38 BAYVIEW AVE - BPA-2007-448, SIDING, ROOF, WINDOWS PUBLIC PROPERTY
DEPARTMENT
KMI13F.&LEY DRISCOLL
MAYOR 120 WA.SHIN .TON S'IREEr♦SAl LM,MASSACHLSLI-IS 01970 (�
TFL,978-745-9595 • FAX:978-740-9W v
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: 3� w Building:
Property Address:
Property is located in a: Conservation Area Y/N A/ Historic District Y/N y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land e
Name:
Address:
3 � Disc v et, v
Telephone: 7 F 7 y — O O /
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation yrry Number of Stories Renovated
Change in Use New
Demolitions Existing
Approximate year of Area per floor (so Renovated
construction or renovation
of existing building New
Brief Description of Pro/posed Work:
�ii2 yL ,S;•A� � �er� �,rrcrnw — �eP.e�i't %Gitc�
- — Mail Permit to: a �� R., ✓ „iy /� 0/90�� - -
What is the current use of the Building? / rn�
Material of Building? if dwelling, how many units?
Will the Building Conform to Law? /�?1 _ Asbestos? �a
Architect's Name G '✓ '
Address and Phone
Mechanic's Name
Address and Phone SZ C _
Construction Supervisors License# HIC Registration#
Estimated Cost of Project $2 sd O Permit Fee Calculation
Permit Fee$ 1y� 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 tthhee above stated
specifications. Signed under penalty of perjury /� J ck i7 � x
Date
J N
v
a.. a
:• z R (� L v
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
a.MnCat w DRiSCOLL
.MAYOR 120 WAsHD4GT0N STREET a SA
r ev,MAssACHasr•r1s 01970
?Etc 978.745-9595 a FAx:9M740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Pript Labe
Name(Busineworsa/u7auomi"vimul):- dV41- /el'I,--
Address: 5 G ��`ll!i•�9N� �i
City/State/Zip:1/��,r. �� �—
/�/� . Phone#: 97�' - 77 Y- G 3,�
Are you an employer?Check the appropriate box*
1.0 I am a employer with 4. ❑ I am a general contractor and I Type of protect(required):
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. Lam a sole proprietor or parmer- listed on the attached sheet t 7. Remodeling
ship and have no employees These sub-contractors have S. Demolition
working for me in any capacity. workers'comp.insunmee. 9. Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no
insurance required.]t employees.[No workers' 12.❑Roof repairs
imp_insurance required.] 13.❑Odw—owe
'ARY apPaom dM cheeks boa e1 mast am all out the sw me bdow sh"ina their workan'
t Ho naowms who submit this al8dsvk mmeWnE they we"a all wadi and rhea him on"cm&wkn must A&Mft a pew aaldwkWS00,05
arch,rConbaeton that cheek this ban must attached an addidonW dmw sbowma the aams of the abcmtraaas awe their wotkws•gyp,PdicY inlbsmatla<
Ian an employer that Is providing workers'compensation Insurance for my employee& Below it tha policy and job ske
Information. /�
Insurance Company Name: C�1e vl f.e
Policy#or Self-ins.Lic.#:- I d P U Expiration Date: e —z o — a 7
Job Site Address: �8 /J/9Yu1 ear /{u- City/State2ip: S.®euii ffJj/ /fJcs
Attach a copy of the workers'compensation policy declaration pa
p ge(showing the policy number and a:pbratlou date)6
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal
fine up to 31,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a ties Pone
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
I do hereby certi under the pout and penalties of pe►fary that the Information provided above Is true and correct
Phone#: 9��' — 7 7Y O.Zf 9
Q&kial use only. Do not wrke is this area,to be completed by city or town of ejuL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#
information and Instructions
Massachusetts General Laws chapter 152 requires all employers to
the service workers
another under any c' compensation forontract ir PlOY e. .
pursuant to this statute.an employee is defined as"...every person
express or implied,oral or written."
o is defined as"an individual.partnership,association,corporation or other legal entity,or airy two er morn.
An carp! yer and including the legal m?tgoing engaged in a joint enterpriser. csentadves of a deceased employer,or the
of the fore end employing employees. However the
of an individual.partnership,associationpar er other legal resides
receiver or trustee not noore than three apartments and who resides therein.or the occupant of the
owner of a dwelling house having construction or repair work to such dwelling house
dwelling house of another to to do maintenance' Y such ere it deemed to be an emp "
or on the grounds or building gaappurtenant�w shall not because employment lOYC
MGL chapter 152,$25C(6)also states that"every state or leeal ltaenaing agency shag withhold the lasutatree or
Peres too to a business or to Construct buildings in the eommonweakY for nay
renewal of a neetw or P� nce of compliance with the insurance coverage required."
applicant who has not produced acceptableeviN"Neither the commonwealth nor any of its political subdivisions shall
Additionally.MGL cbapter 13p Forman le evidence of compliance with the insurance
enter into any contract for the performance of public work until acceptable
requirements of this chapter have bien presented to the contracting authority."
