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28 FEDERAL ST - BUILDING INSPECTION �$ G�dk St Il%N l' APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS I.N111ORTANT: Applicants must cunt Clete all items on this page SITE INFORMATION Location Name Building Property Address Located in: Conservation Area YIN Historic district APPLICATION DATE ►} 13 09 Use Groups (check one) Group Humes 123 Rd C Residentialor more Units) 11 ( 2P 'type of improvement Residential (hotel/motel) RI - V (check one) Assembly (Theaters) Al — New l _New Building_ Assembly(restaurants&clubs) A2r_A2ne_ �f Addition Assembly(churches) At Alteration Business B Repaid Replacement_ Educational E_ 1 Demolition_ Factory(moderate hazard) Fl Move/Relocate Factory(low hazard) F2 VVV Foundation Only High Hazard 11_ Accessory Building Institutional (residential care) 11 _ Institutional (incapacitated) 12 Institutional (restrained) - 13 r Mercantile 111_ //' Storage SI _Moderate Ilazard 101 al, I Storage S2 Lim Ilizard (111'N FRSI HP INFORM:HON(Plea se� yyc pe nr Print C'Iearly) OWNER Name /t y� S,9lEM C0/0.Dl 1/sJaw 27- kS.So,-14r16 Address FFdERXL 5T, i's1)-91n g,14 , 0/�70 Telephone -639— Y Signature I' p oc KP DESCRIPTION OF%%ORK TO BE PERFOR,IIED /(�n- ((�� �� // r� F2r✓rSF6 d VV> � 7ft;1— 61,1 40C/A)6, . J,20) Y . (N/�/Vba a�1 AwD �ao2S _ �j/y�' 1•S I INIA IFD CONS"I RUCTION COST �2 `'�7 S— / . © 0 CON"I'RACTO It INN OR. IA 1'ION � ►1I Name J;UJo �V�osr to Address ;:),5 DRnVIS I---T7P Telephone 6n—a.la- OV23 Construction Supervisor's Lic # ca Home Improvement Contractor # 13C340 JS MWIII'I'EC'I7ENGINEER INFORMATION Name 0 OZirs Address )D Ae9LVA VAn Telephone Mass. Registration # __ t PERMIT FEF.CALCULATION Estimated Cost x $11$1,000 + $5.00= CONINIENT S The tnhdersign ap licaut does hereby attest that all&hforntation stated above is trite to the best of my knowledge under the pet alties of perjury ' Signed (owner agent) APPROVED 13Y : DATE APPROVED: to r of m mg egu aho an lander s Construction Supervisor License License: CS 814P8 Birthdate:'-7/28/1969 Expiration: 78/2009 Trp 16319 . Restriction: 00 CHARLES E HUNTLEY-JR 25 HEARD DRIVE ^-,,�`'., IPSWICH,MA 01938 :-'�-''-`� Commissioner i Xie etl Boar o u>1 meld ons_ an/�'tanRards g g One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 123615 Type: Private Corporation _ Expiration: 3/14/2011 Tra 281050 Schernecker Property Services, Inc Fred Schernecker 179 BEAR HILL RD WALTHAM, MA 02451 Update Address and return card.Mark reason for change. E] Address ❑ Renewal 0 Employment 0 Lost Card 0PS-CA1 0 40M06a&DBSLIFORMCA10021200a r t ;� Bo d ofau�tng llegutado �aod"Siinda.4rs!ls License or registration valid for individul use only4. HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 123615 Board of Building Regulations and Standards One Ashburton Place Ras 1301 Expiration: 3/1412011 Trd 281050 Boston,Mo.02108 Type: Private Corporation Schernecker Property 6entl6ii.inc. Fred Schernecker '- 179 BEAR HILL RD �.,4..,GLe...�. Not valid without signature WALTHAM,MA 02451 Administrator CITY OF SALEM `jqj ,' , PUBLIC PROPRERTY DEPARTMENT . I'll . nI I Ixl+l•11 1 �I M1 11: W,NInNC ION SI:lLLT • 5.0 I'\/,M.w\w.%, I It if 11%X197_- 11%1. 1'77_- 1i.1. 778-713.9593 • 1:%X 97y-71C'1846 Workers' Compensation Insurance Afftdasit: Builders/Contracturs/Electricians/Plumbers % 1 tlicant Information // Please Print Le ihly N illnl:Ino.1111wsa)r�amr.UinNInJl+idual l: /1/ 6e 1ddress:172 i F,IIR L/AG ndo C:i1y,SratC./ip•�/1�l4/ � A 4a�q"/')'hone i!: 617 2/7c;� .ire +ou an employer'! Cheek the appropriate bo:: 'Type of project(required): Q ❑ atn a general contractd Ior an 1 :un a employer with� 4 1 fi. E] New construction engdoyecs(full andlur part-time).' have hired the sub-cuntracturs 2. 0 I ,un a sole proprietor or Panner- listed on rhe attached sheet. 7• ❑ Remodeling ,hip and have no employees These sub-contractors have S. ❑ Demolition %working fill me in any Capacity, workers' comp. Insurance. q. ❑ Building addition INo workers'comp. insurwnee 5. ❑ Weare a cntparation and its I fihave exercised their l0.