70 WEATHERLY DR - BUILDING INSPECTION (3) res, n ��/ r��J1es —
What is the current use of the Building? el
Material of Building? �c'arfs a bx f dwelling. how many unit ? E7
Will the Building Conform to Law? ts Asbestos? N
Architect's Name ,V 4
Address and Phone A114 ( )
Mechanic's Name /jPi leG76A/,t
Address and Phone
Construction supervisors License 0 CAS OS-Z'1-.72 HIC Registration 0
Estimated Cost of Project
t$ / 10L` kd Permit Fee Calculation
Permit Fee$ 3 Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial -
`7 An Additional $5.00 is added as an
Administrative charge. '
Make sure that ail 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 statedd�
specifications. Signed under penalty of perjury
Date
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PUbLIC'PROPERTY
DEPARTMENT
ICI\N�� �D�15C1H1 f'/
WAYDI 120 WA5MNGWW-SMEEr
&M-Lt{MAstAOHLSkIIS 01970
TE1:978-745-9595•ftc 97`740.9"6
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Nams: uc% 4G`j Building:
Property Addresr. /
Property Is located in ;Conservation Area Y� Historic District Y41j--
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: `Sad S'c lafs�/ die _
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing 1�/� /ar/
Renovation Number of Stories Renovated I
Change in Use N
Demolition Existing t/,W/ 02-�
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
EWd Description of Proposed Work:
'Ti{c A'i4- f er ��c4r� irPc� Ofiviv i s /oY 4 6a
CP�/ie s'.„r��s f- ^i�'zuc•�� ,, ��..v7r. krk//Fi'.t"'' �z�� �e�cessr�'
Mail Permit to: ^7v7�o/uo- 'r-3 fro s fv
Safety Insurance Company
20 Custom House Street
Boston,MA 02110 Businessowners Polic
1-800-951-2100 y
Renewal Extension Declaration
Direct Bill - Insured Declarations Effective 07/24/07
BP00002706 07/24 07 07/24/08 12 : 01 AM STANDARD TIME 33051
..........
KEITH MACDONALD TARPEY INSURANCE GROUP , INC .
253 CENTRAL STREET 442 WATER STREET
GEORGETOWN , MA 01833 P .O . BOX 567
WAKEFIELD , MA 01880
Phone : ( 781 ) 246-2677
Form of Business: Individual
Business Description: (S)Carpentry-interior
In return for the payment of the premium,and subject to all of the terms of this policy,including forms
and endorsements made a part hereof,we agree with you to provide the insurance as stated in this policy.
COVEREDLOCATION(S)
LOC: 001,BLDG 001: L:)i CENTRAL—STREET,GEORGETOWN,MA 01833
PROPERTY
This policy contains a S506 deductible unless otherwise specified isee additona] cover�axes section),"
LOC BLDG COVERAGES LIMITS OF VALUATION O AUTOMATIC
NO NO I —INSURANCE CLSI E INCREASE
001 001 Personal Property $17,030 Replacement Cost 04 %
LIABILITY MEDICAL .EXPENSES
Except for Fire Legal Liability,each paid claim for the coverages listed reduces the amount of insurance we'provide
during the applicable annual period. .Please refer to Para rah DA.of the Businessownters Liabili ty Coverage Form:
DESCRIBED COVERAGES LIMITS OF INSURANCE
LIABILITY $1,000,000 PER OCCURRENCE
MEDICAL EXPENSES $10,000 PER PERSON
FIRE LEGAL LIABILITY $100,000 ANY ONE FIRE/EXPLOSION
—,ADDITIONAL COVE GES /_ OPTIONAL. DVERAGES, :-•.-PROPERTIY.
The following additional/optional coverages are afforded under this policy.
Some coverages are subject to deductibles specified in the 1)olicv forms.",
LOC No BLDG No DESCRIBED COVERAGES LIMITS OFINSURANCE
ADDITIONAL COVERAGES, / -OPTIONAL,. COVERAGES,___ LIABILITY
LIABILITY.:
The following additional optio I n.a I coverages are afforded under this poll I icy.
DESCRIBED COVERAGES I LIMITS OF INSURANCE
PREMIUM
Annual Premium $2,215
PAGE 1 141 D1r1ESJEA1VE
Insured Copy A 11 0 R RESE A�W
07/05107 (Print Date)
I
OT
•.:s.:;�_ BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 056432
Birthdate:.08/31/1962
Expires 08/3112008 Tr. no: 28710
Restricted• 1G".
