98 BOSTON ST - BPA-2008-892 INTERIOR REPAIRS ------ --- CITY-OF&ALENi-
PUBL IC PROPERTY
DEPARTVLENT gal �
KmaWA UMo•LV-,X
Srwvat 130 WAs+uN GTM!b rMF r '
"LhK 4wsutH{:s&TIS 01970
Tfi 976.745-95" •Fix:976.740-964
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY VaSTINC1
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address'. c a X-71bn $ f v e e,e.
Property is located in a: Conservadon Area YIN fd Historic Disko YIN +Q
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: _
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN r:TnATtNa BUILDINGS ONLY
Addition Existing
Renovation 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
Ekief Description of Proposed Work: S11 .'-e Y%"a -oe v V'e-�
—..r it eul �4 --e c c. /,I? 7C 2pQ:r
ai/s• �e '� offe-, lnizrs , r /c// neucJ r6a� mid
k"ep/acg 7 cu;nolsua un
r -
� f�lRr S'�-I-�tcure 77T As t )o/do r
+ 4nd rrst� o�dd�.
CeA s79 a10
Mait Permit to: MQcAczdv 14/ ,fth;d,7 7-0— 52? /e/,7
What is the cuff ant use of the Building?'' rS'T�re f-rQn
Material of Building? Wood It dwelling, how many units? �
win the Building Conform to Law? t S Asbestos? j
Architect's Name
Address and Phone ( )
Mechanles Name O m
Address and Phone 2M �6 7 P��ia L�1r OlyGU
Construction Supervisors License 5 CS 9�Z 5(/ 1 HIC Registration#
Estimated Cost of Project SO Permit Fee Calculation
Permit Fee} Estimated Cost X$7/$1000 Residential
OL Estimated Cost X$11/$1000 Commercial
777 An Additional $5.00 is added as an J
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
Jo
The undersigned does hereby apply for a Building Permit t build to the above stated ✓}�
specifications. Signed under penalty of perjury X7 dv
Date
N
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s v. u
CO
ram. Z
-- - �'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.nvltuattr tnlsel:stu
�I srsr 12C Vpa»sw-•raNSrez r a Satter,M.sssACYa t Is 01970
Tta.:97L7e5.9595 a Fits:97W740.9a4e
Warken' Compensadon Insurance Afdavin Builders/Contncton/Electridans/Ptumben
anpllcant information Please Print Legibly
Nameltwuncsstcxaaninliwutmuv�anlr. .� �E(�.-�C_.. l(-/d'h� C)6c]
Address: l �L�//�.' e/a . C 4--;*- -e e t
City/Stateizip: _Sa tew -A4!4 01970 Pdiam 0: 9 74F —,2-1 o —9k-2 a
.%re you as empleyse Cheek the appropriate bass
'ryM of proleet(ragtalrad):
1.0 1 am a employer with •. 0 1 am a general coWtaetor and 1 6. 0 New consttuetiou
employcat(full uultur part-tine).' have hired the sub-contractors
2.0 1 am a sole proprietor or paMer. listed oo the attached sheets 7. 0 Remodeling
ship and have no omploytaa Them have & 0 Demolition
working for me in any capacity. workers'comp. insuranod 9. ❑ Building addition
(No workers'comp. insurance S. 0 We ate a corporation and its 10.0 Electrical repairs or additions
required) officers have exercised their
3.,W1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.410).and we have no 12.0 Roof repairs
insurance tequired.1 r employees. [No woricers' IJ.❑Other
comp inwrance rcquirod.l
•A y yplmmd"chucks boa el art also lie ur am section talow Armen ihdr vwkoa'wmpsw lea PwlWy ioawsrliM
II. Wnwa Who subox!al/amdwo inndimmi;Itley"daft au wwk wtd nit•hie ataaide CCwraipnf nft"�Ut t it a new anhkvil imacaina Y h.
:Cu tic na the thmit dw bet awl 38110c led an addiliond Am Jawing the nape orate arwabarwa red sacra workers'owy.Policy al6rameim
are an anployer that lr prov/ding workers'compensades 11"Iarancef0f my employees. Below 1s the paltry and fob aih
infaraaul"
lasurance Company Name:
Policy a or Sclf ins. Lie. 0: _ .. _. Expiration Date:
Job Sitc Address: Cay/sIawZtp:
Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date).
