NORTON TERRACE - 81 R TREMONT - BUILDING INSPECTION �yi The Commonwealth of Massachusetts
^� t Department of Public Safety J �
�` •t� ,i' \Ltssachusells State BudCode ode(780 CNIIt)Seventh Editionl
City of Salem
BuildingPermit A lication for an Buildin other than a I-or Famil Dwellin
{This Section For Official Use ORIv)
Building Permit Number: Date Applied: Building Inspector.
SECTION 1: LOCATION (Please indicate Block p and Lot M for locations for which a street address is not availa
1 Nc(27au T�u�CE 145( � �-rzt�rttrart't t4, }-�oy�a►�
\o.and Stree -iL-A � 1 'n Zip Code Name of Building(it opplicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Exiting BuildingRepair Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change Of Occupancy ❑ Other ❑ Specify:..
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ Nu x u
Brief Description of Proposed Work:
utit 4. 5101Ai
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): ?
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed '
No.of FloorsJStoriesjincltide basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft-)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly,A=-i_❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 8: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑
It Hazard H-1 ❑ H-2❑ H-3 0 H-4 ❑ H-5❑
L• Institutional 1-1 ❑ 1-2 ❑ i R: Residential R-1❑ R-2 ❑ R-3❑ R-4❑
S: Storage S-10 5-2 ❑ Utie
Special Use❑and please describe below:
Special Use:
SECTION b:CONSTRUCTION TYPE(Check as applicable)
IAD 18 IIA 13 IIB ❑ IIIA ❑ IIIB ❑ IV C] VA V 43
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ ( heck it outride Ho"d Zane❑ Indicate numiCll'al ❑ A trench will not be Licen.ed Di>}x�aI tiite❑
required 0,,r trench ur lF'ca fv:
Pnt me❑ or unirnnlh Zone:_ or on cite>%�tem ❑ permit i,ench+.ed ❑ .
' Railroad right-cit-way: Hazards to Air.Novi anon: \t:1 !?�>t,�r„ �--.�i�n k,, 171,1 11
l �„d :\pplicilde ❑ I.�l niclu re withui aul+ort appn arch area.' I. their rcv IoN cml'Ielyd'
r l at.rttt h, BUdd cnclo�d ❑ le.❑ or No❑ Ye,❑ Ao ❑
I
SECTION 8: CONTENT OF CERTIFICA FE OF OCCUPANCY
Ld twn ,,I Gala. _ Lw l)r, wl'l.l1'c X11(un•uuchr1n: OCCUpont Load l'cr Ph,ne
li,, -the `llpulatiuns
SECTION 9: PROPERTY OWNER AUTHORIZATION
.Name and Addrexs of Property Owner
Name (Print) _ Nit.and Street Cih'/Town 7-- 7#
Propertc Owner Contact Intormotiun:
Title Telephone No. (business) Telephone Nu. (cell) e-maila
If applicahle, the property oiwner hereby authorizes
Name street Address City/To?Yn State Zip
to act stn the pot perty turner's behalf, in all matters relatoe to work authorized by this 1?uihiing permit application.
,* 's SECTION-40;CONSTRUCTION CONTROL (Pleasefill out'Appendix 2)
(It buddin*is less than 35,0RO cu.tt.of.tndtwwi y Fa v andlor not under Ottt tatitimi Cunta>I then check here❑and skip Section 10.i)
10.1 Registered Professional Responsible for Construction Control -
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
• 10.2 General Contractor
CompaName:
Name of Penorl,Respun. ible fur Construction t License No. an Type if Applicable
0iAA
Street p ddregs� 52. L p City/Town State Zip S
&2 a ��?�I < lam',
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$ *V�
1. Building $ Building Permit Fee=Total Construction Cost (Insert here
2. Electrical S appropriate municipal factor)_$
3_ Plumbing $
A. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
S. Mechanical (Other) $ Enclose checka able to
P�Y•
h. Total Cast $ '1, j - LAJ (contact municipality)and write check number here_
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application true and accurate to the best of my knowledge and understanding.
