131 DERBY ST - BPA-08-334 STUCCO SIDE OF BLDG n ,
What is the current use of the Building?
Material of Building? f"R S« If dwelUng,how many units?
Will the Building Conform to Law? �/�-S Asbestos? h� n
Architect's Name
Address and PhoM
Medtanies Name W a /k o t aD
AddressandPhone 537 b�^y {�
Construdhon Su License Z (- 2 HIC Reglatretlon S l03 1
= o a Permit Fee Calculelfon
Estimated Cost
Permit Fee S Estimated Cost X i7/57000 Residential
--- _ Estimated Cost X S11/51000 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 - atw�stsd
specftatws. Signed under penalty of Penury
i` Date
of
N
N
e
QI
1
CITY OF-
PUBLIC PROPERTY
DEPARTMENT
3wuK Yuuau:srrs Ot970
TM-M743.9M*FA=M?40.%%
APPLICATION FOR THE REPAIR. RENOYATION CONSTRUCTION
D&MOLTTION. OR GRANGE OF USL OR OCCUPANCY. FOR ANY EXISTING_
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
---- - Property 1� rv�--��-- ---- - - -- -- - ---- -
Propoty Is 4loeatedJ in a;dormnvilon Area YIN Historic Obeid YIN
2.0 OWNERSHIP INFORMATION
Z.i Owner of Land
Name: 1)F} ISS/-�ncC- � I Den. n,
Address:
Tom: `J�s — D.3S '
3.0 COMPLETE THIS SECTION FOR WORK IN E7(ISZ Na BUILDINGS ONLY
Addition Existing
Renovation X 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: ----- .-
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
6r\1111REIN URISt:l/LL
M. Ay It IXWASHI.\u ONSTREETaSALEM.MASSAOaat:-1-cs0197V
'rhr:978-743.9595 0 FAX:971-740.9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Altnlicant Information Please Print Leeibly
Name taucinc.wOrganizatinNlndrivutwi): Iv �- �M G�/11A-3-t -,
Address: C;i_n�
City"Stare/zip: �LA L) v Phone //: 27J0'
Arc you an employer?Check the appropriate box: Type of project(required):
1.ZL1 ant a employer with 4. ❑ I am a general contractor and 1 6. Q New construction
employees(full and/ur part-tine).• have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. : ?• fRemodeling
ship and have no employees 'these sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. Q Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its !0. Electrical re
required] officers have exercised their ❑ pairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself[No workers comp. C. 152,§1(4),and we have no 12.❑ Rtwf repairs
insurance required.) t employees.[No workers' 13.Q Other
comp. insurance required.]
•Airy applicant lint checks box el mop also till out the+salon below stlowiog davit working,'compensation policy inhumtuwn
' 1 tumvuwnats who submit this affidavit indicating they are doing ail work and than bite outside cemracton mug aulmsR a new amdavit indicating such.
Cuntncvts that chock this box mast attached an additional shad showing the name of the mb-comractors and their workers'comp.policy informatitm.
fain an eusplayer that Is providing workers'compensadan insurance for cry employees. Below is the policy and job site
iafartnation.
t
Insurance Company Name:WA Ate
Policy p or Self-ins./Liss n: wC- �O __._ TExp—iration Date:
tub Site Address: D e z A n CA- City/Stateizip:. 's.41c t fN"r-
.%ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
hailure to secure coverage as required under Section 25A of.%,IGL c. 152 can lead to the imposition of criminal penalties of a
fins up in 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 S250.00 a day against the violaror dviscd that a copy of this statement may be forwarded to the 011ice of
Imc,iigariuns of the DIA for iniur. . c CO agc verification.
l da hereby semij sad pnuhrs of perjury tbutllm infurmution pro videOd�abave is use and correct
17 j, I J /C�Phone ei' '..
Uncial use only. no nor sprite in diir area,to be rontpleted by city or town oJjie iaL
Cityor'rovsn: Permit/Licenseq
Issuing Authority (circle one):
1. Board of health 2. Building Ilepartincnt 3. City/fovea Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: -- - __ Phone p:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers
t se ov d wonvice er ' compensation
ompeother ndeir any thereree oflhire s.
pursuant to this statute,an employee is defined as"...every pc
express or implied,oral or written."
.An employer is defined as"an individual,llaruwfshiP,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 u1 am 111d1 V ldual,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 occupam 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."
NIGL chapter 152.¢25C(6)also stares 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,.425C(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."
Applicant
Please rill 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
,elf-insurance license number on the a ro riate 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 rill out in the event the Office of investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. in addition,an applicant
that must submit multiple permitilicense 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 tilled out each
year. Where a home owner or citizen is obtaining a license or pennit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Ot li a of investlgatiOns 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
omee of InvestlPdans
600 Washington Sheet
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
MAR-27-2007 TUE 11 :02 AM JENKINS,INS, FAX NO, 7812459563 P. 04
I I
ACORDTN CERTIFICATE OF LIABILITY IN URANCE °"3/27/07"'
PRODUCER THIS IFICATE IS ISSUED AS A MATTER OF INFORMATION
Wayne C. Jenkins Insurance Acy ONLYA'D CONFERS NO RIGHTS UPON THE CERTIFICATE
50 Salem St HOLD .THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P.O. Box 69 ALTER HECOVERAGEAFFORI)MBYTh1EPOLICl6 BELOW.
Lynn£ield, MA 01940
INSURER (AFFORDING COVERAGE I NAIC 8
I NSUR� INSURER A' afeInsuranco Corilpariy `h
. ... ..._.. _.._.
