284 WASHINGTON ST - BUILDING INSPECTION (6) �
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,1J�S,P.��� .P1319R TP A.PERMIT.B,�iNG GRANTED
\ C CITY OF SALEM
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I No. � 4�:t .� '`� Date a-3-b5
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, Is Property Located in Location of
the Histonc District? Yes_No� Building �g`t �ASta�r.Y��'C��
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Is Property Located in
the ConservaUon Area7 Yes No
BUILDING PERMIT APPLICATION FOR: '
Permit to:
(Circle whichever apply) Roof Reroof, Install Siding,�Construct Deck, Shed, Pool,
Re ai Replace, Other: Pa.ti� — vt,�a.�-�.
PLEASE FlLL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING �
TO THE INSPECTOR OF BUILDINGS: I
The undersigned hereby applies for a permit to build according to the following
specffications: - II
Owner's Name � � �rn ���N �irois � I�alph �SIro�S <`��2 !
Address & Phone agy�h��Uls1' _,�U� �(01�,�8`� �5'7C��3 li
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Architect s �1ame ��a�h �5�1 r�e.. --a--�,��c I
Address & Phone Sa ��Q-� ��+--p— I�g� 3�y `a1\�
Mechanics Name ��,���� '� � a
Address & Phone �� ��ow� A.u�_-�'�*'�`:����1 ) 3�1'���
What is the purpose of building7
Material of bullding7 ����.a_ If a dwelling, for how many families7
WIII building contortn to law4 ��_Asbestos? �'�
Esllmated cost �n,�� � City License x N P' Slate License# o� q � � a
���\ � Impiov�ent ����4`
�1� � 131�D� XS__�.;
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT T0: NARC��'� �v�NS�.I�C���
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APPLICATION FO�i
PERMIT T6
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LOCATION
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PE MIT GRANTED
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APP OV�D
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INSPECT OF BUILD€NGS . -
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�� The Commonwealth of Massachusetts
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' a�l� - Department of lndustria!Accidents
��� - 0lllceofln�estlgations
��,.,� � 600 Washington Street, 7'"Floor
�-- �;�r Boston, Mass. 02111
� _r5��� Workers' Com ensation Insurance Affidavit: Buildin Plumbiu Electrical Contractors
�A licant' form �on: �. . -` �:, :.� .� u�.. FI asePRINTI ibi � � , � 1 .�a _,
'�I name:Ka�YIIQOJI ��11 � �Y'n� �1 C. 1 �.Up� � l" �� ����_. � - "
address:C�.l l J� lA��..J� 1�� 1.�111 )��V O
.. citv 1�--� I�' �--� state� I�-�l� zio�U`�'60 [ phoneNl���� np�� ���� �.,
work site location(full address)� I
❑ I am a homeowner perfonning all work myself. Project Type: ❑New Construction ❑Remodel
❑ I am a sole ro rm�ietor and have no one working in any capacity. ❑Building Addi[ion
� I am an employer providing workers' compensatiojn for my employees working on this job
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comoanvname: �.l\�i�\LN�- .WN ����'ID ..: � � ;�'� �,�
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� citv: 1 i..., ti-a�-►-::-`'i'��-�2.`:�. ` - �. " ' ohone��N ��a�1_�j�1=lnS�Ov "� "" - "',�
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insuranceco. � 'CZ'(iVf.�-�e--2g ool�cv�k ��`�1Q� qO�X 12 � �-2 r i
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� �j,] 1 am a sole propne[or,general contractor,or homeowner(circ(e one)and have hired[he conVactors listed below who have
[he foliowing workers' compensa[ion polices:
comoanvname: I�KLr�1�J ;� T`"( )(�'T'�(�
address�� ( ��l r�� � � �. . . . . . . .. .
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ci�_�( 1{�.f�Y'1'f' I�Y Ivl � ohoneN � `""{�� ' �y' )VY�
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insurence co. ��`�'^'M'e.(L.c�Q� �. � - olic j# / �✓-1� �' � rt � �
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companV n8me: � ' � �� � � � � . '
. . :S 4 '�eL ' S '2' , i i�: ;d'a•G�,^'�
address: � . ._ - •, . . . . b�' � �' " - 'd
citr. . ��� � �,: ,� v- .� '
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1118Y[811ClC0. � O�1C. �,•� 4 ••�
3Amah.aileiNannlS Aeef"1�' � �.�-.� b . ... ., � ` .. :�, . .� , � '� �
, Fa�lure to secure coverege as reqmred under Sechon 25A of MGL�52 cen lead te the imposition of criminal penalties ofa fice up to 51,500.00 and/or
one years'imprisonmen[as well as civil penattles in the form of a STOP WORK ORDER aod a fine of$100.00 a dey against me. I uoderstand that a �
copy of this stutement may be forwarded[o Ihe ORce of toves[igations af the DIA for coverage verificalioo.
