10 CLAREMONT ROAD - BUILDING JACKET NS.MSTeE f L.EG--ANo.APPROVED BY T IE
IlySP�CT. PWB TO A PERMT B,FJNG GRANTED
CITY OF SALEM
DateO•
No.
Location of
Is Property Located in yam_No Building *L6 C442.�&Q, ' r
the Historic District?
Is Property Located in
the Conservation Area? Yes_No V-
BUILDING PERMIT APPLICATION FOR:
Permit to: of roof, Install Siding, Construct Deck, Shed, Pool,
Re
(Circle whichever apply) Repair/Replace, Other: ^ '
PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name �
Address & Phone !G "
Architect's Name
r i
Address & Phone
� N e.1 Imo•'3��r l �c�2pJ2r9.i, L��r— S.JC"
T)0 Mechanics Name
�/ Address & Phone r^^✓+ ' r
what is the purpose
of building?
- H a dwelling,for how many tamilfes7
Material of building?
WIII building conform to law?
Asbestos?
Estimated cost se• N state License n O 7 2/9�
o ' city License �^\
Barge Improvement
r&C. I ► x
Signatur of Applicant
nature
SIGNED
UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
16 �y /y J � G c
1
:-'oma � /S� A � :'tir �•�
MAIL PERMIT TO:
� 7 1-i (7/t/.l�^i� 1 U9lifP
ai9yS
No.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
o Q(o 2l
APP p .
14
INSPECTOR F BUILDINGS
a
774 Commonwafth ojMgssocbaseds
Deparhatexi ollRdnsaid Accidasfs
tees offona
600 WasAdng6se Soret
Boston,MA 02111
ruwmarassdos/aila
Workers'Compemdon Insurance Affidavit. Bagden Contradors/ElecbidanyPlamben
ADDHemd IntgrmatHon Please Print Leeibly
Name (LA
Address:
City/StatdZiJk1� � �+� MJF '� 7g T Phare#: h�(— 639- 6 6 7'7
Aro you u emlAw s?Cheek tot`appropriate born, Type of prof ect(require -
1. I am a employer with I am a gcoaal conftclor and I 6. R New oomtroction
employed(fhn and/or pa*t®e).o baveh hed tie sub4dimaeams
2.[] I am a sole pmprietcr or panda- listed on the attached sheet i 7. Remoddmg
ship and have no empkwyces These sob-contracbn have S. ❑ DemoNtion
wodit far me in as w CAP&*. p'�1'a} comp,msmaooe 9• QBuilding addition
[No workeas,comp,insurance 5. ❑ We are a corPorat M W ita'
officeta)iaye ese ieoi}heir 10.0 El CWW repairs or additions
3.0 I am a bomeown t.doing all work ri86tofUmppQn rthi , 11.0 Phambiog repairer or addition
myaelt[No warkcW oomD- a 152,11(4 aa4 Wy�havdn0 12 Q Rtiof rrpauf
ioswancenquired�t. employee+.[No Wake `
C01W insmanoereilutied r 13.0 other
•An VP&mtPod6-1-bene/1Md"figo9t4[aeueabelow fowledtbettwalRrPMweanaoarticymaseutbn
t Hor eownra wbo mbm4 ft sffldavd mer A 40ing all wdtma ams hjswtidr eco sendust eubsdt a newaffitsevkinscating etch
tCo.tree4e tW t eck t5b beet unci dWhe l a WMan b sheet showing fM tan Mtte0&c0oftd=e A%*wod='cmg robY niforn3som
ran ag ser pby9r"lsprovtlbaa wurkml compcuadoa brawn MforxW Bdow b dw pd&y m1 foe ske
�l
Insurance Company Name: (ry F
Policy#or Self-im.Lie. M Expiration Date:
Job Site Addapa j� O [ llPn o.:.;
Attult a OW of the workers'compensation poft dedantion page(allowing the policy number and egdratiou date).