' fleas print and sIgn narnc Title Tcicphnne \o Date
wticel Addre.> (-ih;'T,mn !state Zip
I
i_Municipal Inspector to till out this section upon application approval:
\ame I)ate
2�
�. O
ti
ti The Commonwealth of Massachusetts
Department of Public Safety
yy "� \lassaeh usigb ti{ate Building Code(780 CMR)Seventh Edition AA5 j
tS+v p,nn.! /
City of Salem W 7f/ <�
Building Permit Application for any Building other than a 1-o 2-Famil Dwelling
(This Sts.tion For Official Use Only)
Building Permit Number: _ Date Applied: Building ln3pech>r. � '�
SECTION 1: LOCATION (Please indicate Block B and Lot N for locations for which a street address is not available)
-pees i8j /}GE Z& - ID-z" SALVAIIA ttNGIOV&
No.and Street CitY fTov n Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ Alteration q Addition ❑ Demolition ❑ (Please fill out and Submit Appendix 1)
Change of Use q 1 Change of Occupancy q 1 Other ❑ Specify:
Are building plans andfor construction documents being supplied as part of this permit application? Yes q No
Is an Independent Structural Engineering Peer Review required? Yes ❑ Nu
Brief Description of Proposed Work:
lj!'Z'.flLc. ,+6.Lt,xV%. 1 w/niQu+v TPIti« I
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): t'
Existing hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(fL)
SECTION 5:USE GROUP(Check as ap licable)
A: Assembly A-1,0 A-2r q A-2nc❑ A-3 13 A4 q A-5❑ B: Business F E: Educational ❑
' F: Facto F-1 ❑ F2❑ H: High Hazard H-1 q H-2 0 H-3 13 H-4❑ H-5 13
1: Institutional 1-1 ❑ 1-2 q 1-3❑ 1-4 q M: Mercantile❑ R: Residential R-1❑ R-2 q R-3 q R-4 ❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as-applicable)
IAO IB ❑ IIA0 116 ❑ IIIA ❑ 1118 IVO VA ❑ VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: 'Trench Permit: Debris Removal:
Public❑ Check if out,ide Flood Zane❑ Indicate municipal❑ A trench u-ill not be Licensed Di,pa.al Site 0
- „ron,ite,r,tem ❑ required Our trench o r.peclk:_,,....
I'mate ❑ or uxicnb(c Zone:_ permit it,enclosed❑ _
I flazards to Air.Navigation: Ci:N I h't"nc t'„nuni�..=.a Rc......
Railroad right-of-way:
NAd :App ii.d� c ❑ I.wtruclu rc crilhm airport ,tpprnoch arca' I. lhvir rccleve cnmplclvd,
. r C am�ant G.Rini,"16 ,-J❑ )c,O ..r No O Yc,13 \.. ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY {
T.1wm I C inir. Cw l)roupi.l: lc pe of Con>trnrrUan: Occupant Lnad per fluor: iI
dme tau d.3in};a,ntam an Sprinkler SY,iein': tipenal titipuiatfnn
J�19(G 7n
SECTION 9: PROPERTY OWNER AUTHORIZATION
Namemid :\ddnan of Property Owner
Name (Print) No-md Street Cit% Town Zip
Prupei tc ON%ner Contact Information:
r
Title Telephone No. (business) Telephone Nu. (cell) e-mail address
k0pplicab3ethepnrpertt'owner herebyauthorize+
Name Street Address City/Town State Zip
t on the int�erty owner's behalf, in all matters relative to work authorized by this buildingrermit a >>licatiun.
•" E• " SECTION 10: CONSTRUCTION CONTROL (Please fill out Appendix,2)'
at lndtd in•(5less titan 79,t%lU tu.ft,,,t etdwrd.>aru and/or not wider Cunstntctiun Control then check here O and ski 5�atiun !t}.i!
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
ame-
Com`u` - N C 1 ��ysy2 !! -1 l
Nam of Person RespLmsible for Cunstructiun � a�"=rLi""iense No. and Type if Applicable
g -Val
r Street Add
�2 City/Town State Zip
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si ned Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor e�
and Materials) Total Construction Cost(from Item 6)
1. Building $ - Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ 0211 V _ J (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering fny name below, I hereby attest under the pains and penalties of perjury that all of the informatturr contained in this
faa ppplppllication iii. ttrrue and accurate to the bent of m nuwledge and understanding,
h- •i• mt.ind ,ign name F _.... Title Telephone.No. Uate
I
'+trcet Addie, CitviTotvn titate Zip
1
.Municipal tuspector to till out this section upon application approval:
Same U lle
i
CITY OF SALEM
PUBLIC. PRO PRERTY
DEPARTMENT
III '"S 4"r"r] 61 \\ 'i*H 4: "b,
Construction Debris Disposal A ida t it
(rc(Itmed li)r all demolition and lenuvaliun work)
In accurdancc t\ith the sixth edition of tiw State Building Code, 780 CNIR section 1 11
Debris, and the provisions of NIGL e ail), S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I It. S 15ttA.