I do hereby certijy under the pains attd pena!(res ojperjury(hat(he informalion provided above is true and rorrect.
Signature__ ��')� e.,,.\, — Date Z-��"V �
��_ 1 -- C�
Print name �\C.�n Y>Q L 1V q20f����� Phone# 1- 4, —�Jb D
e�� 3
umcidl use only do no[write in Ihis area 10 be cample[ed by city or town oRcial
city or town: ' permiUlittnse k ❑Buildiog Department
❑Licensing Board
❑check if immediale response is requireJ ❑Selec�men's ORce
❑Neal[h Department
contact person: phone#; ❑Other
Irerised Sepi.3unl� "
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' Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", an employee is defined as every person in the service of another under any
contract of hire, express or implied,oral or w�itten. -
, . , . . . , �; .. . '� . . , ',' ,
An employer is defined as an individual, partnersh�p, �sociation,corporation;or,other legal'entity,,or�any twq'or more of
the:foregoing engaged iq ajoint enterprise, and including the legal,representatives of a deceased employer, or the receiver
or irustee of an individual,�partnership, asso�iation or other legzf'entity, employing employeas.t Howevet the owner of a
dwel ling house having not more than three_,apartments anil who resides therein, or the occupanf 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 section 25 also states that every state or local licensing agency shall withhold the issuance or ',
_. , . , v ,
renewal of a`license or permit to operate a business or to construct buildings in the com`'inonw,ealth'fo'r' any '
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, 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 requiremerts of this chapter have
been presented to the contracting authoriry.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to,your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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 retumed to the ciry or town that the application for the permit or license is
being requested, not the DepaRment of Industrial Accidents. Should you have any questions regarding the�"law"or if
you are required to obtain a workeis' compensation policy, please call the Department at the number listed below.
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City or Towns
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[nvestigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference numbec The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made. ^
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
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The Department's address,telephone and fax number. .._.
The Commoowealth Of Massachusetts
Department of Industrial Accidents �
OfflCe Of IlNesd9attOnB
600 Washington Street,7'"Floor
Boston, Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406
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✓�ze l�NMvm.O�ruoe��o�✓�,[uAla.c�ulved.t (
� BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR +
Number: CS 079149 �
i
� . Birthdate: 0411 4/1 9 61 .
� Expires: 04/14/2005 Tr. no: 79149
. Restricted To: 00
MICHAELA NARDONE �j ��� .
30 EDWARD AVE �-'�"^
LYNNFIELD, MA 01940 Administrator
_ i:.
✓�ie ��iiviicnca�ruuv,¢lll. �`��'Cfr.u�r���atellJ
� BoarJ of Building RegulaKonx aud StanJards License ar registration valid for individul use only
� ��� -rU�i HOME IMPROVEMENT CONTRACTOR beFore the expiration date. If found remrn ro:
7 Re istration: Baard of Building Regulations and Standards
��,-�j� [--��� 9� 131108 One Ashburton Place Rm 1301
:;,�> Expiration: .6@2006
Type: PnvateCorporation Bosmn,Ma.02108
NARDONE CONSTRUCTIONSCONTRACTING INC.
MICHAEL NARDONE ��' n ���
, 30 EDWARD AVENUE, ������,� ����
LYNNFIELD,MA 01940 Admioistramr No[valid e�ithout signature
�
' CITY OF SALEM� MASSACHUSETTS
,. � PUBLIC PROPERTY DEPARTMENT
� 9 120 WASHINGTON STREET, 3RD FLOOR
�' � SALEM, MA OI 970
�""�" �� TEL. (978)745-9595 Ex7. 380
Fnx (978) 740-9846
STANLEV J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I aclmowledge that as a condition
I of Building P-ermit# - , all debris resulting &om the cons�uction activity
govemed by this Building Permit shafl be disposed of in a properly licensed solid-waste
disposal facility, as deSned by MGL c III, S 150A.
The debris will be disposed of at:�6�'���h'� �Q��� +�_:� l.�Tc
Locarion of Facility
pt`n�.�� `Z.� ^'��a C /
�
Signature of Permit Applicant Date
FLZLY complete the followsng information:
(PLEASE PRINT CLEARLI�
�rd�nP �.�n�rU�i o r�
Name of Permit Applicant �
1-�c�inrXry� 1,�.)� -�
Fum Name, if any
�c.��.�-, `«�a— �O.. �o� �S�
Address, City & State
The above statute requires that debris from the demolition, renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed so1id-waste disposal
facility as deSned by MGL cIII, S 150A, and the building permits or licenses aze to
indicate the location of the facility.
