131 DERBY ST - BPA-07-162 (REAR, BRICK BLDG.) PUBLIC PROPERTY
DEPARTMENT
Kimmi 1.EY NUSCOLL ' C�-7
MAYOR
120 WAcwNc:rON STxF-gS S# FAX 78-i 40-9 rz-rs 01970
'IEi.:978-745-9595� FAx:97&7�10.98J6
APPLICATION FOR THE REPAIR, RENOVATIONg CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name:�� /�-,6,v0,,5 QglDD.N/.(//!/ Building:`]
Property Address: ��/ J7—/ 6,4C
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land1&A,141=4A/CE 6WOW14,1/41.4f �fl�!' FRB U7 7,eufT
Name:
Address: /Or/ 6WAF C977. s�B,6,z
Telephone: 76 -T6 —ASZ vc/L eq,�/,r,�j aWoa' C#if
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing ,Z
Renovation Number of Stories Renovated
Change in Use Nn
C,emolition
axisting ZZOb
Approximate year of Area per floor (so Renovated
construction or renovation zc�s
of existing building New
Brief Description of Proposed Work:
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Mail Permit to:
What is the current use of the Building?
Material of Building? ✓�� If dwelling, how many units?
bestos?
Will the Building Conform to Law? r4 As
-
'=-t�e Name
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Address and Phonew ------
MechaniesName
Address and Phone
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Construction Supervisors License# 6A3-5</3 ! HIC Registration#
Estimated Cost of Project Permit Fee Calculation
Permit Fee$ ��«s 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 PermiAto ';he&vlel stated
specifications. Signed under penalty of perjury X.
Date
� I
on
9
C6 S
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is IN a, as
JUL-27-2006 15:10 A&K FOWLER INSURANCE LLC 9786642209 P.01/01
�.P • 7/27/06
rPrtoouGEa ~• THIS CERTIFICATE IS ISSUED ABA MATTER OF INFORMATION
A 6 K Fowler Insurance, LLC ONLY AND CONFERS NO RIGHTS UPONT HECERTFICATE
200 Park Street HOLDER.THIS CERTIRCATEDOESNGTAMENREXTENDOR
North Reading, MA 01864 ALTER THE COVERAGE AFR0RDEDBY THE POLICIES BELOW.
INSUREIIS AFFORDING COVERAGE INAIC# _
INSURE INSURERA Preferred Mutual_ Insurance Co
Old English Brickwork INBURER B:
5 Patriot Lane #16 INSURER c. - _
Georgetown, MA 01833 INSURER D.
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NO'RMTHSTANOING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT ON 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.
-�.. POl1CYEFfiR:T 77/21/07
ryPOLICYLIM"
I GENERAL LUvSR EACH OCCURRENCE 8 1 ODO 000
A XTCOIIMMERCIAL GENERAL UABIUTT CPP0110582277 7/21/06 PR °P,,,Pp,•„� $ 50,OD0_
I (CLAMS MADE �X OCCUR MEDEXP(A,ygg PWWM $ 5,000
II—T'� .- I PERaDNALSADywJURY s 1 000 000
I GENEAALABGREGATE S 000,000
IrGEN'LAGGREGGTEUMRAPPLIESPER' I PaOOUCTS COMPIOPAGG s 2,000,DDD
I POUCY P"O- WC
JECT
AUTOMOBILEUYHILm
I—T ANY AUTO (COMBINED SINGLE UMIT $
I I ALL OVRiEO AUro$ . .
s
SCHEDULED AUTOS BODILYINJURY I � (Pa ps•ap
HIRED AUTO$
ICI BODILY INJURY $
LI NON-ONMED AUTOS IPc agldBlO
— I PROPERTY DAMAGE IS
'CARW_ m .(Pp RFGDenH
IL AUTOONLY-EAACCIDENT IS
ANY UA TD _
(OTHER THAN EAACC s ..
AUTO ONLY: ADO
EXCEBBAIMBReAALMBBJTY EACHOCCVRRENCE s
OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE S
RETENTION $ S
WORHERSCOMPENBATIDIIABD WCw
BMROYERS'IJAMI Y
ANY Pa OFR IETORIp(q TNERpT(ECUTN$ • EL EACH ACCIDENT $
OFFICERMEMBER EXCUJDLD?
