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10 BROADWAY - BUILDING JACKET X17 -- 0,`� PUBLIC PROPERTY DEPARTMENT KI SMERLEY DRISCOLL MAYOR 120 WASHINGTON STREET•$ Attar,N1nssACHt:sErrs 01970 IFi 978-745-9595 0 FAx:978-740-9846 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: 10 Z, Building: Property Address: Property is located in a; Conservation Area Y/N n Historic District Y/N r� 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: / 11/ij n , 5,k,�A �hpSGv -It /,X� /Y Telephone: -7 _ -5 � ScC��S 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Aff Existing Renovation Number of Stories Renovated Change in Use /t,yf New Demolition /— Existing 7 pUU F- Approximate year of Area per floor (so Renovated construction or renovation Q of existing building / New 17 pyo Z r Brief Description of Proposed Work: Mail Permit to: 9r0 What is the current use of the Building? Material of Building? d — If dwelling, how many units? Will the Building Conform to Law? Asbestos? "� Architect's Name Address and Phone Mechanic's Name T N'l C eA C L Address and Phone 7 ��r>^ b Re � d Construction Supervisors License# ©5 � b!re HIC g istration#—�di---- // Estimated Cost of Project$ /L91 Permit Fee Calculation =. Estimated Cost X$7/$1000 Residential 0 Permit Fee $ � S'�� / 10 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 the 'above ststated, specifications. Signed under penalty of perjury /X Date .+ y L C 3 u Q ^ y F' S em i r a a Ik v ACORD CERTIFICATE OF LIABILITY INSURANCE 021'2006 11/02/2006 PRODUCER >. IS CER FI AS A MATTER OF IN TI Richard Bertolino Jr Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1200 Salem St #121 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lynnfield, MA 01940 INSURERS AFFORDING COVERAGE NAIC IN NWRED i INSURER A: Arbella Protection Joseph McCall Carpentry INBORERB: AIM Mutual 65 Eastman Ave "SURER c: Swampscott Mea 01907 r INSLmEa D: I INBURERE 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. U�EF TR IxSRD TYPE OP S1811RAxGE POLICY wamm OATEW FmTNE POND(MMDd DINTS L A OENERALUABR 75000024663 08/13/2006 08/13/2007 FAOIOCCURREHCB s 1,000,000 XcoMMERCIu oeNERALLueam PREMISESIEeoc gym) $1,000,000 X X cLAIWmAOE 0OCCUR 1 ME ENP(ARYCPSPKla,) 35,000 PERSON kADV;N Fff $1,000,000 GENERALAGGREOATE 32,000,000 GENLAGGREGATEUMITAPFUESPER: PRODUCTS-COMPIOPAGO 31,000,000 POLICY r7 TECOT LOC AUTOMO&IE LNBWTY COMBINED SINGLE 11MR 3 ' EesaMmx ANYgVfO I A OWNEDAUTOS BOOILY INJURY $ lPsr M—) . scxmuLEO Autos HIREDAUTOS BODILY INJURY 3 (Par=10M) NON.OWNED AUTOS PROPERTY DAMAGE 3 (Per PNBerR) GARAGE WBOfiY AUTO ONLY-EAACCIDENT 3 ANYAWO OTHERTH EAACC 3 AUTO ONLY: AGO 3 EZC®Sglxenn au UTV EACHOCCURRENCE S OCCUR ❑CWMSMADE , AGGREGATE 3 3 DEDVCTIBLE S '., RETENDON 3 3 H LroRlaRe w3weeAnaNAxD 27857908 09/01/2006 ��09/01/2007 TORT umrts ER EMPuWERB-UABILRY EL EACH ACCIDENT $100,000 ANYPROPRIETOWPMYYITNE OFFICEWMEMBFR EXCLUDE07LUDEOT EL OSEASE•FJ,EMPLOYEE SSDD,DDD IISRA�IBaull� .EL DISEASE-POLICY LIMIT 3100,000 sPEUAL movlsloNs pelPw OTHER DEBORIPIOM OF OPERATIOM I LO TIONBIVe11OES I EXCLUSIONS ADDS)BY QIDORBpgEMI SPCOAL PROVMKIMB Separate Cart has been ordrered from Mass Workers Compensation Bureau for holder, CERTIFICATE HOLDER CANCELLATION Delisio Bros SNOISD A OF THE ABOVE DeSeRmm PO MES BE OAKCRI r cn BEFORE WE E%PIRADON RATE THEIffOr. THE 139UIN0 M3UREIL WRL ENDEAVOR TO MAILDAYS WNTIEN 10 Broadway NOl1OE TO TNB p]TMGTE NODS) MAYS) 1b WE LEFT, BUT CgrURE 10 W 90 SNgLL Salem Mass 01970 BIPOSE xD oBIJGATON OR WaUIY OF ANY KIND UPON THE IxBIRU:R ITS AGENTS O0. Fax 978-745-4550 IZFPRESENTATNES. AURIORMOD REFRESQRATf V E Richard Bertolino A ORD25(2 07108) CORPORATION 79 81 1 '01 BTLOTESSL6 dr ouITo-4.lag PueyoIN dLTTbO 90 EO f%oN rz CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KIMBERIEY DRLSCOIl MAYOR 120 WASHINGTON STREET*SALEM,MASSACHUSETTS 01970 TEL 978.7459595 •FAx:978-740.9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (BusineWOrganiTation/Individual): Address: pp City/State/Zip: Ph n #: 7Ol Sg, Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. C]New construction �,�mployeea(full and/or part-time).