Now England Brickmaster Window INSURERa rrican Home Assurance Compa.___
and Exteriors, INC. - -
951 East Street
INSUREr C! 1�ella Protection
Tewksbury, MA 01876 INSURER D,
INSURER E•. k`p
COVERAGES I THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NSURED NAMED BOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING
ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR tl7H BR OCUMENT WIThI(RESPECT TO WI•IIChI THIS CERTIFICATE MAY BE ISSUL=D OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCR1015P ERFIN IS BUBJ CTTO ALL THE TERM$,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAIC CLAIMS• _ I�
IN R _p,. .. _. .—_— POLICY PF FEC vE
n SUR POLICY NUMBER I LIMITS
GENERALLIABILITY EACFI OCCURRENCE :-S_1y OOPT DOO
OA9FGETOREIJT6P'
X COMMERCIALGENEIRALLIASIUTY CP00000144 9/15/-7 4/15/08 PRatISE5lEnoccwoncnL_-,5 - 100T000
,? _ .� CLAMS MADE X OCCUR MM- GXP(Myma person) $ .10 r 000 j
PFIRSCNALi ADV INJURY ,S 1,000,000
.GENERALAGGREGATE _ S. 2,000,000
GEN'L PRODUC
AGGRFGATR UMF APPLIES PER; _... .,....r...._
TS_COMPro $.PAGG 2 OOO,DO,O
POGDY jE ILOC --- -
AUTOMOBILE LIPBILITY COMBINED SINGLE LIMIT
ANYAUTD (E:S sccirldnu S 500,000
ALL OWNED AUYOS O42034000000 7/8/ 6 7/8/07 SOOILY WJURY
C X SCHE°ULE-DAUTOS (Per Pe(=A'1)
}[ HIRED AUTOS BODILY IIJJURI' S
NON•OWNED AUTOS lFa acadrnq
. .. PROPERTVOAMAGF S
i
(Per Ro 1 ml)
GARAGE LIABIUTY AUTO ONLY-EA ACCIDENT F
AWY AUTO EAACCS7
__ AU THAN —- ----
AU ONLY: AGG I'y`
EXCESWUMBRELLALIABILITY EACH OCCURRENCE 5
OCCUR CLAIMS MADE AGGREGATE 5
S
_ DEDUCTIBLE
RFTENT1014 $ S
A - V
WORK 8iS COMPENSAYION AND QfiY DNITS___. .EFi,__..
EMR.OYERS'LIASLTTY WC7690403 3/26/07 3/26/08 ELEACHAOCiQSNT & 100,000
B OFFILHEWMEMBEk EXCLLUDES?DcurnE - 500,000
EL DISEASE•EA EMPLOYEE Y
ir. ,Yescowundo,
SPFCIALPROVISGHS6cbw P1.0)sEASE-POUCVLIWIT S 100,000
OTHER
DL RIPTIDNOPOPBRATIONSJLOCAIIONSJVGHFLESIEXCLVSIONSADPEOBYEIJDM&VMENIYSPBCIAL DV151ONS
CERTIFICATE HOLDER CANCEL TION
SHOULD ANY OF THE ABOVE DESCRI PEP MUCIES13E CANCELLGP BEFORE THE EXPIRATION
DATE THE ROF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL —DAYSWRIYIEN
TO Whom it May Concern NOTIC EY •THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TOO 0505HAI.L
I MFOSENI I OBLIGATION OR LIABIUTYOF ANY KIND UPON THE INSURER.95 AGENTS OR
. .. ...;
RCPRES ta19VBSe_ •.:.:. . ..,'."r`•"
AUTI'IORI R NT'7VE '
ACORD 25(2001/08) 0)ACORD CORPORATION 1908
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
r.Y'''Ai4:Jl L
�L,,. It 12C vY.\LLLV::JN.f.7EET•Tu:M,)t.\<iu a .t:115�:9/'.
Tn.vW4irsys •F.%) 9nAc944
Construction Debris Disposat Affidavit
(required for all demolition atut renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 Cb1R section 111.5
Debris,and the provisions of v1GL c 40.9 54;
Building{ Permit M _ . ._ 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 SIGL c
I i L.S 150A.
The debris will be transported by:
— — (lmma of tauter)
me debris wilt be disposed of in : p Li P OfA,
c)
Wane of ta.i1a
v , r ,::rn.0 ppa.�at
AM/ oftMimg eguldons an tan. s�
One Ashburton Place - Room 1301
4 Boston, Massachusetts 02108
Construction Supervisor License
License CS: 97262
Restriction: 00
Birthdate: 9/22/1958
Expiration: 9/22/2010 Tr# 97262
STEVEN WOLPE ----- -- ------
158 ASH STREET --- - __
HOPKINTON, MA 01748
Update Address and return card.Mark reason for change.
Address (� Renewal Lost Card
DPS-CA1 is SOM-06/06-PC8490
IBo r'1eo t5'fio andi"5St'an a'pd' ,
Construction Supervisor License
License: CS 97262
' Birthdabi.\9/22/1958
i Expiration 9/i22/12010 Tr# 97262
-Restriction: DO/'I,% �
' - y
ST;EVEN WOLPE:;
158 ASHSTREET �� `%-'�•— �%/�
HOPKINTON, MA 01748'i`` -'' Commissioner
Boil of IYWrinuf n7i�on6nd nn ar License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return
Board of Building Regulations and Standards
Registration:, 103185 One Ashburton Place Ran 1301
Expiration:.'7/612008 Boston,Ma.02108
Type: Supplement Card '
NEW ENGLAND BRICKMASTER
STEVE WOLPE
/3
951 East St. - _ ,i
Tewksbury, MA 01876 - dminknator `' of valid w�tWeut5lg tore