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281 ESSEX ST - BUILDING INSPECTION (16) P li1 .iC hits �1�1 .1t 1 1 I�I I AA 1�I I I,vl I r v �I�(� I I ♦ y 11.1 yI,A� 'r.�Ai III �I '.- �I I I'i I I APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS V,I PORTANT: .%pplicantj must cunt lete all items on this page SITE INFORMATION I L Location Name L4I T+ 7✓ Building Property Address ,( ( jj'SS"e� S'f Located in: Conservation Area /N Historic district APPLICATION DATE Use Groups (check one) Group Humes R3 RJ_ Residential (3 or more Units) R2 'Type of improvement Residential (hotel/motel) R1 _ (check one) Assembly (Theaters) All _ New Building_ Assembly (restaurants &clubs) A2r_A2nc_ Addition - Assembly (churches) Al _ Alteration Business B Repaid Replacement�� Educational E_ Demolition_ Factory(moderate hazard) FI _ Move/Relocate Factory (low hazard) F2_ Foundation Only High Hazard H_ Accessory Building Institutional (residential care) If _ Institutional (incapacitated) 12_ Institutional (restrained) 13 Mercantile M _ Storage SI _Modcralc I Lazard Storage S2_Low I LtZMLI ON NU' RSIIII' INFORNM PION(I'lease type or I Iearly) O\VNER Name ,ER �Ir Ceido Address 04 t 55eK S ¢ Telephone Signature DESCRIPTION OF 11'ORF TO BE PERFORMED A" iG_ ES I INLk"I"ED CONSI-RUC'17ON COST e2— i s�0 � pe < Z116 CON I ItACTOlt 1N4-ORNIA'rION Namc Lk t s c S G Address -54 SS f& 6Lty 0197� Telephone `I78 -?,YY Construction Supervisor's Lic # C S 76 7 Home Improvement Contractor # iSb 5Y7_ :'LItC'lll'FECT/ENCINEER INFORMATION Name Address Telephone Mass. Registration # PIS RDI IT FEE CALCULATION "LL 5-5- 5- Estimated Cost x $11/$1,000 + $5.00= 3 2 . SO CONINIEN l:ti The undersigned applicant does hereby attest that all information stated above is trite to the best of my knowledge under the penalties of p jury Signed (owner) (a,ent) APPROVED BY : 462 DATE APPROVED: ` ) CITY OF SALEM 31 � . ,fir PUBLIC PROPRERTY __ DEPARTMENT 1111'. x Is lal•t III I kl o 1 2� W.k>tr1\\;J,^)I:r LL I' a 5nt l'\4, M.\%\.\t I rt it I IN 3197C� I,I. '771.71i93'15 • 1:\.x 974-74C'IY46 Wurkers' Compensation Insurance %ffidasit: Builders/Contractors/ElectriciansjPlumbers %milicant Information Please Print Le¢ihly V:IITd Illu•u,es'17r;;anlauinNlndn utuutl: Address: Ciry,Stare.zip: Phone B: .%re you an employer'! Check the appropriate boa: 'Type of project (required): I. ❑ 1 :un a employer with 4. ❑ I ❑m a gCneral coalraetor and 1 fi. ❑ New construction employees(full and/or part-unle).• hake hired the sub-contractors 2. ❑ 1 ant a sole propricnx or partner- listed on the anachc,l sheet. ; 7. ❑ Remodeling ,hip and have no employees, These subcontractors have a. ❑ Detnolition \corking for me in any capacity. workers' comp. Insurance. 9. ❑ Building addition No workers' coin insurance 5. ❑ We ate a corporation and its I P• 10.❑ Electrical repairs or additions I required.) officers have exercise) their 3. ❑ 1 :on it homeowner doing all work right of exemption per NIGL 1.1.0 Plumbing repairs or additions myself. [No workers' comp, C. 152. ¢1(4). and we have no 12.[�2uuf repairs insurance required.] t anployccs. LKo workers' I3.0 Other comp. in.xurance required.J •\Ip ..pphcaut Ihar checks box it must abo fill wn the•ecnou IMIuW.huwiny Iherr wu(kws eumgsan>ariw,gwGcy utlitrrr,atiur. ' I lomuuw ten who sslbmit this atTlJavit inaiulina the).ue Jofna all,wrt a,W Own him uulude cu,urxmrs must.W mil a new aWdasii indi"mj.Itch. -C\.rar.,smn that ahcclr this box into#atlwhed.In additional nlwxtt.huwiny tlw uamt of this subtonlraelurs and Iheir svrtori comp.puhcy mfurmaliun -- /run m#eoy�(uyrr#hut is pro riding#vurkars'c•umptn safion inaurvu#ce•fur e#y ra#p/upter. Befuly is the pu/fay and job\i(e iafurnmfiun. Insorancc Company Name:__--- Policy +1 ur Scif-ins. Lic. n: _-.. . . __ Eepiraltun Date: job Site Address: _-_. Cuyeslale/Llp: .