KEITH A MACDONALD
253 CENTRAL ST t
GEORGETOWN, MA 01833- ztz
Commissioner
Roar n Rol ing cgu a ions and Stan ar
�'nL1 HOME IMPROVEMENT CONTRACTOR
Registration: 111834
Expiration: 214/2002009 TAf 127372
-:Type:.:..,DBA
KEITH MACDONALD CARPENTERIWOODWORK
KEITH MacDONALD
253 CENTRAL ST -
GEORGETOWN, MA 01833 Administrator
CITY OF SALEM
40
PUBLIC PROPRERTY
DEPARTMENT
,,U: mlar AMA''L
al��•s tDC'1.�9N::.�ciJttT�iu:1L�`�twr.t�ls::'1.
Tn.rO 4p M•f.%a WW4&%%
Construed** Debris Disposst Amdavit
O t;taiml for all demalwats and rtanovadam wart)
Li xeonlaoes with aw dxdt edddoa of dw Start Building Cade.730 CUR Swim 111.S
Debris,gad the provisions of MCL c 40a 3 SIB
SW Wr4 pmn — is issued widt the canddos drat the ddois rewidns ftm
this wad shall bt disposed of in a pmperty licent"wash disposal flteility as dented by MOO a
IIL.s15"
The debris will be transported by:
_elmelr z� .r,
JOAMIfhe&btis wilt be dispased of in :
t aama of fxtGty)
At
,w
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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tastL M+ssung.%iisbHTJ
pu 97 ?4$- S% .F.sx:9W4o. W
Workers' Compettl atloa Insureaee Afftevft: BaildenlCootnutorWE tMda&Lq tmben
-%owhant Information Kum ftialliitefW
Name jamnesslortinu iav
Add 71
City/statwzip:_(g e e Gr.AO off ('hone
Are yom sae=PbYW?Cheek the approprht•bsm _
1.p 1 am a employer with 4. p 1 ant a swordJ=j:
eta roe f Type arProJ�(rMg1�
pwrOU(rull amVor parwinY).• hgve hired themrseums 6• p,.,� Nfew�°�a.ntetiae
2. 1 am a sole proprietor or Partner- listed on the attached allies, t 7. YeJ'Ramo Uns
�`�nip and have ere emPloyeea ibe.. h.v. x p Datrolitiog
warltias for rtar is,any capacity. workara•tam .ttos, v.
(ne water••comp ituuratte• S. p we an.corporation arul fa ❑was additim
regnlrgL] Otlleafa have C {I their 10•p El.altteal repair.Or additions
3.❑ I am a hameowna doing all work right of ettompr MGL I I.p Plumbing repair.or a/klitiata
tnyselt(No werkars•comp. C. 152.11(4).a have no 12.p Raof mpaiainst1fance required)r crnPICY�(1•' ers•ired] 13.p Other
Any wp►n+urr aeetta cgs in aeer ahW 0 cur a■real hu4er mtrw astir n orkgg arapepetfun Drdw9 n.Ygeaioa
ew.ww�.. .�.ft dismit this a MIAMaffidIr cbW MWom a s■r W"its di wart am an ere eeaw.a.we.r..ew.Wwtk a eew.mr.a
r,wrragera ur ace.te:iota soli araderrl erg aldtlmel oral.rowans tee rage of am ar►mnaaom arrt ere.rewkae• ry NL%o •"rt.
�v�ky lekr.aaea
/aYr Yn rmp/oyer that 6 prOwding workers,roarpenraden/nsYranc&jar way rnrplayers Be/ow!s rhr tnsq s
9l 2..
ye PoB _ .!k._.
Insurance Company alanw.
Policy•at Self-its. Lie.• - -- Expiration Date:
Job Site Mhtcsa: City/sIatuzip:
.%ttacr a cupy of the workers,compensating policy declaration paps(showing the policy number and expiration dart),
lfailure 10 wcum coverag6 as required under Section 23A of.&IGL c. 152 can lead to the imposition oferiminal penalties or&
ri n.up In SI.500.00 andtar ore-year imPrisaanem.is well as civil Penalties In the form of a STOP WORK ORDER and a ruse
a(up to i250.00 a Jay at(uinal the violator. Ile adviacd that a wpy of this statcmcm may be lurwarded to the Otlice tit
u�sngau rru VI'the DIA for uxuranec covcra0 ecrificauan.
