29 BARSTOW ST - BUILDING INSPECTION E
b±
eITV OF ZS L;ETV -
PUBLIC PROPERTY
DEPARTMENT _
KI\MERI.EY ORISC0LL
MAYOR
120 W.\SHINCI'ON$"IREET 0 JALNIJ,MA,1SA(}{C;S61'IS 01970
1Ei 978-745-9595 4 FAX 97&740-98"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address: Zy 8&g67-0vd ST2-EET
SprL-O-n , >M� 0/ 9-70
Property is located in a; Conservation Area /N Historic District Y N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land LC,y, J i t 1
Name: C 0 L�C—&7,97J Q J L4—
Address: Zq t3fh2S 7-0 w q.T
n1 R- 0 19 70
Telephone: _ 2
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation ')0 2 Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to: f J
What is the current use of the Building? P-' Z
Material of Building? W00D If dwelling, how many units? 2
Will the Building Conform to Law? �4 $ Asbestos? NO
Architect's Name NV
Address and Phone Ad^/ t j
Mechanic's Name TWOrhirs AK60h1Rrui:i- eonl�� p� oN� rno� -IAJ�,
Address and Phone 36O M/#SS ;4VC 7q�Z�//EsT
Construction Supervisors License#( .s O 'ZD,SCo HIC Registration# 12 Co-70 S
Estimated Cost Project$ �9! , ,=' Permit Fee Calculation
¢£3
Permit Fee $ Estimated Cost X$71$1000 Residential 7 .
Estimated Cost X$111$1000 Commercial
An Additional $5.00 is added as an
Administrative charge. C69
Make sure that all fields are properly and legibly written to avoid delays in processing. J
The undersigned does hereby apply for a Building�P/erm' o bui d to the above stated
specifications. Signed under penalty of perjury
Date 4-06' °�O
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET ♦SALEM,MASSACHUSETTS 01970
TEL:978-745-9595 ♦FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� p e, Please Print Legibly
l'
Name (Business/Organization/Individual): 6N(-.-A= (�t�� �a obgz_j1\(6T
Address: 3S0 AO-SS / VEF
City/State/Zip: ge�L_IWA-)Vt✓ /YIA- Phone #: '7 F3/ — 9 7q — 3123 '
Are you an employer? Check the appropriate box: Type of project(required):
1.NA I am a employer with /9 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. # ®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. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ 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.] t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:ga-p—TPO" 1tV_'waA-n1C.0
Policy#or Self-ins. Lic.#: 7L.2 y(C(rN[9S 17 S Expiration Date: /D J`i5F8 O
Job Site Address: 2q 13"5lzw ST t 5/41.C_-M City/State/Zip: /77 A- 01 9 70
Attach a copy of the workers' compensation 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$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$250.00 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.
I do hereby cert'y un r the pa s and penalties ofperjury that the information provided above is true and correct.
Si nature: Date: 8 /- D(O
Phone#• wt — lq 7LI' 3/ 73
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts 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 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 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)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 insurance. 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 call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate 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 permit/license number which will be used as a reference number. In addition, an applicant
that must 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 permits or licenses. A new affidavit 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 bum 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF SALEM
!• PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOU.
MAYOR 120 WASHINGTON STREET♦SAIEM,MASSACHCSETIS 01970
Ttu 978-745-9595• FAx:978-740-9&16
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris,and the provisions of MGL c 40. S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111,S 150A.
The debris will be transported by:
(name or hauler)
The debris will be disposed of in :
-- (name of facility)
I rJD b o a-hl ✓�l�
(address of faculty)
JK
signature of krnut applicant
S /9vU- 00
date
debmal7.due
08-09-2006 01 :46pm From-BARTLETT LEE INSURANCESOURCES/METRACOMP 7818618319 T-667 P.001/002 F-946
Bartlett-Lee Insurance agency
QfLexington, Inc
35 Bedford Street Suite 10
Lexington, 1M 02420
7818624200 FAX 7818618319
Wednesday,August 09, 2006
i
Town of Salem
Ann Building Departr,,ent
Fax: 978-740-9846
RE:William Cimbrello dba Concept One Remodeling
Certificate of Insurance
To whom it may conc.:rn,
Please find enclosed a certificate of insurance for Concept One Remodeling. Please review and
Contact our office wit. .any questions-
Regards,
Melissa Duhamel-Mc Leod
08-09-2006 01 :46pm From-BARTLETT LEE INSURANCESOURCES/METRACOMP 7818618319 T-667 P.002/002 F-940
der �f'cate of LiabilitY insurance pate of Issue 0810912006
This Certificate is issued as a matter of information
Producer only and confers no rights upon the certificate holder,
BFlrtlett-Lee Insurance Agency This certificate does not amend, extend or alter the
