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37 WARD ST - BUILDING INSPECTION -_-- ��5!-p' PUBLIC PROPERTY DEPAR E TMNT KimuEaLFY DRISCOLL MAYOR 120 WASHING-MN hnAE6r S•LEK MAssACHl:serns 01970 To:978-745-959S 0 FAX:97&7i0-9&% 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: 32 L,/ nr c) 2 i Building: Property Address: 31 L..w c. 5� �jYCbr^� Property is located in a: Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: G11,, (<, VNO Q .� a� Address: 2,-j w�J Telephone: 7 45 I — 7 c — Qi 1 L1 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: Mail Permit to: f _ What is the current use of the Building? Material of Building? VJhV --- If dwelling, how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone Mechanic's Name Address and Phone Construction Supervisors L' nse# OS�DI HIC Registration# Estimated Cost of Project Permit Fee Calculation Permit Fee$ Estimated Cost X$71$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 Date 9,'2 ►- v� NI I C 4 9Q L a F c o O. u _ 1 CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KINMERLV neiSCO" 120 wASUWGRH'I SI 0 SALE64 NL%N5AQWSI,M 01970 WAYOt '►VS.978_745-9595*FAY:976.740.98J6 Construction Debris .quforall demolition and renovation Ilk) In accordance with the sixth edition of the State Building Code.780 CMR section I I1.5 Debris,and the provisions of MGL c 40,8 54; with the condit is issued ion that the debris resulting from Building Permit li 1 licensed waste disposal facility as defined by MGL c this work shall be disposed of in a props y 111,S 150A. The debris will be transported by: inane of hauler) The debris will be disposed of in: (name of facility) -----(addr6W Of facility) I l S{saanue of pemut appluaam date ,hhn.a17.4rc CITY OF SALEM i� 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 Aoolicant Information Please Print Letribly Name (Business/Organization/Individual): ©l-tr_P c e_ F`'T Address: \�� C ow.0 i t S QC 0, �I City/State/Zip: Phone #: Are you an employer?Check the appropriate bog: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I * have hired the subcontractors 6. ❑New construction employees(full and/or part-time).2.❑ 7. Remodeling I am a sole proprietor or partner- listed on the attached sheet. t ❑ g 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.❑ Electrical repairs or additions 3.[3 I am a homeowner doing all work right of exemption per MGL I LE] Plumbing 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.❑ 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 hue outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors 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. Insurance Company Name: ( 0 R E V-e-t1tq., �^S Policy#or Self-ins. Lic.#: /V df 3 6 0 6 el Expiration Date: Job Site Address: U t -' +� �' � s� City/State/Zip: 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 cert' der�Ipains and p allies fperjury that the information provided above is true and correct Signature: Cop Date: C —�tD Phone#: p /�J O 1F rf3 Official use only. Do not write in this area,to be completed by city or town ojficiaL 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 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 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 . J/ee 1°oomrmwmwedlU. o�...f�aaaoc�ueelG BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 080145 Birthdale: 1 012 6/1 9 6 3 ;f Expires: 1012612007 Tr. no: 8042.0 Restricted: 00 GEORGE VASILIADES 515 LOWELL ST ,G PEABODY, MA 01960 Lommiss .. :��s :..,.. �/sC.'