/Ja hereby tort ju rQii rhY ias uidnY1/Ir rr Met Me InjarnYNan praridcd abo f is r/W Ynd r0/rrrr
�i,•:r.r i rr•.
rlL tee.7: _g7Z 77/^ G 73-r-
=Pefsou
unljt An mar wrliv/w tAk are^tobsev= kradbyc'ror Mere a/J$/YLn Pcrmitil teaseeurily (circle one):lealth 2. pudding Department 3. Cityffoao Clerk a. Electrical IusPccror S. Plumbing inspectorou: _ Phone p:
Information and Instructions
Massachusetts General Laws chapter 152 tequi all gnPloyers to Provide workers' compensation for think entploy"s.
service of another under any contract of bir
pursua+t to this autuu.as eas/tgrs
is dsRrrd as«.•fussy Person is the R
tWorse or impliod•and at wrhga."
_ assetiellttR saPsitanoa a odtsr kpl endw'or,any tw0 b male
of tM fats>aoaltw en a � k�rhe
q°ves of a%amplo employer.�lM
receiver ar trartes of a•i dry►dud.P+rot+rshir,+�LOOa at olller lea cadW.�oy1O� °M otthe
bmuse ban"in{east mert thaw due apamneta sad wha ttegi - tb+sait►Q the ooeupw
owner
wed othosssadr wAo Y+parsons m do pe.cuosaucoon or repair work am web dwelling harmer
at an she grounds or building; PPo�nIM mesa s6sB set beearuse of tattt►aampiaym+ot deenwd g b.an eapbyer.
a
MGL cloOff 152.42SQ6)am emtb d""every state K Meal Neessivis orw shall wkkbabt Me Is"an"K
b Operate a beshess K to eetWeott bWdbP la tM cam esees"ess"tee MW
raaawd et a YaanM K H+�M eviaeace of compliance wuh the insurance eevenp tfgalnd."
�"nt who tun set Pr""ea stints+uY of id polilit+i subdivisions sbsa
,additivnalb•Mt3L chapter air theSPerformana of pubbc tbs ell sees Mlle e a
work until aceeptxbk evtdtroee of eamplisrtee w ith tM ituslrsnes
owner imia any of bait' chapter bave been Presented to the contracting audoelty
ApPlksale to out dhAd"and.it
tion aftkbvit convplately by cbeck eking t) boxes that apply Y
Please y od ly addreastes)and phone numnber(s)alone with their employean of
naeesaaey.appply Companion L�or[invited LisbiNty PinsurardsetgbiP+(LLP)with no empMytmas other rhea the
. manc L � required to c� w �.men insurance !tars LLC or LLP does have
or
employees.a Policy is mluired 8e advised that din aRld+vu may be submitted to the Department of
Accidents for cmArmaden of ins nmee coves Abe be sun to sip and date the affldavM. The affidavit should
be resumed to tM city all town dot the application for the permit ac license is being requested. not tits Dapseease+t of
the law or if you an required to obtain a workers'
industrial Ara ide le ShouldPm you il the
any td nub�below. Self-insured companies absurd eater their
cotspartaation Policy
self-i"ssursue+liearmb tstonbK min the
City K Towe OQicisla
Please be sure that the affidavit is comp leti and pruitod legibly:' The Deps mww hse Provided a spa"at the hottest ...
of the at fidsvit far you to fill out in the event the Office of Investigations has to contact you reprdinP the apPlieaus.
on,an aPPliciLgit
m'I,ease be sum to till in tM permit/dim ei"number which will be used m n reference only submit one affidavit to indicating current
that must submit multiple permitllicanw appileations in any given should write"all locations in___(city or
policy information(if necessary)and under"Job Site Address" aPP ho city all town mnay be provided to the
tower"A copy of lM nffldavit that bag been officially stamped or marked by tYbe
applicant a proof that+valid afild vit is on rue Por icons o rmuanit licenses.it Ao any business ffidavit of om commercial 1 venture
year. Where a ham owner or citixca is obtsiniat+license or pen
a dot{lice""or permit to bum leaves ere.)said Perna u NOT required to complete this affidavit
Chc 01'1LX of Investig:itiuns would like w thank yw in advance for your cooperation and should you have any questions.
lease du rwt hesitate to give us a call.
The M.partment's address, telephone and fax numbs+
The eomamwealth of Masilwhusem
DCPUU M otlndust W Accidents
oft*of ln"sdgk&M
we Washin om Street
Bosom,MA 02111
Tel. Al 617-727-4900 t d 406 of 1-977-MASSAFE
Fax 0 617-727-7749
tcviacd 5-26-05 www.mm.gov/dia