• have hired the sub-contractors 2.lV I n a sole proprietor or partner- listed on the attached sheet t ?• Erkemodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its 9. , Heng �a°n required.] officers have exercised their 10.�1dnlectrical repairs or additions 3.(] I am a homeowner doing all work right of exemption per MGL 1 l.b-Irlumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑Roof Other pairs insurance required.]r employees.[No workers' 13 �Other comp. insurance required.] 'Any applicant that cheeks box#1 mud also till wa the section below showing their workers'eompeosenon posey infamatiob t Haneowmm who submit this of harm indicating they an doing aV work and then htba a",&eonttaetas mud attbmg a new atfldsvit ck. so :Contractors that cheek this has mud attached m additional sheet showing the name of the sub-conamors and thea workers,comp•policy icirdamatloo. I am an employer that Is providing workers'compensation insurance for my employees. Below it the policy and Job site information. Insurance Company Name:K1 e �Vy-D L J1i 3-QZ 1 A U 6/A:EQ Policy#or Self-ins. Lic.#: +'i 0 0 O o -a to Expiration Date: Job Site Address: U 1/ 4 D LAJ 14 / City/State/Zip: 5A (.1F/^'( Attach a copy oCtha workers'compensation policy declaration page(showing the polity 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 S 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 certify under the pains and peenalldes ofper/ury that the information provid,ted/above is true and correct Signature: OJJleial use only. Do not write in this area,to be completed by city or town oJJlciaL City or Town: Permit/Llcense# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 6.Other 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone#' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation forseine of hire Pursuant to this statute,an employee is defined as"...every person in the service of another under any e 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 hoose 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 e been presented to the contracting authority." requirements of this chapter hav Applicant Please fill out the workers' compensation affidavit completely, ,bn checking th boxes that theiapply certificate(s)oYou �on tmd.if necessary,supply sub-contractor(s)name(s),address(es)and p g other than the insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees 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 nts for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should Accide be returned to the city or town that the application for the permit or license is being requested not the Department of Industrial Accident. Should you have any question regarding the law or ifyou are required to o kers' their compensation policy,please call the Department at the number listed below. Self-insured companiesshould enterself-insurance license number on the a 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 Investigation has to contact you regarding the applicant.Please be sure to fill in the permit/licene number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license application 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 location 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 af;,davit 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 Investigation 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-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia T CTTY OF SALEM :j PUBLIC PROPERTY DEPARTMENT wra. 130 WAUG GWK stag•SMMk MASAMMWIf 01970 112.M745.9M•PAZ M74a9W Construction Debrb Disposal Aifldavit (required Lac an daaolidan and renovation work) In wmarda me with dw 266 edition of dw Stab Building Coda.7W CMR section I I IS Debris,and dw provisions of MGL a A S A Building Peenit sf is issued with dw oondWon that dw debris mmMug fiom chis wort awn be disposed of in a properly liamsad web disposal fi maty as defined by MGL o ll1.SISO& The debris will be transported by: (sums attratart The dcbris�will be disposed of in: (aama o[heilit» (aJdnaa of heAiry) sipasm otperade vokam dos