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205 WASHINGTON ST - BUILDING INSPECTION What is the current use of the Building? C Material of Buildinglbf.Lk 'v r^--"0 8 If dwelling, how many units? Will the Building Conform to Law?d �P S Asbestos? ti Architect's Name ti// Address and Phone D ( 1 Mechanic's Name �o�A �! u41 e r Address and Phone �� F^ tiJS6 r AA Construction Supervisors License# 09($Q 7- HIC Registration# Estimated Cost of Pro*ect$ O cZ O Permit Fee Calculation Permit Fee$ Estimated Cost X$71$1000 Residential Estimated Cost X$111$1000 Commercial An Additional $5.00 is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above stated specifications. Signed under penalty of perjury X Date 3 0 N H 2L N o d ° E7 ©F E --- r' PUBLIC PROPERTY DEPARTMENT KIMRiM"ORMCOLL MAYOR 1 0 WASHINGMN ST%EEr•S'�\tA1SACHLSLXM01970 Tm-978-745-959S*FAx:97&7a0.9N6 APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION, DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Building: Property Address: (] (AJ 0 ' L.i 4-1) property is located in a; Conservation Area Y/N A _Historic District Y/N/� 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land _ Name: o es L L C Address: Go _ �/ V 11L c ( p _ // h A Telephone: U7 -64-5 S , 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing 2 Renovation Number of Stories Renovated Change in Use New Demolition r>. Existing Qpp�.V, /Ncao Approximate year of Area per floor (sf) Renovated construction or renovation O New of existing building Brief Description of Proposed Work: n0 6 ``1 4 . S 5 �.4,1 41� r �—Iq,,c �l new � du,b ' c Ua Mail Permit to: t? `� CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT exwaFJet.ar uaacott alnroa 12o WASICOMrON,STKW.SALrhb'dwwastWtrs o 1970 Test 9M745.9595 a Ft x:9M740.9W Workers' Compensation Insurance Affidavit: Builders/Contractor$Meetricians/p(nmben Anniicant Information yl�� ` Pleas ta.4ne r 2 t ly Name(BuaiaeWOraaniadGWUdMdual): Address: I 7 -d L,a)C6a 00 City/Statemp: _ S v Mz. : 11 L fd o /0 pimne#: C r? 62 r g .3 I S Are you an employer?Check the approprleto bon 1.0 I am a employer with 4.� I am a general contractor and I Pe project( : employees(hill and/or part-time).• have hired the sub-contractors 6 ❑New construction 2.0 I am a sole proprietor or partner• listed on the attached sheet. t 7. 0 Remodeling ship and have no employees These sub conhactars have S. ❑Demolition o working for me in any capacity. workers'comp.insurce. (No workers' comp.insurance S. 0 an We am a corporation and its 9' Building addition required] officers have exercised their 10.0 Electrical repain or additions 3.0 I am a homeowner doing all work right of exemption per MOL 11.13 Plumbing repair or additions myself.(No workers'comp. c. 152,§I(4),and we have no 12.❑Roof repairs inurance required]t employees.[No workers' i3,0 Other comp.imuramce required] fMy appileaet drat ehseb boa rt moat dso!!0 set xhs ssetloa bolo~dw i%dmk Na0' l+e>leY Hamsowma who submit box mustoffld vitmm odl=s M dwym sobs atl untie ad time hka omida COMM=matt admxk a saw slRdwh I dkedus rock tCoaeacswa rbn chock Wta boa muat.wehad m addldoaal dmst dwrisa rim ems of do al*wntrace s and dwk wlona•eamR poffY id nnod s. /am am employer that Is providing women'compensadom inswnace for my info►madow employees Below b the poNry and fob tint Insurance Company Name: Policy M or Self-ins.Lie. Y Expiration Date: Job Site Address; City/State/Zip- Compensation Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)6 Failure w secure coverage as required under Section 25A of MGL c. 152 can lead to the it mot 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 a�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 Investigation of the DIA for insurance coverage verification. /do hereby card .&under the paLu and penaldes of perlwry that dM informadoa provided above Is urea and corns Signature: n W/l / 7o'-?,o►, K V d/� Da„ �,��`0 7 Phone#: r!7 2`t3 G 7 8 3 F l use oni5t Do not write in this area,to be completed by city o►town oQ&laL r Town• Permit/Llcense Authority(circle one): rd of Healtb 2.BuBding Department 3.City/fowm Clerk 4. Electrical Inspector S. Plumbing Inspector er t Person Phone p• Information and Instructions Massachusetts General Laws chapter 152 requires all employees to provide W*rkc s' compensation for their empWyeea Pursuant to this staWW an employee is defined as"...every Peron in the service of another under any contract of bite." a imdPlled.oral a written" express asaoeiatie,.cOrP°�Oa�other legal entity.or any two or more An employer is defined as"an individual,paemashtp. vas of a deceased employer.a the Of the fottgoing engaged in a joint enterpriee.and inchtding the legal teprtaeatatt !oyes However the an indiviAlual. association thr a %m a other wet resides therciD.or the ooculiant of the ownerreceiv o a dwellsustee off daunt partnership. to do maintenance.con:0'�1O°or rot»work on su cla dwelling haw owner of a dwelling not more than three apaetmeota dwelling boos of anther who empWYa persons shall because of such employment be deemed to be an employw.