Failure w uxure coverage as required under Section 25A of.%AGL c. 152 can lead to the imposition of criminal penalties of a
fine up in S1.300.00 and/or one-year imprisonment,as well as civil pcnalliaat in the form ofa STOP WORK ORDER and a fine
of up to S250.00 a Jay against III* violator. lie advised that a copy urthis stauasem may be forwarded to the ODice of
Gt�'.angauuns of du DIA for insurance arvcra.c verification.
/✓o hereby certify aarhrr the pains and penuldrr v/perjury that the information provided above is owe and rorreeC
ii•rrnura . . Uate•
Phnire 7:
011kief are oa4t 00 not write/a th/s arem.to be casap/eted by e/Iy or Iowa a/J1e i"i
City or Town: Pcrmit/IJecase e___ _
Ivauing Aulburity (circle ore):
1. Itoard of Ilralth 2. Building Department ). Civrovta Clock 4. Electrical Inspector S. Plumbing Inspector
6. Other
Conlacl Person: _ _ Phone p:
Information and Instructions
,%iysachusetts General Laws chapter 132.requires all employeprovideue Wither coation for any disk ersillikiyeeL
of hi%
Putsuaru to this stantR an e�is defined as`...every person
enptess or implied,oral or written
anoeiaoo+,forpoation or other kgel entity,Of any two or mote
• n WA u deThed n"at iauivi � r sentasives of a dteeased employer.or the
of the foregoing engaged in a joiee enterprin.antis the legal eprc However the
usooierioo or other legal entity,employing employees
receiver a trustee of m se having
of 113 ersb+R and who resides dwm- er the oaupw of Wa
owner of a dwelling house having not rme than thane apartments
dwelling house of another wAo employs persons so do maintenance.cuostructiaa or repair work on such dwelling house
or on the grounds or building appurtenant tha m shad not because of sttoh muplaymmt be deemod to be an employer•"
.%tGL chapter 132.42SC(6)also states thou"every state or Weal licensing apssey shell withhold the Issuance or
restaproduced accept"o raft a business or a construct bufldlage his the eommonweaph for uy
appu ni of•geense or peanut t?K with the Insurance coverage required"
M wise bas am accept"svfdew o<enaptlanoe
AAddilkMity.MGL chapter 152,123CM states'Neither the comtnouwealth nor any of its political subdivisions shall
enter into any conasct for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting auahoriry."
Applkens
Please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation and.if
necessary.sup*mlscwuraotor(s)name(s),address(es)and phone number(s)along with their cenificae(e)of
insurance. Limited Liability Companies(LLCM or Limited Liability Partnerships(LLP)with no employees other than the
members or psRoers.am 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 Departme
nt of Industrial
Accidents for confirmation of insurance coverage. Abe be sure to sign and date the amdaviL The affidavit should
be retuned to the airy or townthat 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'
compensulon policy.Please call the Department at the awnbw listed below. Self-insured companies should enter their
self-insurance license number on the lm+•
City or Town OfHelsk
ptease he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottots.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
t'icase be we to till in the permivlicense number which will be used an a reference number. In addition,an applicant
,hat must submit multiple permirilicense 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 literate or permit not related to any business or commercial venture
(i.e.it dog license or permit to burn laves etc.)asid person is NOT required to complete this affidavit.
Vhc Off ice of Investigations would like to thank you in advance for your cooperation and should you have any questions.
1case do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
01i1a of InwNdpadees
600 Wuhin6ton Street
Boston, MA 02111
Tel. p 617-72749M ext 406 or 1-877-MASSAFF
Fax 0 617-727-7749
;taviod 3-26-US www.nuw.gov/din
CITY OF SALEm
PUBLIC PROPRERTY
DEPART.%MM
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fL��•s 13CV.%Ac .-%*S.saeTl�ltf��Lllvtlt»r.Lt1a::�
T1:VW46 a1.O.%*9w46' m
-f=
Construction Debris Dvposat Amdsvit
(mluimd fbr an demolition and tmtovation worst)
is mconlancs with the sixdm edition of dw Sate 9uMft Code.7W Clip taetioa I I I.!
Debt*WA dw proviskwas of M. CL a 41%S 34i
fluiid "S pynh A _ is iswtad with dw condition that the debris resulting Am
this wort shall be disposed of in a pevperlY licensed waste dispoed fadlIty as defined by MOO c
1tl.9INA.