�o9lv/rtMtulC¢LUL.o�✓G�abM.C�wL¢�6 I r Board of Building Regulations and Standards t ,UP— HOME IMPROVEMENT CONTRACTOR 1 J Registration: 124356 Expiration: 6/1212007 Type: Private Corporation Olympic Painting/George Co., Inc George Vasillado 515 Lowell st. "� ✓ w Peabody,MA01960 Administrator r DATE(OAVDDIYYYY) A.CQRD„ CERTIFICATE OF LIABILITY„INSURANCE o9roe/2oo6 �DucER.:_6031 883-5528' THIS CERTIFICATE IS ISSUED AS-A MATTER OF INFORMATION . ,�_ ONLY AND'' CONFERS NO RIGHTS UPON THE CERTIFICATE )RRIVEA,U INSURANCE AGENCY, IN - - - HOLDER.' THIS _CERTIFICATE DOES NOT AMEND,- EXTEND OR L5 MAIN ST ALTER THE COVERAGE-AFFORDED BY THE POLICIES BELOW. O BOX 369 NAIL 7i ASHUA - NH 0 30 61-03 6 9 INSURERS AFFORDING COVERAGE BuRED INSURER A:NAUTILUS ONDONDERRY, MANCRESTER CONST SERV CORP INSURERB:AIG, BA: OL�IBIC INSURER C:PROGRESSIVE 5. TANWAY AVE INSURER D: tASHUA NH 03063— - INSURER EI :OVERAGES THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTAIIDING 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 BV PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION 4SR AD A, TYPE L POLICY NUMBER OATS(MMIODNn DATE IMMIDOMII LIMITS AR N R E OF INSURANCE 4,ODO,OOD A X GENERALDABIuw './ / EACH OCCURRENCE S DAMAGE T'O RENTED X COMMERCIALGENERALLIABIL(IY PREMISES Fa occur-ca 12/09/2005 12/09/2006 MEOW(An one on7 3 5,000 CLAIMS MADE a OCCUR NC502722 4,000,000 ' - PERSONAL 8 AM INJUkY S /. ./. ./ GENERAL AGGREGATE S 41000,000O PRODUCTS-COMPIOP AGG S 4,000,OD GEN`L AGGREGATE LIMIT APPLIES PER: POLICY JECT_ X LOG / / / / C X AUTOMOBILE LIABILITY 35190760 05/11/2006 05/11/2007 COMBINED SINGLE LIMIT _ S 1,000,000 (Ea accident) X ANY AUTO BODILY I ALLOWNEOAUTOS on) S (Per parsanl X SLHEDULEDAUTO$ X HIRED AUTOS BODILY INJURY S (Par txcldan0 X HON•OWNED AUTOS PROPERTY DAMAGE S (Par eccldrnp AUTO ONLY-EA ACCIDENT E GARAGE LUIUILOY - OTHER THAN EA ACC 3 ANY AUTO AUTO ONLY: AGG E EXCESSIUMBRELLA LIABILITY / / / / EACN OCGLIkkENCE S AGG— OCCUR �GIAIM3 MADE _ _ _ S DEDUCTIBLE E RETENTION 3 WW - 9 WORKERS COMPENSATION AND T4C2791321 (MpS3) 09/25/2006 09/25/2007 X 70 IMITS X ER EMPLOYER$'LIADIIJTY - - - - - E.L.EACH.ACCIDENT 3 SOO,000 ANY PROPRIETOR/PARTNF.(UEXEOUTIVE - 500,000 OFFICERIMEMBER EXCLUDED? NOT EXCLVDEO . / / / / E.L.DISEASE EA EMPLOYEE E 500,000 II yes.OasOlbe tmOaT - EL.OISUSE•POLICY LIMB 8 SPECIAL PROVISIONS below A OTHER INLAND MARINE IN8113963 01/13/20C Ol/13/2007 190,000 DESORIPTON OF OPERATIONSILOCAMONSNEHICLES,EXCLUSIONS ADOEO BY ENDDRSEMENTISFECUIL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ( ' EXPIRATION DATE THEREOF, THE "UINO INSURER WILL ONOFAVOR TO MAIL 30. DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO LEFT,BUT F UR O DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY VINO UPON THE INSURER,rTSAGE NT$OR REPRESEN7ATNEB. AUTHORM D EPRESENTATIVE- - p)ACORO CORPORATION i9B8 CORD 25(2001108) _ Page t of i ELECTRONIC IAStk FORMS, -(00()32T:a595 - - - - - Lt