABILITY PREMISES RENT.Dnce $ 100,000
CLAIMS MADE F—IOCCUR TBI 12/11/2008 12/11/20 MED EXP(Any one person) $ 5`,000
PERSONAL L'ADV INJURY S 300.)000
GENERAL AGGREGATE $ 600'.,0,00
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 600.,.000
1 17 POLICY J (?T LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BODILY INJURY $ .......
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY - ”" -
NON-OWNEDAUTOS (Per accident) $
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHERTHAN EA ACC $ --
AUTO ONLY: AGG $
EXCESS/UMBRELIA LIABILITY EACH OCCURRENCE $
OCCUR F—I CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION S $ ..q'.
MPLOYERS'LIABILITY
WC STATU- OTH-
EWORKERS COMPENSATION AND TORY LIMITS ER
MPLOV
ANY PROPRIETORIPARTNER/E%ECUTIVE E.L.EACH ACCIDENT $ _
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE$
{ If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS .
'CERTIFICATE HOLDER CANCELLATION = -
( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE;THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAID
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT,
Salem Building Dept FAILURE ITO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE.
INSUR ",ITS AGENTS OR REPRESENTATIVES.
�." AUTHO, D E ESENTATIVE _
j - Salem MA -
A{pC, ORD 25(2001/08) UU (DACORD CORPORATION 1988
P�.M INS025(0108).05 ELECTRONIC L -ASER FORMS,INC. 800)327-0545 Page of 2