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26 WINTER ST - BUILDING INSPECTION
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EITY-O"AL 1 -- PUBLIC PROPERTY �\ DEPARTMENT Permit for Demolition and Foundation only KI.%IBFJU.EY DRISCOLL �\ MAYOR 110 WASHINGTON h rREer•SAI1+K,MA,hSACHMI-M 01970 TEL-978-735-9S95 #FAX 976.740-9846 APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION DEMOLITION, OR R CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: Washington Square Building:Joseph Story House Property Address: 26 Winter Street Property is located in a; Conservation Area Y/N N Historic District Y/N Y 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Neil Chayet and Martha Chayet Address: 26 Winter Street, Salem, MA Telephone: 978-745-0003 3.0 COMPLETE THIS SECTION FOR WORK IN EXISI.ING BUILDINGS ONLY Addition yes Existing 3 Renovation yes Number of Stories WNew 3 Change in Use no 1 Demolition of Garage yes t fl 2460 d fl 1460 Approximate year of 1,851 Area per floor (sf) d fl 1470 construction or renovation of existing building 1400 Brief Description of Proposed Work: Demolish detatched garage and renovate three story house and add one story two car garage and kitchen. Mail Permit to: _--- T . What is the current use of the Building? residence Material of Building? brick & wood If dwelling, how many units? three Will the Building Conform to Law? yes Asbestos? yes Architect's Name Richard Rice Lon Address and Phone Newport, RI ( ) Mechanic's Name Delulis Brothers Construction Co. , Inc. Address and Phone 31 Collins Street Terrace, Lynn, MA Construction Supervisors License# 039580 HIC Registration# 109784 Estimated Cost of Project$ 50,000 permit Fee Calculation Permit Fee $ 355 Estimated Cost X$7/$1000 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 Date 11/13/06 CIO O 1 I CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KnNREaiFY DRLSCOLL MAYOR 120 WASHINGTON STREET*SAIEM,MAsSACHUSEM 01970 TEL-9M745.9595 •FAx:9M740.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lealbly Name(Business/Organization/[ndividual): DeIulis Brothers Construction Co. , Inc. Address' 31 Collins Street Terrace, City/State/Zip: Lynn, MA 01902 Phone#: 781-595-8677 Are you an employer?Check the appropriate box: Type of project(required): 1.❑% I am a employer with 25 4. ❑ I am a general contractor and 1 6. ❑New construction employees(fiill and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. ©Remodeling ship and have no employees These sub-contractors have 8. ®Demolition working for me in any capacity. workers'comp.insurance. 9. ®Building addition [No workers' comp. insurance 5. [1 We are a corporation and its required.] officers have exercised their 10.3 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.®Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.© Roof repairs insurance required] f employees.[No workers' comp. insurance required] 13.❑Other. 'Any applicant d st checks box III must also fill one the section below showing their wodtes'compenution polity informatlos f Homeowners who submit this affidavit kdiaung they ne doing all work and then him outside conttastors must submit a new affidavit indicating seek, :Contnectors that check this box must attached an additional shad showing the name of the sub-camnictors and their workers'comp.policy information, lam an employer that is providing workers'compensation insurance for my employees Below is the polley and fob site information, Insurance Company Name: American Home Assurance Co — (see attached) Policy#or Self-ins.Lic.#: CPA130127616 Expiration Data 1/1/07 Job Site Address: 26 Winter Street City/State/Zip: Salem, MA 01970 -- Attach a copy of the workers'compentatioat policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,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 violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. f do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Date 11/13/06 Phone#: 781-595-8677 OJJleial use only. Do not write in this area,to be completed by city or town off vial, City or Town: Permlt/Llcense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#' Information and Instructions Pursuant Massachusetts tts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another undo any contract Of 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 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,§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.MGL chapter 152, §25C(7)states"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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary.supply sub contractors)name(s),addresses)and phone numbers)along with their certificates)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 irmirance. 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 can the Department at the number listed below. Self-insured companies should enter their self-insurance license member on the a 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 fill in the permittlicense number which will be used as a reference number. In addition,an applicant that moat submit multiple permit/license 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:pernits-orlicenses.. A.new af:,dsvk must be filled 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 bean 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 any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number The Colnlnonvicalth of Massachuset49 Department of lndustrial'Accidents Me 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.nim.gov/dia ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYY) TN 0 /Y7/05/2006 PRODUCER (978)887-4900 FAX (978)887-2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOESNOT AMEND, EXTEND OR 16 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 - Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC # INSURED DeIulis Brothers Construction Co. , Inc. INSURERA Acadia Insurance 31325 31 Collins St Terrace INSURERS: American Home Assurance Co Lynn, MA 01902-2205 INSURER INSURER O: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDINt 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 ADD'L TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MMIDDM' DATE MMIDDIYY GENERAL LIABILITY CPA130127616 07/01/2006 07/01/2007 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGET RENTED $ PREMISES Ea oc.ance 250,00 CLAIMS MADE 1XI OCCUR ' MED EXP(Any one person) $ 5,00 A PERSONAL&ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PRO LOC ECT AUTOMOBILE LIABILITY MAA130127715 07/01/2006 07/01/2007 COMBINED SINGLE LIMIT $ ANY AUTO (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) PROPERTY DAMAGE $ ,(Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLALIABILITY CUA130127815 07/01/2006 07/01/2007 EACHOCCURRENCE - $ 10,000,00 OCCUR ❑ CLAIMS MADE AGGREGATE $ 10,000,006 A $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC893-39-72 01/01/2006 01/01/2007 0PRYLIMITS ER EMPLOYERS'LIABILITY B ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? If E.L.DISEASE-EA EMPLOYE $ 1,000,00 SPECIAL describePRO ISIO SPECIAL PROVISIONS OeIow E.L.DISEASE-POLICY LIMIT $ 1,000,00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT)SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL City of Salem 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Building Dept BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 120 Washington St OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHORIZED REPRESENTATIVE Robert Sennott/LA ACORD 25(2001108) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) CrrY OF SALEm :' PUBLIC PROPERTY t DEPARTMENT w,aWt,e►tatroou. N.rae taow�umttnon stmr�sus�x�a�oayartsOt!'Te ty1:47fTii9Saa�FNe flLT�49eta Construcdon Debris DtsSmat Affidavit (required fa an daoo(idon and renovatiest wart) in amadame with the sitteh edid"of the State Hnn ng Code.M CUR setdian!!1.5 Debri%and die psovidone of UM a 4%S% Buildini ft- A is Caned with the conMon that the debfie rending IWO this wort&a be dispow d of in a properly hmsed waste disposd bdnty as defined by MC$.o l t 1,s lea►. The dews will be transported by: Northside•Carting (mom efbwtso i The debris win be disposed of in: 12 Swampscott Road (name of txitit» Salem, MA 01970 (addrm of heiliry) sisaamn of pemtit tpF(kyns 11/13/06 date 'e6n.r?'Jut