29 WEATHERLY DR - BUILDING INSPECTION d` C.1TY OF S�U_.L,m
DEP:ARTNIE.NT
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11J.:9-8-'.1i-7i95 # P\N.')-8-'.10-98.10
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
11NIPORTANT: ,kpplicants must com ilete all items on this page
SITE INFORMATION �+
Location Name t-JOe4'k. t U71 cOCrrlln V}„p Building 19L-
Property Address
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes R3_124_
Residential (3 or more Units) R2 t/
Type of improvement Residential (hotel/motel) RI —
(check one) Assemblyl(Theaters) Al _New Building_ Assembly (restaurants & clubs) A2r_A2nc_
Addition Assembly(churches) Al _
Alteration Business B_
Repair/ Replacement Educational E_
Demolition_ Factory (moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_ -
Institutional (restrained) 13_ ,
Mercantile M
Storage SI MUdCMIC Hazard
Storage S2 ►.ow Hazard
OWNERSHIP INFORMATION(19ease type ur Print Clearly) �
OWNER Name Wect-( ..dj . prlve Gar[/aM)n�rhs
Address
Telephone
Signature
DESCRIPTION OF WORK TO BE PERFORMED
ESITNL%l'F.D CONSTRUCTION COST
Chad 0-6 r
J
CONTRACTOR INFOIL\IA I ION
Name �/ /p5 I tI �a _50 1,1
Address X0ash ti„ ti
Telephone A/
Construction Supervisor's Lic # 7( � 77
Home Improvement Contractor#
,%ItClll'rF:C'r/GNGINEI,'R INFORNIATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEF.CALCULATION .
Estimated Cost x $1151,000 + $5.00=
CONINILN't:S
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the penalties of perjury
Signed (owner) ((gent)
APPROVED BY : ' `�`t✓
DATE APPROVED: ��
Ilo�r�^�:�y11S�W1L1IC�ielfsa1��151fi�T�44i1(/'
HOME IMPROVEMENT CONTRACTOR
` Registration: 1174.30
Expiration: 1013/2013/20f0 TrrY 275407
Type: Private Corporation
ENVIRONMENTAL—RESTORATIONS-INC_—
CHARLES-MINISALLI
10 HAZEL OR
HAMPSTEAD. NH03841
Administramr
I
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID L DATE(MM/DD/YYYY)
N EVIR-2 07 31 OB
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
DeSanctis Insurance Agcy, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
36 Cummings Park ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Woburn MA 01801
Phone: 781-935-8480 Fax:781-933-5645 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Evevaet Indernity Insurance
INSURER B: Harleysville Insurance
Environmental Restorations Inc INSURER C: Commerce L Industry Ins. Co.
10 Hazel Drive INSURER D: Acadia Insurance Company
Hampstead NH 03841 -
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 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.
LTR NSR " POLICY EXPIKAIIUN
TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MM/DDIYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X COMMERCIAL GENERALLIABILITV 4000005946081 06/O1/OB '06/O1/09 PREMISES(Ea occurence) $50,000
CLAIMS MADE � OCCUR - MED EXP(Any one Person) s5,000
X Inc.PollutionLiab - PERSONAL&ADV INJURY $ 1,000,000
Asbestos/Lead - GENERAL AGGREGATE $ 3,000,000
GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGG s3,000,000
POLICY X PRO- LUC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
B ANYAUTOI - - I BA9J3901 04/12/06 04/12/09 (Eaacaaent) $ 1,000,000
B ALL OWNED AUTOS BA19J3901 04/12/08 ''.O4/12/O9 BODILY INJURY
X SCHEDULEDAUTOS (Per person) $
X HIRED AUTOS BODILY INJURY
,X NON OWNEDAUTOS (Per accident) — S —
PROPERTY DAMAGE $
(Per acodent)
GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $
ANY AUTO - OTHER THAN EA ACC S
AUTO ONLY:
AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ 3,000,000
A X OCCUR ElCLAIMSMADE 40UM000594081 06/01/08 ,06/01/09 AGGREGATE s3,000,000
$
DEDUCTIBLE $
X RETENTION $10,000 $
WORKERS COMPENSATION AND - X TORV LIMITS ER
C, EMPLOYERS'LIABILITY. , I WC69G6445 OB/Ol/OB 08/01/09 E.L.EACH ACCIDENT $ 1,000, 000
ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? MA,NH,RI,NY E.L.DISEASE-EA EMPLOYEE $ 1,000,000
Des,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
OTHER
'D Equipment CIM025607810 ' 04/23/08 '.04/23/09 Scheduled $58,965
- Deduct $1,000
DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
ILLUSTRATION OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
ILLUS-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF;THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
ILLUSTRATION OF COVERAGE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESE TIVES.