\ttach is copy of the workers'compensation policy declaration pale (showing the policy number and expiration date). 1=ailurc to secure cucerage as required under Section 25A ul'>IGL c. 152 can lead to the imposition of criminal penalties of a Anc up to]L500.00 an1L'ur une-year imps isomncnt, as \vcll as cic if peoallles in the farm of a STOP WORK ORDER and a fine Of up to S25o.no a Jay .igainst the violator. Be.advised that J Copy of this sialcmctil may be forwarded to the 011tce ut III\�.\tl'�allVll>of :ife [)I,% :or Imw.uxc a.c crage \cr ilical:on. /Ju hereby t.rtifv rurder the pains our/pettahiev of perjury that the infurtnuNon provided ubove is true uud correct. t)�/iciu!rut un/y. Du not write in this area, to Ar ruurp/rred by city ur Iorvn njjiriu/. I ( ill, or l'nwn: _... _—. Permit)l.icvnse 0. Issuing; .\ulhorily (circle nne): I. 11„a nl of Ilcalth !. Iluddin� Ih lt.trtutclN .I. Clerk J. L•'lectriatl luspcc for 5, Plumbin4 In\yccwr b. Otber _ C.,ntacl 1'cnu l: .. .. Phone tl: l Information and Instructions Lu;uchusetu Gcncral Laws chapter t 52 requires all emplo)ers to provide workers' eOmpen,uhon for their employees. 1'ur,aant to in Is .,atule,an employee Is defined as - .et err) Pelson in the scrviee of anul lie r under.toy contract of hire, C ,pre,s or Implied, oral or written. An .•,"plop., I<defined as "an Individual, partnership, .usociatwu, corporation Or other legal entity, or any two or snore .'t the foret!0ing engaged if a point enterprise. and including the!cgal representatives of a deceased cmplu)cr, or the receiver or trustee ut of Individual, parnurship, assoclalWn or other legal conty,employing rniplo)ccs. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the .l%velhng Irou.e of another who cmploys persons to do maintenunce,aanstruction or repay work on such dwelling house or oli the grounds or building appurtenant thereto shall not because Of such employment be deemed to be an employer." ss - states chat "ever state or local licensing agency shin withhold the issuance or IS_ _SC 6 also Y �IGL chapter . s ( ) renewal of a license or permit to oper ate a business or to construct buildings in the commonwealth for any ;ipplicanl who has oat produced acceptable evidence of compliance with the insurance coverage required:' kaditunully. MGL chapter 152, j25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfoniiance ul'puhlic work until acceptable cvidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." .Applicants Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)nanic(s), address(es)and phone nuniber(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 allidavit. The affidavit should he rctlnied to file 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-insurcd companies should enter their self-insurance license number on the appropriate line._ City or'rown Officials Please he surc that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of die affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. I'I:asc be surc to fill in the perna/license number which will be uscd as a reference number. In addition, an applicant that must submit multiple pennitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Jab 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 flit for future permits or licenses. A new affidavit must be filled out each - near. Where a hurtle owner or citizen is obtaining a license or permit not related to any business or commercial venture (1, it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he I)I lice of lnsesligatlonr would ilwc to ,Malik )au in advance fur your cooperation and should you brie sly questions, please do nut hesitate to give us a call. fhc Dcparnncnf's address, telephone and fax number- The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, MA 02111 Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE Fax q 617-727-7749 