48 WEBB ST - BUILDING INSPECTION What is the current use of the Building? V1eb L
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone )
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration# N 3 3 6
Estimated Cost of Project$ 9 SO0 Permit Fee Calculation
Permit Fee$ '7`16 Estimated Cost X$7/411000 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 build to the above stated
specifications. Signed under penalty of perjury X, o-�
Date 0-S —
IlkM �
z,
--
PUBLIC PROPERTY
DEPARTMENT /
MAYOR 120 WmmNcmN b'n F •SAI VUU MASSACHOs617S 01970
141:978-745-959S*FAx:978-740.9646
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION,
DEMOLITION XI
OR CHANGE OF USE OR OCCUPANCY, FOR ANY ESTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
�B cQtb i
property is located in a.conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: HQcek
Address: S�
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing 2—
Renovation Number of Stories Renovated
Change in Use Ne`w,
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation New
of existing building
Brief Description of Proposed Work:
I It�e�G 1 L I A 4 k,01) zFLO o& O
40
- GifinNGC e,0Co H a S .
Mail Permit to:
Information and Instrucuuus
General Law chapter 132 re9uirta ail employes to provide workere compensationa[their employee.
y )� an�09 is defined y" Avmy Pawn in the service of another
under rented
ommi
expmss�implied,oral of written'
amdadm torpew"or other legal entity,or any two or meta
An ucrpfeyer m defined s<"an mdivtdtcsl.partnership.inc ���"Ves of a dearaed emplayec.or the
m a Joint anterprisr.and employee. However the
of the at as tang ang an i� . awocia�n err m a � of do
receiver as ttttpa of sa iod►wdaal.partsashtA or
owner of a dwdlirog bovfe O0t more then totes maintimeaMapatdnmtsconsw
desion walk an such cheating hsoaa
dvra> bows of another who etmtoYs t6a�tawmaha�a ar of loymem be deemed to bean anpbYac•�
or on the groatnds at but nL aPPuctednt soar withhold the faowaes err;
MGL chapter 152.12=6)also statestbat"e'Y state er load Bceuain{a in the asssaweaW tar ANYrenewal of a Sennsoper"to eta a business a eewiraet baddbv
who bas sat produced Wdana of a sa npfian wkY tits lasers'"cersaW l nb&OsWmthan
'Ppddrnooally,MGL chapter 152.$ sin" the commonwealth o until acceptable evidence dcOMPUM with the insurance
enter into auy oft haci for the pa bin pre of public
thec a ..
requirements
of this chapter httw bin presented pteeetad
APt nots apg�vk compktaty.by ebahing the boxes that apply to Your uiutadm ed.it
P s),'ddreL Limited
and Phone dog �no mploym ottbor thin the
;tea. Limitod Liability Comp!n1°�(LL C1 or Litttttad Liability macrana if an l.t.0 or W does haw
members a> 10 carry workers compensation Dqwmwm of hsohtsaid
employe",a policy is Be'� Aised that Me�beessue te my�tpr�and dddate to Me affidavit abaild
Accidents fa of 1 OW&=@ c"en�'��P�err liceata is being requessA net the Department of
be returned or town that;*4 applicationMSUidiiij d*dkmr a law or if you s required to obtain a workers' their
com Sbeotd e!si a the numbs Hissed below. sett insured companies should enter
eamPeaati°°Policy.Pleave all tfa Depatmlid,
self-titntraaa ilaoss tnmtbs on the
CUy of Two Ofllelab at the bottom
Please be sure that the affidavit is complete and Printed legibly. The Department has provided a sQw
of the affidavit for you to till out in the event the office of investigations has to coned you regarding the aPPl WHOM
number which will be used as a colorants mcmbs. ffi addition.i m aPPilant
Please be rum to fill in the ernsiu less se applications in any i➢�yar,need only submit one affidavit indicating cursmt
that mtut submit muletpia PttmttAicenae
policy ialacrosdan(it nocawry)and under"Job Sita Addroea"the applicant should write"all locations of
err mated by the city a town may Provided town)."A copy of the affidavit that has been otlicialtY stomped per of liceosa. A now afudt vir motet be filed out each
applicant as prod that a valid affidavit is on Ella fermi�not related to any btuineae vanaue
at commercial
yew.Whoa a home owner of bu mn is obtaining ro lets this affidavit.
(i.e.a dog licanw at Pswtt m burn lava eta.)said person is IdOT required rAmP
Oaksa otbmw>siffm would bite in thattlt Yes in advance for your cwpaam and should you have any questions'
The
please do not hesitate m give us a all.
The Deparoncoes address,telephone and fat number:
The Commonwealth of Matsachusettg
Depgtmneat of b&un al Aeddeata
OtAa of lavadZI&M
600 waahln9M Sk"
BasM MA Oat 11
TeL#617-727-4900 ext 406 of 1-877-MASSAFE
Fax#617-727-7749
(revised 5-2"s wVyVy.atag VVI&
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
aa<�
MAYM
t10 VA4erw.-rCAr Swear a JUM4 M&WXM=rM 01970
TEL:9711-70"" a FAX MW09M
Workers' Compensation Inset aace Amdavit/ golldeyContraetort/Eleebjeb gW h=bM
Applicant Informatlot.
Plan tet..a r.ats.s..