F39M to swore average as required under Section 25A of MGL o. 152 can lead to the fiMmition of criminal penalties of a
fine up to S 1,So0.0o and/or one-year impriao®em,as well s civil penalties in the form of a STOP WORK ORDER and a flue
of up to$250.00 a day against the viobnor. Be advised that a copy of this statement may be forwarded b the Office of
Investigations of the DIA for insarence avenge verificatim
r b IFerrby urr�wdt►Jl1s pdws dal psraob/et of pa/wry tlYat tes 1wja�nnallow provide!oboes is tays.nl cerrecs
Sisaauae: C✓n /l. �� , �— Date• DU n o/0
Fhune#
0•okid use m#6 Do eat wdm Is Ah any to Ar eoeaptstal by cLfp orAmm*jL-Ad
City or Town. Permitlucnu b
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Chyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.other
Contact Persos Phone*
Information and Instructions
campeaation tar their emP '
Maenad General Laws chapter 152 MOO an CHOI�Oiai p t 4 =�ofMM
Pursuant m this OWN, as savpfoyes
is defined as"...everyl m the ravtcegf amther ender any
exlapa or implied.oral oz written." ,
>a defined as" mo&d^empomdoa at otba legal entity,or anY
two Or 111018
An ea,loy. in � the Iegatr�a�a ofs decasad eaQloYa 0C ft
Of the foregoing eagsw d' ! enteerpris ' association or other legal eodty,employing employo:L Ho weveg
receiva a IMM of an individual,p a d who raids therchk or the ocewo of dear.-
owns of a dwdit bouse isvkg out more�°free botise
dwelling boose of sootha wbo carp"persons n do mamtenaoce.consnucdon or repair wor .oa sack dweltiag
t b»�s appurtenant thereto shall notbeause of serol:employmembe deemed lobe ere employs"
oi on&e
MGL chapter 15Z§25C(6)also states that"evaY arab err local 8eeadag agency dad withbold the lswatsee or
a bash or to condrod bdldtngr la the eommoawaMY for say
renewal d a tlewe or paw tovAb
Ilesd wbo W sot prod..d a.pt bk evidence of Bald the or I y of
$ eovenge reivisio "
AAddditionallY,MGL chsPta 152,125C(7)sates"Neither the oommonwestm ttog any of its political sshdivisio� shall
_jusesay conaact for the pace ofpublic we*untl aaeptabk evidence of compliance wiffi tie insmmm
requirements of this dbapta Lave been presented b INS caomcdog aothOdwl "
Applkan"
Pkase fin out the wo*cw�pmsmn affidavit compietoly'by ded6a the boxes that apply n your duration sad,if
necesmy,supply mss)namc(a),address(a)an¢phi.MnWs)along with their mdfkate(s)of
insoraoaa Limited LnbrlitY Compsaw(iq or Limited Liability Parmashipa(L�)with"r employees l rveodithenen ria
members or Parma:,ars not requited to carry workers' msnranee' If m LLC err LLP does lave
�kyees,a policy,is requka Be advised that>bit affidavit may be submitted to the Departme0t Of Industrial
Amy gen coa8rmatien of immance coverage. Aka be tare to dgasad date the 2MdnvlL The affidavit aLaaW
be reoisned to tie city or town that the application for the permit of home Is being requested,so oa te,
brdnstrialAccidenls, awlt Of
Should you have may gnadous regadi�die len'or if You are requited
to obtain at tie mamba#a d below. Self-msued companies shoold eater their
IGN*please,call tie Dq-arti wt SMself-instttaoce fivase number on die
City or Tows Ofltelak
Please be sure that the affidavit is complete and printed legibly. The Deparmneot has provided a space at the bottom
of the affidavit far
you to fill out in the event the Office of Investigations bas to contact you regarding the applicant
ffi in the pami
Intense be sure m liceme number wbkh will be used as a refaesce mnnber. In addi"an applicant
that most submit mnitipk p licationa iu any given yea,need only submit one affidavit indicating cttrrent
Of
policy mformamon(if necessary)and under"Job Site Addreaa"the appbcaat should wrote"all mayloexb ns m (city
town}"A copy offt af5davit that has been of6aa>br sM4K4 QEb7f-'a►Y ar town It u be Pim ided to the
applicant as proof that a valid affidavit is on file for&=permits or bcenses A oew affidavit or com titled out each
Of cidacu is obtaidng a Hume or permit not related,to any bttsimaa for oorrmraeist veamre
year.Wien a borne Dana n is NOT regni:td m comPlete this affidavit
(Le.a dog&Me or permit to Lima kava ere)said Paan
The Office of Investigmtious would b'ke to tbaak you in advance fog your cooperation and sbould you have any questions,
Please do not beabst;to give us a call
The Departments address,telepbone and fax number.
The Commonwealth of Massachusetts
Department of Indastdal Accidents
Office of Invtildvttlons
600 Washington Sbtd
Boston,,MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALI=M9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. IJSOVICE, JR.
MAYOR TELEPHONE: 970-749_9593 EXT. 390
FAX: 970-740.9949
Salem Buil nn Denartnm..�
Debris DI_�nnE ( Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
Of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
>` r'4 (Location of Facility) Joh
e
Signature of A licaat
Date
Client#:24795 CORP01
.: DM CERTIFICATE OF LIABILITY INSURANCE 03;02106°"Y"Y
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
B.K. McCarthy Ins.Agcy.Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
10 Centennial Drive HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Peabody ,MA 01960
978 532.5445 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA NGM Insurance Company14766
Corporal Construction Inc. INSURER B: Travelers Casualty&Surety Company
46 Shepard Street NSURERC
Marblehead, MA 01945 !NSUREID!