❑ Electrical repairs or additions rryuircJ.J ofcers 3.❑ 1 ant a homeowner doing all work right of exemption per MGL 1 L❑ plumbing repairs or additions myself. (No workers' comp. c. 152, g 1(4),and we have no 12.91 Ruul repairs insurance required.) r employees. iNo workers' s d✓D IJ.❑ tither comp. insurance required.) �D/s✓�i' �/ •wu� .,Ipbcanl Ihet decks box rII n1aY1:11101111 utlt the wcnoll IWInw iilowilly I11,lr wurkua'cunlprnuaiun Iwtay ndilrrtuliun. 't lumeuwnen who tnbitul this affidavil indicA,mi;Ihe)are doily all work 111)II1ln him W111de cwt,wian m WI 1417mll Anew JIndavil intli Yin`„1Ch. C,•m rxuln shat thcck thin box mtultawachcd an addeiunal sheet.huwnly nw-1m1w of the tub-contractors and their twrkaW comp.policy 1nfllrinnnun /um un lvup(uyrr that is pruridinq rvurkcrt'c•mnpentntinn in.turvulce jar lay elnpluyrc•.r. Behnv is rhe pu/fcy mol fob rile I/IjUnotion. r I n,uranuc Company Natne:-�,Q Q ���17� / //U� T/,.t1 U/v/f/✓G�j_- llohi .v a ur Sulf-inn. Lic. r': wq7lD / 440 . _ Expiranun Date:(' h/�?/ �Gq�J p�7/T/ lob Site Addres.%;j .��6klfG �T- Clty;SlataZlp:��A/�i d//1. /r111 , 0/5`70 7 7 /�/ Attach it copy of the workers'cumpenxation policy declaration page(showing the policy number and expiration date). hallurc u/secure coverage as required wider Sediun '_5A ul MUL c. 151 can lead to the imposition of criminal penalties of a Ane up to 130.500.00 und/ur one-year imprisonment,a4 wrcll us civ it penalllu fit the loan of a STOP WORK ORDER and a fine of up at 51-50.00:1 day against the vwh(or. sic advl.ccd that a copy of tilt statcineni may be Iumirded to the Officc of Im:..usaunro ul :hc OIA :or inauarcc alwcr.tgc wcri Beason. I du hereby l ertify ender t e point and p3�odhev of per%nry that are ilajorinallon provided u ore ' true and correct. \I •'W illsd -- --- - — Dif— / t)/Jiciul sue Lady. /)) lull -,rive in thi.t area. to be rumpleted by lily ur lown ajficial. I ( iIv u I'ou'n: ... Permiul.ieentt d I,,uing.\Whurily (circle life): i I. D11arJ of IIr.Jill !. Budding, Dcparuncut .1. Ciel.-fut+u Clerk 4. L•'lectrical Iotpceror 5. plumbing lo+peetor L. Of her _ ('ontacl l'crsmr: .. .- I'hone it: Information and Instructions Iass.Ichusetu Gcncral Caws chapter I i2 requires all employces to provide workers' compen;.ulon hnr their cnlpluyces. I>ur.u.mt to dos.lalute, an rmpluree Is defined.0" er cry pclson in the service of another under any conuact of hire, c vpre>s or impllcd. oral or written..' \n employer 1s defined as"un Individual,partnership, association, corporarlun or other legal entity,or any two or more ,.r the loregolr;g engaged in a pant enterprise. and including the legal representatives of a deceased entpluyer,or the recelver or trustee ul.ui utdrvldual, pa mcrr hip, association or other legal entity,employing employces. Howeaer the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the who employs persons to do maintenance,cun+tructimn or repair work on >uch dwelling house I use If Y pe , dsv�lhny w P or oft the grounds or building appurtenant thereto shall not because of such employment be-deemed to be an employer.' >IGL chapter 152. �25C(6) also states that"every slate or local licensing agency shall yvithhold 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." .Udinonally, MGL dmpter 152, a25C(7)crates"Neither the commonwealth nor any of its political subdivisions shall cnoer into any comract for the perfomnance of puhlic work until acceptable evidence ul-cumpliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary.supply sub-contractor(s)name(s), address(es)and phone number(s)along with their cerlificute(s)of LLP with no em Io iecs other than the � rice. Limited Liability Companies (LLC)or Limited Liability partnerships(LLP) P Y mema Y ed to car workers' compensation insurance. If an LLC or LLP docs have nets are not required carry P members or part q employces,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 dale 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. Self-insured