90 WHARF ST - BUILDING INSPECTION (3) L 1 `
(� CITY OF SALEM
PUBLIC PROPERTY
(� DEPARTMENT
OKIDIt5ERLFY DRISCOLL
MAYOR
120 WA$NINGTON STREET $l1LE:bf,MAs$ncli USF_TTS 01970
TEL:978-745-9595♦ FAX:978-740-9846
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page
SITE INFORM ON
Location Nam -Building Property Address '"�
�G\Qn (YV-\ U\"Cl
Located in: Conservation Area Y/N_ �/ Historic district
APPLICATION DATE
Use Groups ReS.aQr,� a\ / Comcrnrc'.
(check one)
Group Homes R3_R4_
Residential(3 or more Units) R2
Type of improvement Residential(hotel/motel) RI_
(check one) Assembly(Theaters) At_
New Building_ Assembly(restaurants&clubs) A2r_A2nc_
Addition Assembly(churches) At_
Alteration Business B
Repair/Replacement Educational E_
Demolition Factory(moderate hazard) F1_
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 S1_Moderate Hazard
Storage S2_Low Hazard
OWNERSHIP INFORMATION(PI type or Print Clearly) `
OWNER Name '
Address S \ 0\910
Telephone
Signature
DESCRIPTION OF WORK TO BE PERFORMED
(a10`C"
r
ESTIMATED CONSTRUCTION COST
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREFT+SAI.EN1,MASSACHUSEM01970
TFJ.:978-745-9595 ♦ FA.x:978-740-9846
CONTRACTOR INFORMATION
Name '-J; M:c`nc c\R-f
Address
Telephone c`b!-`3o-i o
Construction Supervisor's Lic # S"--A 1 O
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name
e Addr
T phone
ass. Registration #
PERMIT FEE CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
COMMENTS
The undersign4appcdoesh ebyatt at all information stated above is true to the best of my knowledge
under the penary
Signed (owner) (agent)
APPROVED BY :-J-,
o� 6
DATE APPROVED: cl
08/06/21009 THU 14:08 FAX 1 781 639 2290 ROCHETr REALTY y Salem Office 0 001./001
_b
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
Burlington, Massachusetts
(800)876-2765 NCCI NO 40959
POLICY NO. L WCC 5001342012009
ITEM
PRIOR NO. IVVCC 5001342012008
1. The Insured Village Construction Inc
Mailing Address: Mr Michael Rockett Marblehead MA 01945
190 Pleasant Street
(No. sine Towner City Coon
4' Sale Try Code
❑ Individual ❑ Partnership ® Corporation ❑ Other FEIN 04.3241709
Other workplaces not shown above:
2. The policy period is frorrp3/11/2009 ro oil'1/2010 12:01 a.m.standard time at the insured's mailing address.
3. A, Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 eachaccident
Bodily Injury by Disease $ 500,060 policylimit _
Bodily Injury by Disease $—. 500,000 eachemployee
C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A
D. This policy Includes these endorsements and schedules: SEE SCHEDULE
4. 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 Premium Basis Rates
Cotlo Estimated Per$100 Fslimalatl
No. Toll Mnual of Annual
Remun¢ration Remunemlim premium
IN1-RA 137531
SEE EXT NSION OF INFOR 1ATION PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 550.00
As indicated,interim adjustments of premium shall be made: Deposit Premium $ 138-00
❑ Annually ❑ Semi Annually ® Quarterly ❑ Monthly
MA Assessment Chg.
$294.00 x 6.3000% $0.00
This policy,including all endorsements,is hereby countersigned by ( t—a_[!!lti 01/27/2009
AUhada.d Signalure D.I.
GOV GOV KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Boson Insurance Brokerage Inc
MA 15022 123 1505 1 1 24 Federal Street 4th Floor
WC 00 00 01 A(11-88) Boston,MA 02110
includes copyrightetl malorial at the National Coundt on Compensation Insurance,
use With its peimisslon.