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 D' TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICYEXPIRAVON LIMITS
LTR NSRDATE(MMMDNY) DATE(MMIDDIYYI
A GENERAL LIABILITY MP193500 03101/06 03/01/07 EACH OCCURRENCE $500000
X COMMERCIAL GENERAL LIABILITY DAMAGETO RENTED $500.000
CLAIMS MADE OCCUR MED EXP(My one person) $10000
-2 S
PERSONAL&ADV INJURY $500000
GENERAL AGGREGATE $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $1.000.000
POLICY 7 PE7 10C
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea amdent) $
ALLOWNEDAUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY $
NON-0WNED AUTO$ (Per acadent)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR FICLAIMSMADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION AND ACRU63433Y18296 03/03/06 03103107 X WC SLIM OFR
TH-
EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $100 OOO
OyFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100000
es,descrilee under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$500,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION _
City of Salem DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Attn,Building Inspector NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
One Salem Green IMPOSE NO OBLIGATION ORLIABI F Y D pONT EINSU ,ITS AGENTS OR
Salem,MA 01970 REPRESENTATIVES.
AUTHORQED REPRESENTATI
ACORD 25(2001108)1 of 2 #M50182 LEG o ACORD C RPORATION 1988
PLAN TO BE KEPT
ON SITE
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ft Prawtv Loaded in 7osas3ma ®f
wNkbibOYMalf Y4ML.No arf,,
Oo�rMM1'I ASM? Yom_No
BU LOW PERIYT APPLJCATION POW
Poll ox
(C GW W*hoYar apply) Roof• hum cavoY01 DUK Shad• POOL
w ,,
Rapai�JOgCR a-
PLEASE PILL OUT LEOIYLY A COMPLETELY TO AVOID DELAYS W PROCESSMIO
TO THE INSPECTOR OF BUILDINGS:
The urdWsoW toreby aPPke for a pom* to bold a000dq to to folw&*g
OWWS NMW Q r)( FFX—
/b CJ(Aa —uA 7 /
Address a Phone o-A 951/- 5-r2FCL.
AMhkWS Nanw
Addma & Phone j 1
ModlanlQa Nan*
Address d Phone d, 9Ys (9ki r G39- 047e,
"M it SO PAPOM it WNW 5 N 61�e- I �-y
um"a bdldW I a g for how mwq Nmlloo7 T=
vm kdit oorro011 b W?
Ew�swd oor 6� OW UMw o N O` alw LIM M#
Im. inpmvmpmt
SVab n of AppYoarn
UMD UwOER THE PENALTY
OP PMMAMN
D((E11 ,cm
R�tON OF WORK TO U DONE
gee LA cA-- AcA2 (2 zrc-0 ' PIA- Fa"U"
4an.e �t Chi
MNL PERMIT T0: �� ' t�; 66f/aa?� u7 4y ubla►{e�ar� �h� /9rfS'
` 0
NO. K/
APPLJ",M MR
P�l TO
LMAT"/�
4004OP4
NOTE.-
THIS PLAN IS NOT TO BE CONSIDERED AN ALTA/ACSM
LAND TITLE SURVEY, NOR IS IT TO BE USED FOR
RETRACEMENT OF PROPERTY LINES. DAVID A. AULSON
SALLY A. AULSON
BOOK 14150 PAGE 305
MAP 27 LOT 555 1` 50.00
RESIDENTIAL = R1
REFERENCES: N es
DEED: BK. 22095 PG. 318
N�
PLAN: PL.BK. 24 PL. 19 0�
00
s=
Q
HILDA G. LEE 41
ARDIS L. LEE R7.
BOOK 13270 PAGE 65 �O
Qv
LOT 42
59000 ±S. F.
JANE BEAULIEU
161. ROBERT STACEY
MARIANNE BRADLEY
0 0 BOOK 10586 PAGE 55
00 0
EXISTING o
0
1 STORY
ADDITION
9.4'
EXISTING m
2 STORY z
LOT 41 WOOD FRAME o x
DWELLING #10 N ti
PLAN BOOK 24 PLAN 19 0
z
00
n
5.9' _
16.8'
w
�- 50.00'
CLARE,wow ROAD
PUBLIC 40' WIDE
I CERTIFY TO THE SALEM BUILDING
INSPECTOR THAT EXISTING DWELLING AND
GARAGE SHOWN HEREON ARE LOCATED ON
THE GROUND AS SHOWN AND THAT IT IS
THE RESULT OF RUMENT SURVEY. PLOT PLAN CHK. BY-
OF LAND OF LAND
MICDHAEL y� 10 CLAREMONT ROAD SALEM, MA
BOVIO PREPARED FOR. CORPORAL CONSTRUCT/ON /A
U609 cc HANCOCK 6 30 O6
P"
ron Survey Associates, Inc. SCALE.• 1" = 10' ✓OB
/f f� 185 CENTRE STREET, DANVERS, MA. 01923 NO.
PR FESSIONAL LAND SURVEYOR VOICE (978) 777-3050, FAX (978) 774-7816 0 5 f0 20 12943
F.- Lard R,e R21129�Xds1 12 .d y "11, 2"- I o,.