companies should enter their selr-insurance license number on the appropriate line. _ ('ity or Town OMAN Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of tale affidavit fur you to fill nut in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permitaicnixe applications in any given year,need only submit one affidavit indicating cunent 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 permits or licenses. A new affidavit must be filled out each year. Where a hums,owner or citizen is obtaining a license or permit not related to any business or commercial venture e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I h.: I)dice of 111�estlgatlon> would llnc to thank you in Avaiwc fur your cooperation and should you ]lave.my questions, Incase do out hesitate to give us a call. ncc Dcparunent's address, telephone and fax number- The umberThe Commonwealth of Massachusetts Department of Industrial Accidents Otflce of lovestigadons 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 :.'u-u5 www.mass.gov/dia CITY OF SALEM l rs PUBLIC PROPRERTY ,•�yN V� DEP AR"I'MENT 1 '. A r,l III I T 1 1,\I I \f. ,\f 11 .. •, 1 .I'I _ Construction Debris Disposal .affidavit (rciluired lbr all demolition and renovation work) In accordance wth the sixth edition of the State Building Code, 780 CMR suction 1 11.5 Debris, and the provisions of MGL c 40, S 54: Building Permit It is issued with the condition that the debris resulting from this work shall he disposed of in if properly licensed waste disposal facility as defined by MGL c I 11, S 150A. The debris will he transported by: (name(it hauler) I he debris will be disposed of in 1= Z_�- e v" )' (name of facility) �®°,� L/ Ez� 1 6 taddresa ut facility) /­L'natmc of x n apphc nt lial, DATE(MMM01 YYYY) ACORDu CERTIFICATE OF LIABILITY INSURANCE 12/30/2008 PRODUCER (617)7Z3-0700 FAX (617)723-727S THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Cleary Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 226 Causeway Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Boston, MA 02114-2155 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED Sc ernecker Property Services, Inc. INSURERA: Acadia Insurance Company 31325 179 Bear Hill Road INSURERB: United States Fire Insurance Waltham, MA 02451 INSURER C: INSURERD: ---LN—SURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING 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. NSR 0' TYPE OF INSURANCE POLICY NUMBER POLIOYEFFEOTIVE POUCYEXPIRATION LIMnB GENERAL LIABILITY CPA 0183614-12 06/01/2008 06/01/2009 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED E 3OO OOO CLAIMS MADE OCCUR MEDEXP(Anyompman) $ 5,000 A PERSONAL BADV IWURY S 1,000,000 GENERALAGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S 2,000,00 POLICY rXJPE',C'T LOC AUTOMOBILE LIABILITY MAA 0183615-12 06/01/2008-. 06/01/2009 cOMBwED SINGLE LIMIT ANY AUTO Iraauldwt) s 1.000,00C ALLOWNED AUTOS BDINJURY E A X SCHEOUIED Al1TOS (Parr pemmperson) X HIRED AUTOS BODILY INJURY E X NON-aWNED AUTOS (Per acddml) PROPERTY DAMAGE E (Per acddml) GARAGE LIABILITY AUTO ONLY- EAACCIDENT $ ANY AUTO OTHER THAN EA ACC. $ AUTO ONLY: AGG $ EXCESSIUMBRELLA UABILT' CUA 0183616-12 06/01/2008 06/01/2009 EACH OCCURRENCE S S'000.0001 X OCCUR F�CIAIMSMADE AGGREGATE $ S1000100 A s DEDUCnBLE s RETENTION $ E WORKERS COMPENSATION AND 408-697000-2 12/31/2008 12/31/2009- XI wcsrATU- I I DTH- EMPLOYERS'LULBILMY B ANY PROPRIETORIPARTNERIEXECUTNE E.L EACH ACCIDENT $ 1,000,00 OFFlCETLMEMBER EXCWDEDT E:L DISEASE-EA EMPLOYE S 1,000.000 a daecdbeunder SPEC ML PROVISIONS below EL.DISEASE-POLICY LIMIT S 1,000,000 07HER DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE OLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Schernecker Property Services, Inc. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 179 Bear Hill Road OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Waltham, MA 02451 AUTHORIZED REPRESENTATIVE John Bernardin 7CB ly ACORD 25(2009108) OACORD CORPORATION 1988