www.mas3.gov/dia n CITY OF SALEM 'l ( ', PUBLIC PROPRERTY DEPAR"I'MENT •. ,. •:1;i11 r � 1�I I V. \L�•,\i .. .. i .._I'1 ': I11- ')'8.'i; \Y 'i'5.'4:v${L Construction Debris Disposal at•tidavit (rcyuircd lbr all demolition and renovation work) In accordance ith the sixth edition of the State Building Code, 780 C NIR section 1 1 1,5 Dcbiis, and the provisions of MGL c 40, S 54; Building Permit N is issued with the condition that the debris resulting front this work shall he disposed of in it pruperly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will lie transported by: (namc Lit hauler) I he debris will be disposed of in �l7 vyL tmm�r ul laeilily,),_ �G(/`l dll Sir/ mil (address of lanlilvl ,1 alwc of pcnnll .lppllcanl 3 ag-1r2 dale Gerald T. McCarthy Insurance Agency, Inc. P.O. Box 839 -- 92 North Street, Salem, MA 01970 978-744-6433 - Fax 978-744-3575 March 30, 2009 Building Dept. City of Salem City Hall Salem, MA 01970 Re: Holloran Development- Acadia Ins Co Pol#WC202000168800 Dear Sir: Enclosed please find a certificate of insurance as evidence of liability coverage for the above mentioned. By law, certificates for workers' compensation insurance must be issued by the assigned insurance carrier; therefore, we have faxed a request to the above mentioned company to issue a worker's compensation certificate of insurance which they will mail directly to you. In the meantime, please be advised by us that this coverage is, in fact, presently active for the period of November 06, 2008 to November 06, 2009 1 hope you will find everything in order; and if you have any questions, please feel free to call. Sincerely, Deborah Tournas dt ACORD DATE TM. CERTIFICATE OF LIABILITY INSURANCE I 0330/2009 • PRODUCER Phone: (978)744-6433 Fax: (978)744-3575 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION GERALD T MCCARTHY INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 92 NORTH ST HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P O BOX 839 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. SALEM MA 01970 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A'. Union Mutual Insurance Company 25860 HOLLORAN DEVELOPMENT LLC INSURER IT C/O JEFFREY HOLLORAN INSURER C: 41 FAIRMOUNT STREET SALEM MA 01970 INSURER D: INSURER E: 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 y. MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATELIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBRIADDti TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRD DATE MM/OD/YY DATE MMIDDNI GENERAL LIABILITY B05060718 10123/08 10/23/09 EACH OCCURRENCE $ 1,000,000 I_X1 DAMAGE TO RENTEDCOMMERCIAL GENERAL LIABILITY PREMISES(Ea occurenei $ 50,000 CLAIMS MADE OCCUR MED.EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 I GENERAL AGGREGATE $ 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO. S 2,000,000 I Xl POLICY r—] PRO- F JECT LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ — ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Per person) S -ti HIRED AUTOS BODILY INJURY I NON-OWNED AUTOS (Per accident) $ rJ -- PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR n CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ I RETENTION$ $ WORKERS COMPENSATION AND TO YLIMITS OTHER EMPLOYERS'LIABILITV EL EACH ACCIDENT $ ANY PROPRIETOR/PARTNEWEXECUTIVE OFFl6E.MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ U yes,describe untler SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT 5 OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATN: BUILDING DEPT EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE CITY HALL TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, SALEM, MA 01970 IT'S AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE /,,��///���/� // �ryy Attention: /�Gt?'e6`O T rnNs,` - ACORD 25(2001108) Certificate# 3869 ©ACORD CORPORATION 1988