Applicants tingaffidavit completely.by checnber the boxes that apply to your situation and,if
Please fill out the worker'compensation and hone numbers)along with their eertificate(s)Of
necessary.supply aub-contracror(s)name(s),address(es) P rships(LLP)with no employees Other than the
insurance. Limited Liability Companies(LLC)or Limited Liability partne
ate not required comPmsadon insurance. If an LLC or LLP does have
uired to carry workers'members or partner*. Be advised that this affidavit may be submitted to the Department of affidavit
employees,a policy is mgmred a coverage. Also be sere to algo and date the at8davit. 'The affidavit mould
Accidents for coufimaadon of inauiranc Of
be returned to the city or town that the application for the permit or license is being requested,not the Department
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a worker'
compensation Policy,please Call the Department at the number listed below. Self-insured companies should enter their
self-inamtmce license number on the a •
City or Tows Officials
please be sum that the affidavit is complete and printed legibly. The Department has provided a space die
bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding pP
licanL
Please be sure to fill in the pemtittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitflicense 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
applicant as proof that a valid affidavit is on file for future permits or licenses. A new af ,dhvir must be filled Out each
year.Wh a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
ere
(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 Commonviealth of Massachusetts
DVutnent of ladustlial Accidents
Office of Invesilglidens
600 Washm&n Shvd
Boston,MA 02111
Tel. #617-727-4900 wd 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 WwWMU Sa.80v/dla
CrrY OF SAL.EM
PUBLIC PROPERTY
DEPARTMENT
Wraa ttow sts»ar6suaKMAMACCsn181170
lb:M?4&"U 0 PAZ V&74& ON
Construcdoa Debris Disposal Affidavit
(mquLmd fw an demolidos ad canovadaa wak)
is aceadame with the silctb edidoa of dle Shoe iSnildin6 Coda.7W C1R secdom 111.5
Debr*and dw provisions of MGL o A S 5%
Builft Partnit li is issued with the condifice&at the debris raaieioa fte
this wart"be disposed of in a peope ft iicaotad waft depend&dHty as delined by 1 43L a
1 u.s 1sa►.
The debris wiu be OwspoMA by:
(now ofbsalsr)
i
The debris/wiU be disposed of in:
(name of 1leility)
- -(mldew of heility)
z
sisaaeaa of petn ' appliaaa
date
'e6riwZG+a
Oct-04-06 12:04'3P _ , P.01
ACORD CERT11FICATE OF LIABILITY INSURANCE CSR �TEJ04/(aeaDaYYYn
THIS CM111FICATE 181BSUED ABA OTTER OF R
CtRF MFDNATM 06
D ley Insurance ;ILgeney Chestnut Green, Suil.I-1 24 ONLY O�D CONFERS RD RKe1TS UPON THE CENTIFICATE
THIS CERTIFICATE
OR
Seven Federal Street ALTER THE COVERAGE AFFORDED BY THE I LIES BELOW.
Danvers NA 01923-3624,
Phone- 978-777-9394 ?&R:976-777-3306 INSURERS AFFORDING COVERAGE
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INSURER& Preferred EGutTnal "'---- --
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Rile Hrotha:.rr Construction wsursTA B. Granite State.Insurance
Har Olo Btliley D$7! INSURFRO ,
Danverro MA &]J23 JUMFIERM.
COVERAGCS
INSURER E .. . —.__.—_..
INE POLICIES OF INSURANCE LUTWn R i,UW HAVE SON ISSUED TO Tiff INSUH:D NAMEDABOVE FOR THE PoLICYP9HO0 WTUCAIED ROTYVDHSTANDING
ANY REOLIm MENT•TERN OR CoNORP Wi OF ANY CONTRACT OR OTHER DWip ENTWITH RLSPECT TO WHICH THIS CERTIFICATE MAY RF ISSUED OR MAY PCRTAW THE HSURANCL AFFORI:E]DY TIC PCLICWS DESCRIBED HEREII ISSUBIECT TO ALL THE TERNS,EXCLUSIONS AND CONDITIONS OF SUCH
POI ICIES AGGREGATE L"M SHOWN is L'.Y NAVE BttN REDUCED BY PAID CLAII R
Muslim
LTA TYPEOFINSURANGE_ POLICYNUYRER W IPA YEXPWCI�'-'-. LIMITS ..
GENERAL LIAURM
EACNOIx;URRENCE s 300000
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X COMMERcwLGEPSRALrAImRv I CPP0130S64252 10/16/06 i 10/16/07 PREMTSEx1EXucarencel _ Is50000__
CIAIA,9MME C (iL'CUR) N®CIP(MyAro�) _$5000
.- PERSONAL B AOVINJURY I11300000
' I GENERALAGGREGATIF I x 600000
CENLAGGRCGATFI MITAPPI E:S PER PRODUCTS-COMP/IX'AGG�i 600000
'.4 POLICY dECOT IOC .. ---'
AUTOMBILEtIAMUTY -.
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EACHACCIDEM �s 100000_.
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DESCIUPT-N OF OPEmilim TLDCATBMI:iVE{pC�Lp f EXCLUHONS ADD®BY E 0045ER@RI—skmPROWIONS
As par policies,
CERTIFICATE HOLDER -. CANCELLATION
Fa:jjPO $ROVLDANY OF THE ABOVE DBSC M POLICIES IN CANCELLEDREFORB THEEXPRMATIDN
MATE TMEREOP,THE snING U&SURENWILL ENDEAVOR TO MAIL 10 MAYSWRhWA
For se c0fttaiol'I Purposes to only. NOTICE TOTHE CERIITiCATE HOLDER NAMED TO THE LEPt BUFTwLURE TO also MALL
Please contact agency por
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