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284 WASHINGTON ST - BUILDING INSPECTION -CITY-op-SALE - �� PUBLIC PROPERTY DEPARTbIENT KIMBORLEY DRISCOLL MAYOR 120 WASHINCTON SI'RF.Er*$ALL l MtSSAC}{1561"IS 01970 TtL-978-745-9595 0 FAx:978.740-9846 APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION DEMOLITION,OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: Building: Property Address: a ky VW h 1 kxl di Property is located in a; Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: �U�1 Address: VVW si, kUfel* Telephone: G(� W S'7 6 e 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation ✓ Number of stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: V,u� I � �b►tu�� c ruJU la he,Iv boovb) i ce wf Mail Permit to: What is the current use of the Building? Q-eJ Ift►LC" ^ Material of Building? ��C m� s�t�CCU - If dwelling, how many units?— Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone Mechanic's Name JJWJ ,f"I— rp Inc, Address and Phone Construction Supervisors License# HIC Registration# Estimated Cost of Project$ ILILW Permit Fee Calculation Permit Fee $ f 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 d to the above stated specifications. Signed under penalty of perjury X Da a 7 5 O r�i •J 6 to O I o CITY OF SALEM PUBLIC PROPERTY . DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASHINGTON MMEET♦SALEM,VtASSACHUSETIS 01970 '1L.:978-745-9595 • FAx: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; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) s*replicant ate Irbiistifduc CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASI IINGTON STREET *SALEM,MASSACHUSETTS 01970 TEL: 978-745-9595 * FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print/L,�e¢ibly Name (Business/Organization/Individual): ' f �� C1Mv JI FI lP� / .�� Liy Address: :700 CG Memel, s` city/state/zip: J , h1 YY Phone #: _ tft 7`LY-17d' , L7-J'd3- Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I ❑ 6. New construction employees(full and/or p time).* have hired the sub-contractors 7. �e 2.❑ I am a sole proprietor or partner- listed on the attached sheet. tmodeling 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.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ 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 must 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. [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: I -elidiCaa-) (�!-y t e&6.- Policy#or Self-ins. Lic.#: yi Cryy" F( qtf— ^�C Expiration Date: / o Job Site Address: d( J— kk-06GG"Ov City/State/Zip: Attach a copy of the worLrPcJmp'eA1a't1i31 o icy dec oration 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 certi and r the pai s and penalties ofperjury that the information provided above is rue and correct. Si nature: Date: Phone#: 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 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-NIASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia AMERICAN HOME •ASSURANCE COMPANY 137,81 71991-0000 • WC 894-19-2C -------------------------------------------- 013-82-o6o6-oo •-•o• . o . - . NEW YORK AMERICAN EXTERIOR b WINDOW, INC. 300 COMMERCIAL ST. , SUITE 2 7 M ON, MA 02 1 1 0-0000 emberam Companies of American interna tional Grou p EXECUTIVE OFFICES: SEE NAME AND ADDRESS SCHEDULE - WC990610 70 PINE STREET, NEW YORK, N.V. 10270 LD# MA UI UETT COMER WORKERS COMPENSATION AND EMPLOYERS EKINGSTON, BROKKEMSTCIAL INSURANCE AGENCY INC LIABILITY POLICY INFORMATION PAGE MA 02364-1 lo9 INSURED CORPORATION PREVIOUS POLICY NUMBER RENEWAL 007228490 OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC990610 ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insunad's mailing address FROM o6/08/o6 TO 06/08/07 ITEM A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation here: Law of the states listed 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 $_ 500.000 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 OC 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. Classifications Estimatetl Total Rate Per Estimatetl Code Number Mv Remuneration $100 OF Re- Premium LAJ Annual ❑3 Year anuneration Annual ❑3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $264 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $284 MA MINIMUM PREMIUM $500 MA IT indicatedbelow, interim adjustments Ipremium TOTAL ESTIMATED PREMIUM $OO 40 M1 llb tl ❑ Semi-Annually ❑ Quarterly ❑ Monthly DEPOSIT PREMIUM ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM SCHEDULE - WC990612 04/19/06 PARSIPPANY 82 slue Date 39967 Issuing Office Authorized Representative WC 00 00 01 Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 135991 Type: Private Corporation AMERICAN EXTERIOR AND WINDOW INC. Expiration: 5/30/2008 JEFFREY NADLER 300 Commercal Street suite 2 BOSTON, MA 02109 — -------- Update Address and return card. Mark reason for change. oPs-cai „ ;oM-oaios�acessa f -I Address ;] Renewal i J Employment E 1 Lost Card