Name( dual):_
Address:— 0\ jo-j
City/statvzp: '2�� 0 f�� Phone N FBI - I b bd°4 3
An you an employer?Cheep the appropriate host
I.P I am a amployar with 4. Q I an a Smug cemtac0nr and I Type of pn)ed( '
employees(fan andlar part-time).• have hired the d• ❑New construction
2.[3 1 am a Sole proprietor or parmao- lined on the attached sheet•t 7. ®Remodeling
ship and have no employeaa These won haw S. ❑Demolition
for me in any capadry. workers'comp,iasuaoce
[No wodrom'Comp,inA{ranee 5. ❑ We an a corporation and its 9. Q addidaa
3.01 homeowner doing all work tight of have axerei"d thele 10.❑Electrical�or+dMom
myself.(No workers' exemptiO0 Per MOL 11.Q pkumpios at addJNoa•
comp a employees.
[NO we have 12-❑��
msuraoee�)t �pbYeee.[No workers'
contp.insurance requited.) 13.13 Other
Raa�%ft a�6adr ft dal dwh ban e an Q8 air tlr peruse irlow reo.AexffidWk a ewr Woke-
roa4ora+tar pdtey taarrmdaa
rCaassmn60ebuk*kboxz wmanhw="mmaro m aC wet dAerldnau sabamtaiaitaaseaAldrvit�dle�ae� .
sae�6a a-e of rr sob-6
wasamon wd i6dr wal+ae'MMP6 tWay 10 e
I an an ewpfoyer that isptwvi�wt workers'cow
lAf�� Helaine JwtaraM*f#rwl rwP/oyeaa 9adow Is Ad?PO ky awl/ok 0,
Insurance Company Name Edo �iu6irc{ �nSU/Q2r LpLn kv Ofla?
Policy N Or Self-in Lie.M -T,4 UJ a-n 23 z Q ✓
Expiration Date•. �! - r Q— O�
Job sire addre,s:1 8 We55 st . Cityistatarzip: S'a
Attach a copy of the workers'compenutloa poBey declared"page(showing the polleir number nab exphntloa date}F&dum to"cum coverage as miuited under Section 25A of MGL 0. 152 can lead to the impositiae of criminal
fine up to 31.500.00 and/or one-year imprisonment,as well as civil penalties in the Cam ota STOP WORK ORDER amend of Rar
of up to$250.00 a day against the violuar. Be advised theta of this
tnvptigatioos of the DIA for ins•agce coves verdicuiod amtemeat may
Cotwsrded to
the office
of
I do hereby,18160 awlar As poise and pewaMa ojpajwry uYot the te
Sisuaturc:
\YQ Y e \ '� /orwadow provldd abate 4 am and correct
Dare n5 �Gi o�,
OfJleiaf we OxIA Do pot write 1A arts areal to be eowpGbl by cby or jeep o,QfetoL
City or Town: Permit/Lkeme N
["alas Authority(circle one):
I. Board of Health I.Building Department 3.Clryrrown Clerk I. Electrical Inspector S.Plumbing Inspector
L Other
Contact Person:
Phone N•
GTIY OF SALEm
:t
mum PROPERTY
DEPAXrMENP
alvoe t31fnamtianssmr•sau><x..aocas+sOts'fe
�ontir+sas+s•lWas7►�+►+w
Coas&ucdoa Debris ,Dlspaat AM"Va
(segaiced fm an dmou"and ma""wesio
1a exadooa with dso f %HdlW Cbft 7W OA sedift 111.!
eb�is,p eed duo D 10 bsssd aid ft oondidom ft lee dsb&c "be Dolt
"
a of bt o psopss�lloeesM wsreo disposst ddltgt s deAnd by D(R8.e
�wodt.Aeu b.disposed
•n,.de6ete wiu be trwposoed bys
(alms ditsrMr/
The dobdo wig be disposed of in:
(Hams at haiuM
n R
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sieaa4m of prmvt�polkad
dut
tUP
GUARD Workers' Compensation and Employer's Liability Policy
IYorGUARD Insurance Company -A Stock Company
INSURANCE Policy Number FAWC702328
R O Renewal of NEW
NCCI No.[25844]
--. Poll; Information Page...
[i] Named Insured and Mailing Address Agency
FABIAN AND SON CO. FOY INSURANCE AGENCY LLC
9 Valley Street 156 Broad Street
Salem, MA 01970
Lynn, MA 01901
Agency Code: NHFOYPI8
Federal Employer's ID 510-43-8814 Insured is Corporation
[2] Policy Period From April 19, 2007 to April 19, 2008, 12:01 AM, standard time at the insured's mailing address.
[3] Coverage _
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states; Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $100,000
Bodily Injury by Disease- each employee $100,000
Bodily Injury by Disease - polity limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A, and the states of North Dakota, Ohio, Washington, West Virginia, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change
by audit. (Continued on another page)
-
Total Estimated Policy Premium ; 3,489
Total Surcharges/Assessments $ 489
Total Estimated Cost 3,134
623
INTERNAL USE RP Page - 1 -
MGA FAWC702328 Information Page
Date : 04/27/2007 WC 000001A
MANOTE
16 South River Street*P.O. Box A-Ho Wilkes-Barre, PA 18703-0020.www.guard.com