AUTH REPRESENTATIVE
ACORD 25(2001/08) 9 ACORD CORPORATION 1988
. .. .... ...
Board of Building Regulations and Standards
Construction Supervisor license
License: CS 71077
- I 81rthdatg�__$/25/1960
. Ez IcaHon=--
- 712¢7,2009.._ TrJf 16343
Restaction AO
AWN M.
CHARLES J MINASALCI `
20 CRANE RD
E HAMPSTEAD, MA 03626 Commissioner
{
CITY OF SALEM
I Iti PUBLIC PROPRERTY
> 0 DEPARTMENT
'INI It:R l.IN:)KNCV1.1.
\1� oir 12C WMHI.NGIONSri(m, ♦ SAU'N,M.%ssm:i it sf.'t is 01970
978-115-9595 ♦ 1':sx: 978-740.7846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
iLpnlicant Infuriation ( + (�f + / f Please Print Leeibly
NametlJuciucss0raantruiaNindividuall: CnUtr-z rmJci4 ttpSHaRFlo t t�J^.^C_
Address: to �✓I't-Y ( Oar )ta YI ra a,&4r.Q ✓tl�l
City'Stace/%ip: far �fu2 il/ f Phone +': �3—
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! G. ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 mn a sole proprietor or partner-
listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
I No workers'comp. insurance 5. ❑ We are a corporation and its 10. Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers' comp. C. 152, §1(4),and we have no 12.0 Roof repairs n.
insurance required.] t employees. 1N'o workers' 13.k] Other �°- OPP el CIIJ SA1�4s,
comp. insurance required.)
-Airy applicant that chucks box#1 must:dsu till out the action below showing their workers'cumpenwtion policy infurn,atiun.
' I lomuuwners whu submit this affidavir indicating they are doing all work and then hire outside conunutors must euhmil a new affidavit indiwling such.
�Contmctun that check this box must attached an additional sheet showing the name of the sub ontracturs and their workers'comp.policy information.
I mn air employer that is providing workers'compensation insura ice fur my employees. Below is the policy and jab site
iufurmatiom /
Insurance Company Name: S�'e_ r1(n1+
Expiration Date: A,(
Job SIle Address: a 9 (Or(A0rr��f1� Cityislateizip: 7)Q 6 - IJA40
Attach it copy of the workers'compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of}IGl- c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 and/or one-year imprisomncnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violomr. Be advised that a copy of this statement may be forwarded to the Office of
Invcstigutiuns ul the DIA for insurance covcratc vviticalion.
l da hereby terrif under the pains and pens/tics of perjury that the information provided above is true and correct.
'11L'i1tllllr€ --- :-t•w�y' Dater ��aC/- �$
Phul:u:Y:
Official rise only. Do not write in this area, to be completed by city or from official.
City or Town: Permit/License
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.Citylrown Clerk 4. Electrical Inspector i, 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 emplgree 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 :n individual,panmership,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."
,1vIGL 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, bIGL chapter 152, }25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perforunce 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-insumd 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 till in the pennitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/licetse 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 tilled 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 bur 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 ;my questions,
please do not hesitate to give us a call.
The Dcparnnent'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-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
{0' '" CITY OF SALEM
Ar: PUBLIC PROPRERTY
ra s
DEPARTMENT
.'d 12" A \auM..,INS I:rr ♦ 5A i r M, Nl.\;;\( :.. 'I
Construction Debris Disposal Affidavit
(re(luired 1br all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CN1R section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it 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
t 11. S 150A.
The debris will be transported by:
ono t-✓O 5-fc
(name of hauler)
The debris will be disposed of in
6 PI5_VK s
' (name of I'aality)_
X11 54-y e 1
Lyn )(A"
(address of facili(y)
s aturc of pcumit meant
/-za`*
date ——