The debris will be transported by:
Inane uthauler)
I he debris will be disposed of in
Marne of Ijwhly)
dlwe of pw•nnn dlq,lrcant '
ee /Io --
CITY of S.1L. 2M, ANSSACHL'SETTS
Bt;B.D6 c;DEP.%RT.%m%iT
120 W.\SIMNGTON STREET. Sao FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
Kl%lBF1tIEY DRJSCDII
MAYOR THOMAS ST.PIEA"
DIRECTOR OF PL:BLIC PAOPERT1f/gl'B.LILNG CONMSSIONER
Workers' Compensation Insurance AMdavit: Buiidtr&/Contractors/ElectriciansiP[umbers
applicant Information p Please Pri��ntt jbi
Le¢ r
Natrte tousime organ,zatiomind.vidual): 45p&Lr_ MY tom' �-Tti�f Ci�Z, JA4 t
Address, '> & 12-INSuAryiG
AV
city/State/zip: HEW-bn9 Phone N: 4('t -- S1Zb- 64 957
'Z--
,tire you so employer'Cheek tits Appropriate box: Type of project(required):
I.0 I am a employer with 4. [] I am a general contractor and 1 6. Q New construction
e
mployees(full and/or pan-time).' have hired the sub-contracton
2.2.�(1 am a sok proprietor or partner- listed on the attached sheet I 7. ySi Remodeling
ship and have no employees These sub-contractors have $. I`Ji Ilernolition
working for the in any capacity, workers'comp.insurance. 9. 0 Building addition
[No workers'comp. insurance S. 0 We are a corporation and its 10.[]Electrical repairs or additions
required) ot'lcers have exercised their
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. (No workers'comp. C. 132.§1(4),and we have no 12.0 Roof repair
insurance required./t employees. (No workers' 13.0 Other
comp.insurance required.]
•tiny apPlicatrr aha]checks tsar tit mail 3100 rill wt the aectioa below ahaeosg their workm'tate ptoond te policy inluemation.
I I I,wrenwr►ta who subenh this atgdavit indicting they ar doing all wok and then hue ouawie co urnclora taut suhmit a naw affidavit indicting tack.
:r',mnaaon that check this has muet.attachod an additional abort showing the name of nr Aabtasuxctor and their worker'comp.policy iorcemattan,
I ant an employer that is providing workers'compentodon insurance for my etnplayses Be%w tr the polfey and/ob slit
information
insurance Company Name:
Policy M or Self--ins. Lie.p: Expiration(kite:
Job Site Address: City/State/Zip:
,tnsch a copy of the workers'compensation policy declantloa page(showing the policy number and expirstlos dads}
Failure to secure coverage as required under Section 25A of MGL e. 132 can lead to the imposition of criminal penalties of a
fine up to St.500-00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a find
of up to$230.00 a day against the violator. Ile advised that a copy of this statement may be rurwurded to the Office of
i nvcsngations tifthe DfA far insurance coverage verification.
file hereby certify under a pains and penoldes ojperfury that the information provided abort is true and correct
:,,,,, , tit 13atC,4✓ i.s��S f ��
Pho it:
iAJjcial use only. Do aor writr in this area, to be rwrtpteted by cry or town v/frriat
i
City or l'uwn: __. Permiul.iccnse AI`_.
Issuing Authurily (circle ung):
I. Iluard of Ilealih 2. Building nepartmcnt J. City/Town Clerk a. Electrical inspector S. Plumbing inspector
b.Other
Gutlact Person: __. Phone N:
CITY OF SALEM
aj PUBLIC PROPRERTY
DEPARTMENT
Consti-LIC6011 Debris Disposal .affidavit
(feyuircd Ii)r all dcnwlition :old renuvatiun %vurk)
In accurdance 11 itll the sixth edition of the State Building Code, 780 CNlR section 1 1 1.5
Dcbris, and the provisions uf.ti1GL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c
I 11. S ISUA.
The dchris will be transported by:
(name of hauler)
I he debris will be disposed of in
(name of 13alriv)
I aJJre.. ..I'I]c slily(
V _
ap aluie of pennu .ggdicanl
�C � d
las:
CITY OF SM.l:M, ANSSACHUSETTS
[3u=LNGDEPART EINT
120 W{SFIIIVGTON STREET, iso FLOOR
TEL (978) 745-9595
F.vt(978) 740.9846
KI.