Theydebris will be min y:sported b
l
I,CtG2� MQcjtQ &J
_._ lname.�fharatKM)
rho debris will be disposed of in :
. ,I�b�l-�is �cle
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o • wrcpreVUY LL: LO lOL�OOlOZFJ C A POWERS RANDOLPH PAGE 01/01
AA1Jj1RLC A]L 1TL�L C/GLS/LVVI 11:VJ: VL Ali 4�NtJE. VVJ/VUJ raw TAFTVir
ACORD. CERTIFICATE OF INSURANCE DATE(MRI1D0)YYI 09.28.07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
C A POWERS&SONS LLP MOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
233 NORTH MAIN STREET ALTER THE COVERAGE AFFORDED SYTHE POLICIES SELOW. '
RANDgTPH.MA 0236E COMPANIES AFFORDING COVERAGE
COMPANY
."INS A AMXWCAN 7d7RTCRTNSURANCF.CUNPANY
INSURED COMPANY
e
M.ACHADO DUARITi
14 ALBION ST COMPANY
C
S.ALFM,MA 01970 COMPANY
D
COVERAGE
MS18T0 CFRTPYTHAT THE POLICES OF MBVRAHCE USTEOBELOW HAVE SEEN=AD TO THE 1k%LW ON?6EDAWW MR THE POIJOY NDrANrmTANNNO
uioRa�wr rore"M ORiJD a NROCMpcy xSeO OE,ReiT00ouLTIN+EWre Ex µo�NdIT1eN8Horf6EuOHPCOiICM UmvrsWED 1 MyHAAVEbeFNMUOAAAICG
l
PAID CLAIIm
cc POLICY CPF POUCYEXP
LTR TYPE OF INSURANCE POLICY NUMMIR DATE(MMIDDMT DATBRI►RODTYYI LRAIIS
GMIRRAL LIAFMLIrY GENERAL AGGREGATE 8
COMMERCIAL GENERAL LABILITY PRODU07"OMPADPAGO. P
CLAIMS MADE OCCUR. PERSONAL 88 AOV.INJJRY 6
OWNER'S IG CONTRACTORS PROT. EACHOCCURRENCE 8
FIRE OAMAOR(Any we Fit) S
AUTONOSILG WAEl.RY MAD.EXP6NGE(Any e e per,,P) 5
ANYAUTO COMRINGO SIRGA UNIT E
ALLOW7JGDAUT07 EDGILY INJURY(Per Pe13M) O
SCMEOULE AUTOS SOOILY INJURY tPn AOGtlellp R
HIREDAUTOS PROPERTY DAMAGE R
NON.OMRJED AUTOS
GARAGE LUYDRRY
ANYAUTC)t AUTO ONLY.EA ACCIDENT 7
OTHER THAN AUTO ONLY:
. EACH ACCIDENT F
AGREOATE E
EXCESS LIABILITY
UMERELLAFORM EACH OCCURRENCE S
OTHER THAN UMBRELLA FORM AGGREGATE S
WYIRRERIE COMPENSATION AND
A EMPOLVOtM UARIUrY U&7738A00A•07 07-23-07 07-28-08 STATUTORY LIMITS X
THR PROPRO70W EACH ACCIDENT 5 100,000
PARTNERS0MCUTNG INCL DISEASE.POLICY OMIT S 500,000
OMC@R8 ARl: X EXCL DISEASE-EACH EMPLOYEE S 100,000
OTHER
DESCRIPTION OF OPCRATCNSA.00ATIORSNHNCLESIRESTRICTNNISISPEC)AL I/EMS
THIS REPLACER ANY PRIOR CBRILFICATE IWIED TO TEECERTN7CATE HOLDER ArIECTIM IYORICERS COMP COVERAGE.
THE.WORRERS'CONPEIIRAMX 9 XTCYDOES ROT PAOV(DE COVERAGE rOR MACEADO DUARTE.
CERTIFICATE HOLDER CANCELLATION
6HDULD ANY a T✓F.ABPJ,PE9GRI�O PCLICIEC 32 CANCe.Lta BPPOtETH!
-TTY OF PEABODY FXPIRATON GATE THEPEOF,THE I;DLTND LdAPANV Yn L ENDEAVOR TO MAR 10
DAYD WRITTEN N0'IOE TOTHE LEFTI-ILptF Ho.DER NA4®TO THF.LaPT BUT
24 LOWEI.L ST PALUPETO MAIL OUG:NOTICE E &L MP069 NO OELI3ATION OR IMM{,ITY OF WT
tIND UPONTHE COMPANY,R6 A6 R- TS ORPEPRE3ENTATI'JE3,
PEABODY,MA 01960 AUTHORUMD REPRESSNTATNE
W A Bolinder
ACORD 25.E(BOOT