N EwcApe lFl•Bf ELOISEASS-EAEMPLOTFE
$
6PEdAL FROVI'M SNA'rs ELOISEAIE-POUCYLIMIT Is
OTHER
DL RIPRONOFDF ATMN$16ODATIONSIVENCLE$IEXCLNBONSADDMBYENDORSEMENTI.SD PRGVOOM
Insurance verification
CERTIFICATEHOLDER CANCELLATION
MOULD ANY OF THE ABOVE DESCRIBED POLICIESBE CANCELLED BEFORETHROGIIRATION
DATETHERrOF,THE ISSUING INSURER WILL ENDEAVOR TO MALL 10 DAWWRIT E
Steve Navarro NOTICETO THECERTIPICATE HOLDER NAMED TO THELEFT,BUT FNLURB TO 0000 SHALL
Pam 978-739-4821 IMPOGENOOBL=TION OR LIABDJTYOFANYRIMD UPON THISINSURM.OSAGENTBOR
REPRESBIT
AIITMOR12" N
ACOR'D 25(2001100) 0 ACORD CORPORATION 1088
TOTAL P.OS
AI:111:11® CERT1 FICATE OF-]NSU RANCE DATE(MM\°D\VV)
y- - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
BELLOWS—NICHOLS AGENCY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
PO BOX 469 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
NEW IPSWICk- NH 03071 COMPANY
28PYP A THE TRAVELERS INDEMNITY COMPANY
INSURED COMPANY
KANDOLL, DALE B B
67 HIGHLAND AVE H3 COMPANY
MILFORD NH 03055 C
COMPANY
D
OGVERAOES
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM\DD\YY) DAM!&1M\DD\YY)
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGO. $
CLAIMS MADE L�:]OCCUR. PERSONAL&ADV.INJURY $
OWNER'S&CONTRACTOR'S PPOT. EACH OCCURRENCE $
FIRE DAMAGE(Any one flre) $
MED.EXPENSE(Any one person) $
AUTOMOBILE LIABILITY COMBINED SINGLE
ANY AUTO LIMIT $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per Person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per Accident) $
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND STATUTORY LIMITS ` NIA
A
EMPLOYER'S LIABILITY (UB-1385C96-1-06) 01-24-06 01-24-07
EACH ACCIDENT $
inn nnn
THE PROPRIETOR/PA TIVE INCL DISEASE—POLICY LIMIT $
RTNERS/EXECU
OFFICERS ARE: X EXCL DISEASE—EACH EMPLOYEE $ 100,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THE POLICY DESIGNATED ABOVE IS CANCELED
EFFECTIVE 8/29/06
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATkON
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
STEVE NAVARRO LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
131 DERBY ST LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
SALEM MA 01970
AUTHORIZED REPRESENTATIVE'
ACORN)25.5(31e9) �Oftb GQR/r/FDRA7'!JJON/•C/38ff3 s.
TRAVELERS 01862-AM
2420 LAKEMONT,AVE STE 100
ORLANDO FL 32814
STEVE NAVARRO
131 DERBY ST
SALEM MA 01970
ACORD
CERTIFICATE
OF
INSURANCE
(On Reverse)
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 �' Please Print Let=ibly
Name (Business/Organization/Individual): 57Sy4150(/ 4;y/ilk
Address: E71
City/State/Zip: LYailL /�a • O(f05� Phone #:
Are you an employer? Check the appropriat box: Type of project(required):
1.❑ I am a employer with 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 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I LE] Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.,WRoof 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 time 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:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 cer y ad the s and penalties ofperjury that the information provided above is true and correct.
Signature: Date: f3 �
Phone#: - �- _5r9aB
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 h6en 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 adva5e 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
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
CITY OF SALEM
�I• PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON SiAFHr•$ALEm,MASSACHISETtS 01970
TEL.978-745-9595 • FAx:978-740-9&l6
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
1 L 1,S 150A.
The debris will be transported by:
(no.of naule
The debris will be disposed of in
-- (name of facility)
(address of facility)
sig c of ptrout applicant
B�zs
date
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