[HEgLEY DRISCOLL
VLAYOA THOb"S ST.PtI M
Ol&ECTOR OF PL ELIC PROPERTY/9V ILDLV G COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4jrpllcant Information Please Print Leeibly
Naine (dutin�•st Organizatiomindtvtdu l): 1rQ&Lr_ MY F— 46\11-rac-M ' /&4 t
Address- 's(0
f, yztWE thG AVS
City/Stateizip: �{st�C'�r1t� Phone N: 4['! - 62Yi' 645 "2-
Are you as employer?Cheek the appropriate,box: Type of project(requireQ:
I.0 1 am a employer with 4. 0 1 am a general contractor and 1 b. 0 New construction
r.mployees(full an&or pan-time).• have hired the sub-contractors
2. I am a sole proprietor or partner-
listed on the attached sheet y NRemoleling
m
ship and have no cploycea These sub-contractor have g. Demolition
working for me in any capacity, worker'comp.instuance. 9. 0 Building addition
I No workers' comp. insurance 5. 0 We are a corporation and its
requited.)
officers have exercised their 10.0 Electrical repair or additions
3.0 I am a homeowner doing all wont right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 hoof tcpsirs
insurance required.,r employees. [1Jo workers' 110 Other
comp.insurance mquimd.j
-Any applicant that chairs Eos al mar JIM fin out the seelinn Mass 1110smsg 1111:1 workers'co npensan,M policy infor nation.
't tined man who submit this aRidsvit indicting I"=doing all watt and Ilion him outride Catrt odic mug whmit a few amdavit itsdisacitts welt.
:c',ntrrswn rhes cheek this baa must attached an 341itiwml+Man showing the name of the mb�U`101 ion and their wurhm'comp.policy infarmouon.
/am an employer that is providing ivoriren'compentadon Insaranee for my employees, Below is the paUty ondm site
information.
Insurance Company Name: --
policy M or Self-in& Lia. H: Expiration Date:
Job Site Address: CitylState/Zip:
,mach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A ol'MGL c. 132 can lead to the imposition of criminal penalties of a
Ane up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the intoe ofis STOP WORK ORDER and a lite
of up to$230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
invbtigations of the DIA for insurance coverage verification.
I ito hereby certify uadrr r pains and penolt/es of perjury that the injormarlon provided above is true and correct.
Vin• t tr ' i)oto-
official use o dy. Donor write in this dreg,to be Completed by city or town offrciat i
1 City or fuwn: __ Permit/f.lcense
f issuing .Nuthority {tircfe oncy
E Iloard of Ileallh 2. NuildinL Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing inspector
6.O t her
4untact Person:,_ _. __. Phone p:
06/02/2009 21:57 FAX Q002/003
JUN-03-2000 WED 00 'o AM KARL L IN'S UR?.NCE FAx h!�' 1 „'i'31d7173E F. Opi
ACORD CERTIFICATE OF LIABILITY INSURANCE nATEIMMIDDA WI
n osro2noos
PIiObUeN THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Karl Crowell Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
38 Cordage Park Circle ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Sults 224 (508)747 7744
Plymouth MA 02360 INSURERS AFFORDING COVERAGE NAIC M
INSURED Eagle Eyes Contractor, Inc INSURER AI GRANITE STATE INSURANCE CO
366 Riverside Ave INSURER ARBELL-A PROTECTION INS CO
INSURER C'
Medford MA 02155 NsuRER D:
w n :
COVERAGES
THE POLICIES OF INSURANCE LI3TEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REGUIREEMENT, 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 DESCRISEO HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REOUCED BY PAID CLAIMS.