* a on the grounds or building appurtenant MGL chapter 152.12SC(6)also states that"every state or Weal licensing��b the cow, �wt"a parsta a business or to cenb,et wit•the insurance coverage regtdrad." renewal of a license or permit is teteptsble evidence Of cemptls,ce Politics'subdivisions shad appgieaat cobs btu not prod,eed state"Neither die commonwealth not anY of its Po Additionally.MGL chapter 152,$25C(7) le evidence of compliance with the insurance into,any contract for she performance of public work until acceptab cowui of this chapter have been presented to tie cone acting authOritY" re4 Applicants 1 tO Our situation end it affidavit completely,by checking do boxes that apply Y Please fill out the workers'companeation es and phone number(,)along with their certi8este(s)of than the necessary.supply aab-conteaetor{e) �s)( �or Limited Liability ParmOrshiW(LLP)with no employe" insurance. Limited Liability Companies member Perrone,are not required to workers'compensation msurmce• If an LLC a LLP does have employees.a policy is rWuind Be advised that �beessure to sip and date the afil"VIL 'Ile affidavit Should Accidents may be submitted to the Department Of ludinaw for confirnwtion of insuraece coverage Of be returned to the city a town that the application fa the permit a license is being requeete4 not the be retu Industrial Accidenta Should you have my questions regarding die law a if you are required to obtain a workers' Iat the number listed below Salt-insured companies should eater their compensation policy.please call the Depulzu" self-insurance license number an the City or Tow,Officials Please be sure that the affidavit is complete and printed legibly. The.Department has provided a space at the bottom of the affidavit foe you to fill out in the event the Office of Investigations has o contact you regarding the applicant curfew Please be sure o fill in the permitftense number which will be used as a reference number. In addition,m applicant that must submit multiple Perrin applications in any given year,need only submit one affidavit indicating(City o policy.information(if multiple necessary)and under"lob Site Addrae the applicant should write"all lmcadOus in__(city a or marked by the city a own may be provided o the own). A copy of the affidavit that has been officially stamped a licenses. A new al ,drvu must be filled Out each applicant as proof that a valid affidavit is on file for&=a Permits not related o my business a commercial vesture year.Where a home owner a citizen is obtaining i license is permit (i.e. a dog license a Permit o bum leaves ate.)said person is NOT required o complete this affidavit would like tothank you in advance for your cooperation and should you have my questions, The Office of Investigations please do not hesitate to give us s call. The Department's address,telephone and fax number. The Commonwealth of Mess uhusetts Department of In aMill A=denta Offke of lavtesl:19001111 600 washin&M street Boston,MA 02111 Tel. #617-727-4900 W 406 of 1-877-MASSAFE Fax 0 617-727-7749 Revised 5-26-05 www,mus gov/dm CrrY or SALE PUBLIC PROPE M DEPAR'TM Drr �1waa tarn..iasor�l.L.O.l4..OL�lllall* Coasbvd ka DArb ObPOW Afikbwlt 6.qp "6 aft Amnon d maws"woo m aoOWkwo wide dW dwk WWW+a t s sd.sWIftCoft 7e CUa ISOM 1113 o� � "�00' i.f�..tl.rs m.eovanr4.�t le.ded.a.utis ffao. Ws wae��hll dfxi adf.a pe�itir scowl woo&pod hdf4g ao 406W by!ilm a �u.s110A. The dsbrb wM b.bmapod W bP (aaras afbuMr� rm d4bdo will be dfsoow d of in: ( "a(hsod (*WFM of hew" Lp+Rua of punt' s�lkse{ Client#:29552 RESOU .ACORD,u CERTIFICATE OF LIABILITY INSURANCE 03;o9;ow7DD"YYY' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE MARKETING AGENCIES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 306 MAIN STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. WORCESTER, MA 01608 508 753-7233 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Zurich American 16535 RCG LLC INSURER B: American Home Assurance 19380 17 Ivaloo Street,Suite 100 INSURER C. Somerville, MA 02143.3656 INSURER D: NSURER 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. S POLICYEFFECTIVE POLICYEXPIRATION LTR NSR TYPE OFINSURANCE POLICY NUMBER DATE MMIDD/YY DATE MMMDIYY LIMITS A GENERAL LIABILITY AC0852207410 01/01/06 03/20/07 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $250 OOO CLAIMS MADE 51 OCCUR MED UP(Any one person) $5 000 PERSONAL B ADV INJURY $1000000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $1000000 POLICY PRO LOG JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea amdent) $ ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Per Person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per amdent) PROPERTY DAMAGE $ (Per acadent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND WC8942196 05/15/06 05/15/07 X WC STATU- OTH- EMPLOYERS'LIABILITY EL EACH ACCIDENT $1 OO,000 ANY PROPRIETOWPARTNEWEXECUTIVE OFFICERJMEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYEE $100,000 If yes,descnee uner SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT s500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Work @ 203 Washington Street,Salem,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Dodge Area LLC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN 203 Washington Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Salem,MA 01970 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,n5 AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #132974 GCE © ACORD CORPORATION 1988