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25 WINTER ISLAND RD - BUILDING INSPECTION 9L-A"SIdWT-SEfII� APPROVED BY T44E JWSPECTDB ,PFJIOR TP.A PERMIT .B,EINC GRANTED CITY OF SALEM :aN No. (�Ll�/✓ ,�.`' '4 � Date z°z3.OS Is Property Located in Location of _ the Historic District? Yes No Building 15(3'.N'ttwt ' Is Property located In the Conservation Area? Yea No_ r BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Replace, Other: Ne \fie PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name N)-- A0 16ARAH F Fa, Y,3,A l " q rt,,tQ 5, 5R\� Ma 1D\q1 v Address & Phone w 3o_l Sr` V)caren 5 Oa a to Architect's Name P=� a \e_ Address & Phone �'a 'SA— Ha (9-a ) JA4- 8laa Mechanics Name ' Address & Phone L ) What Is the purpose of building? Material of bullding? men GeNcnmcQ. If a dwelling,for how many families? 1 A�Qi.ak' 61.. ie WIN building conform to law? r I Asbestos? Estimated cost 300 4WO City License k N A State License o C3990OR Bare Improvement Signat re of Ap licant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE 1!//^£✓'MO\TR(f1nl�� OT \cC''J 4'Qf.'l�Tl c3� �1.TT� �J 11�; q a� nca..1 MAIL PERMIT TO: 1 V aw i No. APPLICATION FOR PERMIT TO LOCATION:- PERMIT GRANTED ` ADDROV D �9 BOA �srr�� ECTOR B ILDINGS ! I DATE(MMIDD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 10/20/2004 PRODUCER (800)333-7234 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION EASTERN INSURANCE GROUP LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 WEST CENTRAL STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR NATICK, MA 01760 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# 'RED Groom Construction Co. , Inc. INSURERA: Acadia Insurance Company 324 Essex Street INSURER B' Swampscott, MA 01907 INSURER C: INGURER D: NSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDIN 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. INSR ADVI TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICYEXPIRATION LIMITS GENERAL LIABILITY CPA0096951 03/10/2004 03/10/2005 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ SO,OOO CLAIMS MADE a OCCUR MED EXP(Any one person) $ 15,000 PERSONAL A PER &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,006 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY FX PRO JECT 7 LOC AUTOMOBILE LIABILITY MAA18793982 03/10/2004 03/10/2005 COMBINED SINGLE LIMIT ANYAUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ A X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) -' X $500. DEDUCTIBLE PROPERTY t GE COMP./COLL. r ) $ GARAGE LIABILITY .. AUTO ONLY-EA ACCIDENT $ ANYAUTO ' OTHER THAN EA ACC $ AUTO ONLY: AGG E EXCESS/UMBRELLA LIABILITY CUA0096953 03/10/2004 03/10/2005 EACH OCCURRENCE $ 10,000,000 X OCCUR O CLAIMS MADE AGGREGATE $ 10,000,000 A $ DEDUCTIBLE E X RETENTION $ 10,00 $ WORKERS COMPENSATION AND WCA00969SS 03/10/2004 03/10/2005 X '0 sraru- oTH- EMPLOYERS'UABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE E 1,000 DDD R yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 SPECIAL PROVISIONS below A ED/RENTED CPA0096951 03/10/2004 03/10/2005 $50,000. LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPEC WL PROVISIONS ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRnTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Rosemary Fulham PMA n��M•G�Y ACORD 25(2001/08) ©ACORD CORPORATION 1988 �o CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR 1. SALEM, MA 01970 TEL. (978)745-9595 EXT. 380 FAx (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition — - -of-Building-Permit# — ,-all-debris-resulting-from-the-construction-activity— -- ----------- governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, S150A. The debris will be disposed of at: E •-Z D-i 5 :5 4__' Location of'Facility .2 3 4� Signs a of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant s GROom 1 r��cAtcr (0' Q'YN�4 nc Firm Name, if any . . . _ ...3a� ���,x 5-r :56e..,p:u�-,T ►�IA oh9o� Address, City & State The above statute requires that debris from the demolition,renovation, rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S 150A, and the building permits or licenses are to indicate the location of the facility. I ,t The Commonwealth of Massachusetts Department of Industrial Accidents �±� - � -- Oltleeollmres�atlo®s 600 Washington Street, 74h Floor Boston Mass. 02111 Workers'Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors rA name: address: cis state: zip: phone# work site location(full oddressl� ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ 1 am a sole proprietor and have no one working in any capacity. ❑Building Addition ------ —❑—I am aft e,mployer-providing workers'compensation-for my-employees-working-on-this job.e : and ,x �S ' e r. . , i e 'i r �'tiJ"a ,. address. Ma- v F Ya, ♦tin , ... insurance cp. nplterM »"�' ❑ I am a sole proprietor,general contractor,or homeowner(tire(¢one)and have hired the contractors listed below who have the following workers'compensation polices: company names , s address: - > "t` `v y{ •r ry o IN W„�};}L >u a+{3i fiE' E R in arse Y r x $ 'e? v .''�.::t Company name.e.. ,• `. ,+ •' - " addrEffi: 441 . *� , �., .�.,rca'f"�'� to F .� €• rF in Failure to secure coverage as required under Section 25A of MGL 152 can Ind to the Imposition of criminal penalties of fine up to$1,500.00 and/or one yam'imprisonment m well as civil peaalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the?"formation provided above is true and correct. Signature Date Print name Phone# omcial use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department []Licensing Boerd ❑check if immediate response u required ❑Selectmen's Office contact person: hone#; ❑Health Department I ,e„W shcsl.nsn) P ❑Other Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",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 ajoint 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 section 25 also states that every state or lac—al-licensing agency shall-withtrold-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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits maybe returned to the Department by mail or FAX unless other arrangements have been made. The Office of'Investigations would like to thank you in advance for you 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 =8 a UNIS11D81118as 600 Washington Street,7'"Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406