INBR DD' POLICY NUNOEq POLICY BFFECTNS POLICY EXPIRATIDN LIMRB
OENSRAL LIABILITY EAOHOUIYPENCE $ 1,000,000OC
HMAGE TO RENTED
B X MMERCIALOENERALLIABILIrY 8600042340 04/09/2009 04/0912010 O
• 50000
CLAIMS MADE II OCCUR MED EXP An we ebvn JS'000
PER NALSADVINJURY 41 000,000
GENERAL AGGREGATE s2,000.000
EN'LAGGREDATELIMITAPPLIESPEPo FR00VCT5-COMPIOP AGG • 2,D00000
X LI PRO. LOC
AUrOMOBILR LNBILItY COMBINED SINGLE LIMIT
ANY AUTO (Ea xdtleM)
ALL OWNED AUTOS BODILY INJURY
BCHEbULED AUT08 (Per PP!san)
HMI!O AUTOS EOOILY INJURY
(PIA acdeRM)
NON-OWNED AUTOS
PROPERTY DAMAGE
(Pa"dtleM)
_qWGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EAACC •
AUTO ONLY GG
BXCFSSNMBRELLA UABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE - AGGAeOATE
DROUCTIRLE
RETENTION S - S
WORKERS COMPENSATION AND
X IAC ErpiU- O?I+•
A EMPLOYERS'UAGUTY WC004-29-7448 09/21/2008 09/21/2009 E.4.EACH ACQUEN1 S500.000
ANY PRapRiETO”
OFFICEWMEMBEREEACLU°E09 ARTNEWEXECUTNE
E.L DIo EASE-EA EMPLOYEE S 609 DOD
II ,tlREvllW antler EL 0IUEASE-POLICY LIMIT •500.0 OD _
OTHER
DRBCRIPTIONOPOP•RATIONSILOCATONSIVRNICUSIRXCLU9 NSADDRDRYENDORSEMENT!SPECIALPRDVIBIONB
Additional Insured:City of Salem, Massachusetts and Salem Housing Authorlty
Contractual liability coverage Included in CGL, no XCU exclusions
Project: Exterior trim work at Norton and Bates Terraces
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DEBORIBSD POUCIEB BE CANCELLED BEFORE THE EXPIRATION
SALEM HOUSING AUTHORITY DATE THEREOF,THE ISSUING INSURRR WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
CITY OF SALEM NOTICE TO THE CERTIFICATE HOLDER NAMED TO THP.LEFT,BUT FAILURE TO 00.90 SMALL
27 CHARTER ST IMPOSE NO OELIOATION CR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
SALEM,MA 01970 REPResa?o
AUTHORISED ROPREBRNTATIV• �KC>
ACORD 25(2001/08) _ RATION 1936
CITY OF SALEM
_l
;� PUBLIC PROPRERTY
DEPAR"I"DENT
:.d ,. i.' ii 111.,..••,,:.11 I T NM M.
III 'I'X 'J1 '1 Fry . I x •i'X 'J_ ',i Jr,
Construction Debris Disposal At'lidavit
(retluired lilr all demolition and renovation wurk)
In aceurdancc itll the sixth edition of the State Building Code, 7S0 CMR section I 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S I50A.
The dchris will be transported by:
Inamc til hauler)
I he debris will be disposed of in
(numr tit tae Jay)
(:IthhL•VG til Ida II11V) \,X- '
V
.Ip Jlulc nt p.'lunt apphcJnt
,IJtr
^� CITY OF SUEM, ANSSACHUSETTS
BUILOINGDEF xnt&N-r
�M 1220 WASHINGTON STREET. Ya FLOOR
TEL (978) 745-9595
FAx(978) 7409846
KI,
{BFjtIEY DRTSCOLL
,VSAYOR 'THOMAS ST.PMM
DIRECTOR OF PUBLIC PROPERTY/Bl MMSIG CO.%L%IISSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
analicant Information Pllease Pri11nttLegsb1Y
Name (8usin�voOrpnizatioty Individual): �n�df''r r'Y � Tac'-pare ZA'" r
Address: 3 CQ 6 Nz_l UJF.K�lw C fyi'
City/State/Zip: 14 r-tV19 Phone
Are you an employer?Check the appropriate lox: Type of project(required):
4. C] 1 am a general contractor and!
1.0 1 am a omployer with 6. C]New construction
un to ees full and/or part-time).• have hired the sub-contractors
P Y ( listed on the attached sheet I 7. Remodeling
i' 2.�1 airs a sole proprietor or partner-
ship and have no employees These sub-contractors have S. d I}emolition
working for me in any capacity. workers'comp.insurance. 9, C]Building addition
[No workers*comp. insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
li
required-) officers have exercised their
3.C1 t am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp, c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. LNo workers' 13.0 Other
comp. in urine required.]
-Any applicant this checks hos sit must also fin out the scales below Activist Their workm'Mropemwi act policy information.
'1 hmreownor who submit this affidavit indicting nay ate doing all wort and than hire outside ne
conctor►must submit a new abildovit indicating suck.