.. `o1'�L..�e��
N�TICE � W NOTICE
TO � a TO
:
EIVIPLOYEES � Q� ElVIP�,�JYEES
9 0�/ V
O,�M SVe
The Co�nm�nwealth of 1V�assachusetts
DEPAIgTM�1�1T ()F Il�'IDUST'I�AI. ACCIDENTS
500 VVashing�on Street, Bosto�t, Massachusetts 02111
617-727--4900 — http://�4ww.mass.gov/dia
As re uired by Massachusetts Gcneral Law, Chapter 152, Sectiaos 21, 22& 30, this will give yau nolicz that
I�we) have provided Por paymenCto our injured employees under the above mentioned chapter hy
insuring with:
THE TRAVELERS INSURANCE GOMPANIES
NAME OF INSURANCE COMPaIV Y'
ONE TOWEt� SOUARE
HARTFORD, C7 06183
ADDRESS OF WSUR;�NCE COh4P,4NY
(6KUB-908X138-3-04) 0?-18-04 'FO 07-18-05
POLICY NUMBER EFFECTIVE DATES
= SALHANEY INS AGCV 5264 WASHINGTON ST
D�
e� WEST R�XBURY MA 02132
_= NF,i�1E OF INSURANCE AGENT ADDRESS � PHOI�'E#
a�
,� NARDONE , MICHAEL A DBA 30 EDWARD A'JE
� NARDONE & SONS CONSTRUCTION
'' L'VNNFIELD
°� MA 01940
� �= EMPLOYER �DDFESS
' �—
m�
= ElbIPLOYER'S WORKERS C0;�4PENSATIl7N UFrICER (IF A\�Y) DATE
�= 1VIEDIC�, 'Td�AT'�VIE1lTT
= The abovc namcd insurer is required in cases of personal injuries arising out of and in the coursc oF
°�— employment io furnish adequ�te and reasonable hospital and medical services i.n accordance w�.Ui the
°= provisions of the R�otkers' Compensation Act. A copy of' the Firct Report of Injory must 6e giver to thc
°� injured employez. The emplayec may select his or her own physiciaa. '[ne reasonablc wst of the ser��ices
�� provided by the treating physician will be paid by ine insuma, if tne crea[ment is necessary and reasonably
� connected to the work relate.d injury. In cases requiring has�iitat �.ttention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSP7TAL ADDRESS
�ro �� �osTEn B� ����o��
00884d wsovscoz .
_
INSTALL NEW WINDOW
OIN EXISTING OPENING
I�I � _
O�FIGE
EXISTIN6 WINDOWS
; TO R£MAIN
K I TGHEN
' � � � � � 0 ■ ❑ ■ ■
o � o � �
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ii
ii
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i2,-6„ u �'' GONFERENGE PRO�ESSIONAL
OF�IGE — BUILDING
� �
10'-4" _ �
3' I
II �
II '
� II �
5'-8" I I
OF�I GE � '
� � ,
�
121 INSTALL NEW WINDOWS 1 4�� � �,8��
IN EXISTIN6 OPENIN65 �'
3'-I O"
`� EXISTING DOOR TO
UBASEM T STAIR
� HANDIGAPPED
i
� G 55 BL
�5 � 51 NK t�
6' 48" Gn 5 � �a?`'"�� �/a�
PLAY 3/68 ^��E� r+G ��7��`"� ry'4`�� y�
TH�R�4PY ,� A��� � Cr
TYP I G L HAND I G?�i�PED . L��`'' 1� �"�''
, '"ST°,'—'— "E"' """°°"' S ,4LL L,4YOUT ��i� � �
IN EXI5TIN6 OPENIN6 �
�2' I/2 " = I '—O a;
;� � .� ., �'-�'"
�� 3' 2'-6" �---5'-6�� n ��•..'`.• .-�
� 6RAB BARS SHALL BE ,;� ' /
NOTE: �—I/2" O.D., I—I/2" ',.a,`-� . ' �""^ -
OFF I G� �-L PARTITIONS IN LOWER ARE b F�M �`��, ��_q�� ,': , 'J
SHALL BE NEW. ASOVE FIN. FLOOR ' ; ,-�^�'
ALL DOORS IN LOWER AREA � � s "- �/ ' .'
. r,o,,,
SHALL BE 36" WIDE. r :•%' �� -
+ , �. ;;�..
�-a �%' - -
il
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