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70 WASHINGTON ST - BUILDING INSPECTION (7) CrmoFSALEm / -ige' PUBLIC PROPERTY DEPARTMENT KI.%RSENEY ORLSCOLL MAYOR 120 WASISINGrON SI7lEhT♦S"LEK S ASSACHLSLI-M 01970 TF1--973-735-9S9S * FAX:978-740-98" APPLICATION FOR THE REPAIR RENOVATION, CONSTRUCTION. DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1A SITE INFORMATION Location Name: Q, 0tl iC 1e nn Building: Property Address: 174 t0a S'1(03, KD St"e F, Sateen ks� 0 "20 Property is located in a: Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: i Address: '7j) Wo S5 ?h Y7 50- ton S-jY2e \5Ld I -I e 3/0 Telephone: r7,?- �j y-L/,?- -�. 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: What is the current use of the Building? Material of Building? If dwelling, how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone ` ��(� Mechanic's Name \\�ct��,6 Qc1oA1�\c . Address and Phone l Construction Supervisors License# b 7 2 Y y HIC Registration# Estimated Cost of Project$ a� as 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 b ' o above specifications. Signed under penalty of perjury " Date vo /ems Q � N es W w > .~°. — 1 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KLNBERLEY DRISCOLL MAYOR 120 WASHNGTON STREET •SALEM,MAssACHusETTs 01970 TEL'978-745-9595 ♦FAx:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aualicant Information (� Please Print Lesibly N&<3 (Business! rganization/Individual): k\ \N�"6 PGA P�`-. �MG, �,�.e,".,.., rt t L L-'C— Address:\, �W\CaV� City/State/Zip: 1 )c1nu tc Phone #: Q� f!�" '—I Cc 38te o Are you an employer?Check the appropriate box: Type of project(required): �1.E I am a employer with� 4. ❑ I am a general contractor and I —* have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 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 S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.[I 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 hire outside contractors most submit a new affidavit indicating such. tContractors that check this box most 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 jab site informadom Insurance Company Name: < Policy#or Self-ins. Lic.#: C- - S`� Expiration Date: 0 - 1 Job Site Address: �7c�sk",n �o City/State/Zip: i_ Ate, t ��1 O lck—I Attach a copy of the workers' compensation po cy 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$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 certify e e p s and e a s o erjury that the information provided above is hue and correct Si nature( Date: Phone#: \�� l C 5- 4 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 imbiber 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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. i 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 021 It Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 ' WWW.maS3.gOV/dia ----SOANCE COMPANY HEREIN CALLED THE COMPANY ISSUED BY THE STOCK IN AMERICAN HOME ASSURANCE COMPANY 67333-0000 WC 894-86-57 13781 T --------------------------------------------- 013-82-07o6-oo .•-.- . - NEW YORK PH I L I P V01 S I NE DBA ALL AROUND PROPERTY p 18 MAPLE STREET Oil" Companies of DANVERS, MA 01923-0000 American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK. N.Y. 10270 SEE NAME AND ADDRESS SCHEDULE - WC990610 LD# MA 1 : THOMAS GREGORY ASSOCIATES INS AGCY INC WORKERS COMPENSATION AND EMPLOYERS 601 EDGEWATER DRIVE #255 LIABILITY POLICY INFORMATION PAGE WAKEFIELD, MA o188o-4555 INSURED IS PREVIOUS POLICY NUMBER INDIVIDUAL RENEWAL 00 3o0166 OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC990610 ITEM 2 POLICY PERIOD 12.01 A.M.standard time at the insured's mailing address FROM 07/22/06 TO 07/22/07 ITEM A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ SOO.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AL AR AZ CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SO TN TX UT VA VT WI ITEM4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below Is subject to verification and change by audit. Estimated Total Rate Per Estimated Remuneration Premium Classifications Code Number ❑ ❑ mu eratlon Annual ❑3 Year Annual 3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $292 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $284 MA MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM �7, 14o. It indicated below,interim adjustments of premium shall be made: 1 Semi-Annually 0 Quarterly El Monthly DEPOSIT PREMIUM ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM SLj�jDULE - WC990612 14+. ':• l 06/14/06 PARSIPPANY 82 Issue Date Issuing Office Authorized Representative WC 00 00 01 39967 V INSURED'S COPY ALL AROUND PROPERTY P.M. MAINTENANCE, LLC Estimate Ali 11� � 18 Maple Avenue Date Estimate# Danvers, MA 01923 9/26/2006 3191 Phone# 978-762-3860 Name Address Vemco trust Fax# 978-762-7521 C/O Cums,Vemet and Associates 70 Washington Street, Suite 310 Salem, MA 01970 Project Description Oty Cost Total RE: DET office: 1st floor 70 Washington Street 1. Glaze two,(2),openings with Clear Laminated safety glass. 2. Trim outside with flat pine trim to match existing. Labor&Materials 650.00 650.00 RE: DET Office: 2nd floor 70 Washington Street 1. Cut in two,(2),openings beside existing door. a. Opening: 24" X 75" 2. Glaze with tempered obscured glass. Labor&Materials 870.00 870.00 Price reflects all work listed above. Any unforeseen complications shall be discussed with agent before proceeding,and billed at$50 per man hour,plus materials as an additional charge. Please sign below upon acceptance: A 50%deposit is required upon acceptance. Authorized Signature 70 Washington Street Salem, MA 01970 Quotations valid up to 45 days. Clerical Errors Subject to change. Total $1 szo.00 i. ✓8c7ARD`�S��C�N�i2E LATIO�NS ., License: CONSTRUCTION SUPERVISOR F " Number:.CS 074264 n `, Blrthdatei 04/29/1967 Expires:04/29/200ti. Tr.no: 21132 Restricted: 00 PHILIP S VOISINE. 77 BURLEY ST DANVERS, MA 01923 Commissioner -.:)0-35,000 d enclosed space - (MGL'C.112:S.00L) IA-Masonry only IG-1&2.FamilyHomes -ailuie:to_possess a current edition of the Aassachusetts State:Building.Code `s cause for revocation of this license. "` DIG SAFE-CALL CENTER: (888):344-7233 Board of Building Regulations and Standards lugHOME IMPROVEMENT CONTRACTOR Registration: _128558 .,- plration: ,4121/2007 Type: !DBA ALL AROUND PROPERTY MAINT&CONT PHILIP VOISINE, 18 MAPLE AVE. DANVER.MA 01923 Administrator w CITY OF SALEM r: PUBLIC PROPERTY DEPARTMENT mr-mmo ouscou. LS6r19O1970 W�roa t�WtivaHc'uu�5nt�'r*$•^.. �� TEL 978.745-9S9S•FAIC 978-740-9846 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 MGL c 40.S 54; i1 is issued with the condition that the debris resulting from Building Permit ly licensed waste disposal facility as defined by MGL c this work shall be disposed of in a propar 111,S 130A. The debris will be(transport Ied by: toartte of Nader) The debris will be disposed of in : (\�J C -- (name of facility) J, (addms of facilit)f) qof pcmtit applicant Q . aL. . o \., date „cbri.m7dbrc