01 Lexington, Inc- coverage afforded by the policies below.
3E Bedford Street Suite 10 Companies Affording Coverage , __I
LE <ington,MA 02420 one Beacon Insurance Co.
7b18624200 Company
A I
�---- - 'Company
i,c qrj cIMBRELO.W B
l-ot ceps One Remodeling Inc, comCpany
company
1 mad Brook Rd D
N. Brookfield, MA 01535- company
E
Company
F
Coverages enod indicated,notwithstanding any
This is to certify that the policies of Insurance isted below have been issued to the Insured named above for the policy p
f requirement,term or condition of any contract Dr other document with respect to which this certificate may be Issued or may permin,the insurance
claims.
afforded
by the policies deeribed herein is subject to al the terms,exclusions and conditions of such policies,limits show may have been reduced by p —1
Policy Number Policy Effective Polley Expiration Limits
Co _ Type of Insuranoe y Date Date
Lin Ganeret Agg�r00ate $2,OD0,000'
! I "eneral Liability 1012212006 10/2212006 )Products-Comp/OP Ago $2,000,000
A I] Commercial General Liability SB11177240
Personal 8 P,dv Injury $1,000,000
J claims Made 'L�Occurrence Each occurronce $1,000,000
Ovmers&Contractors Prot Fire Damago(any one0re $300,000
1 Mod Exp(Any one person) $6.000
- f Combined Single Limit
j futon obile Liability
8 ,] Any Auto 'Bodily lnJury
All owned Autos (Per Person)
Scheduled Autos eodily lrgury
(� Hired Autos (Per Accident)
� Non-Owned Autos 1property Damage
a Auto Only-Ea Accident
C Garage Liability Other Than Auto
Any Auto Each
�J Aggregate _
=-� Each Occurrence
I Excess Liablllry Aggregate
D j Umbrella Form
Other Than Umbrella Form C we st,du- ❑ Other
tory —J
r Workers Compensation and Li card
enl
E Limp oyers Liability EL Each Ar:cid
� EL Dlseesa-Poll Limit
the I•r,,pnetor/Partnbrsl ❑ Intl EL so .Ea Ern 1 0
Exec dive officers are: Excl
Other
C)escription of operations/Locations/Vol cles/Special ItemsPax:878-74"846.Work to be complete I at-Sill Coleman,29 Barstow st,Salem MA 01970
Cancellation
Certificate Holder Should any of the above described policies be cancelled before the
e rtific to Office expiration thereof,the issuing company Will endeavor to mail 10
days written notice to the certificate holder named to the left,but failure to
Town of Salem mail such notice shall Impose no obligation or liability of any kind upon the
93 Washington St company,its agents or representatives.
Salem, MA 01970 Authorized Representative
. 1.
BOARD Of BUILDING REGULATIONS- ,
License: CONSTRUCTION SUPERVISOR:
Number. CS\.._;. MOW
r � BlRhdate:,10l03l7�7 r
i ; ExWres 70/03@005- Tr.no: 19268
THOMAS K KEOHANE _ V
41 MAPLE S€ '
STONEHAM MA 02180 Actlng ml onec
,per BO 7d o mlding Regulstidns nd Sta
Ste\ HOME IMPROVEMENT CONTRACTOR
Registgo—q 126705
ExpitaLon= 812006
yp i Eliyidual -
THOMAS KEOHA U.,!
THOMAS KEOHA�E- _
41 MAPLE STRE - - --��---
\ �4
STONEHAM,MA 0218'- .kdministratOr