:c',muanor that check ibis box most ddi
attached an atiord shRl showing the(tame of the eib. mrsdo s and their worker'comp,policy infomution,
I am an employer that Is providing workers'compensadon Insurance for my employees. Below Is(he policy and job site
information. V
Insurance Company Name:
Policy#or Self-ins, Lia.N: Expiration Date:
Job Site Address: City/Statetzip:
,tittach a copy of the workers'compensation policy declaration page(showing the policy number and expirstlon date).
Failure to secure coverage as required under Section 25A of MGL c. 132 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Ile advked that a copy of this statement maybe forwarded to the Off ice of
Invcstigatiuns of the DIA for insurance coverage verification.
1 do hereby certify under a pains and penahles sifperjury that the information provided above is true and�carrecR
Ci.. t Ir I}utc: s fl�
Phone#:
f}flicial u e only. i3o not twits,in this area,to be completed by city or town n/ftcieut
City or Tuwn:_.___. __. eermtrA.lcense#Y_.._
Issuing authority(circle one)-
1. Board of Ileullh 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Ctuttact Person:_ - __. __ Phone N:"
06/02/2009 21:57 FAX _ Q1002/003
JUN-03-2009 'WED 09 : 20 AM KARL CR,C'uvELL INSURANCE FAX. No. I6JU471736
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE IMM°DRYYYI
06/02/2009
PnOGUDaft THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Karl Crowell Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
36 Cordage Park Circle ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite 224 (506)747 7744
Plymouth MA 02360 INSURERS AFFORDING COVERAGE NAIC#
INSURED Eagle Eyes Contractor, Inc INsuRER A: GRANITE STATE INSURANCE CO
366 Riverside Ave INSURER B. ARBELLA PROTECTION INS CO
INSURER C'
Medford MA 02155 NSURER O;
INSUReR 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 SUGH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INBR kDD-I. POMCY NUMBER POLICY BFFECTNB POLICY EXPIRATION LIMITS
GEN INIAL LIABILITY EACH OCCURRENCE $ 1,000,000
B X COMMERCIAL GENERAL LIABILITY 6500042340 04/09/2009 04109/2010 DPRrMIqp'q F.AMAGE TO RENTED a50,OQo
CLAIMSMADE FX OCCUR MED E%P An one anon 5,000
PERSONAL 0. VINJURY $1,004,000
GENERAL AGGREGATE 8 2,000.000
EN'LAGGREGATE LIMITAPPLIES PER' PRODUCTS-COMP/OP AGG 21000 000
X POLIC PRO LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea acWtlenB
ANYAUTD
ALL OWNEO AUTOS BO DILY INJURY 6
60HEDULED AUTO$ (PM 0e,w i
HIRED AUTOS BODILY INJURY $
NON•OW 14E9 AUTOS (Pw acciaenp
PROPERTY DAMAGE
(Per acddeN)
RAGE LIABILITY AUTOONLY-EAACCIDENT 3
ANYAUTO OTHER THAN EAACC 0
AUTO ONLY. GG
EXCESSIUMBRELLA UABILITY EACH OCCURRENCE $
OCCURCLAIMS MADE AGGREGATE B
DEOUCTMI-2
RETENTION I S
X WD6TATU- DTH
WpRNERB OOMPENBATION AND
A EMPLOYERS'LIABILITY WC004-29-7448 09/21/2008 09/21/2009 E.L.EACHACCIDE 500000
ANY PROPRIETOWPARTNEWEXECUTIVE
OFFICERIMEMBER EXCLUDED? e OISEA6E-EA EMPLOYEE $ 600,000
'Ir
T Al,"'a""SK! E.L.DISEASE-POLICY LIMIT 6500,000
OTHER
DESCRIPTION OP OPORATIONS I LOCATONSI VEHICLES I B%CLUSIONS ADDED EY ENDORSEMENT I SPECIAL PROVIEIONs
Additional Insured:City of Salem,Massachusetts and Salem Housing Authority
Contractual liability coverage Included in CGL, no XCU exclusions
Project: Exterior trim work at Norton and Bates Terraces
CERTIFICATE HOLDER CANCELLATION
SHOULD ANYOF THE ABOV6068CRIB50 POLICIES BE CANCELLED BEPORE THE EXPIRATION
SALEM HOUSING AUTHORITY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL30 DAYS WRITTEN
CITY OF SALEM NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LOFT,BUT FAILURE TO 00 SO SNAI L
27 CHARTER ST IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
SALEM,MA 01970 REPRESBNTATIVES-
AUTHORIZED RBPREBiNTATIVE ee. . GKC>
ACORD 25(2001/09) . . RATION 1988