28 FEDERAL ST - BUILDING INSPECTION (2) The Comnionwralth of Massachusetts
R
t Board UI BIIIIdlllg ReglIIallUllti and SlaI1d:11J5 MI Nli. ll' \I I I )
%LISSachusettS State Building Code. 7SO (AIR. 7"'edition �I.
o Building Permit Application To ConSllnct. Repair. Reno%ate Or Demolish a R. I ioJ.huma,
O One- f or Tit u-
l•'tu))i!c Dtrrllir)•t 1. _
cial Use
` BwlJing Permit Num •r, Phis Section Ft�� Applied:rel Only
E�—
v� Signature: 1-= -
Bud d "I,('uuunl„Iuoi n Inspeiwr of&uldmgs Dale
SECTION 1: SITE INFORMATION — -- --
1.1 Pro^rP,.,address: 1.2 :assessors Map & Parcel Numbers ,
t :tilt INumher P'u,cl Vumher
t I.Lt h 'his ;ut accepted srtYet. sex_---_ no - `.Lip i
.t 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Isy IU Frontage Ili)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rcur Yard
Required Provided Rcyuued Provided Rcyuaed PI...IdeJ
i
1.6 Water Supply: IM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside EyesFloo Zone? Municipal ❑ On site di>INsal system ❑
- _ Check iFyes❑
SECTION 2: PROPERTY OWNERSHIP'
Owner'ofRecord: Z8
Nam IPrinU L/� fi drew for Service: -- _
§nature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) AlrerattoMs) ❑ Addilitut ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Speedy: �'f�Y It C X 1p
Brief Descrlptio of Propused Work-':
I
SECTION d: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: — 1
Item Official Use Only {
ll_ahur and iel a :ds)
1. Building .5 3o SD• ru-o I. Building Permit Fee: $ Indicate ho,, tec a dctcnnua•J.
❑Standard City/Town Application Fee
2. Electrical S ❑ Total Project Cost' (Item 6) x multiplier _ x
3. Plumbing 3 -. Other Fees: S
4. Mechanical (H'V.kC) g List:
5. Mechanical IF,
Su t r. nicl Total All Fees: 5
Check Nit Check Amount: _ (',Ish \mount i
o. Total Project Cost: S 3gSD, oo 0 Paid In Full 0 Outsta ndlne Balance Do
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSI.)
✓b Cff*Kb, O . 4fQr f-, I Nun>�er I[spllaLllnl D'Itc
Nalloc rl-(SI,- Ilulder I,IDYhrt6C.a Mill O20F z- LI,I CS1. 1\Ix I,ee below I
S t S fhfF• —�---
-
� \' �� O l I111 e,IrlCled lllllU j`.lN1U Cn I'll _ �
R -Re,ln.ted I,2 F•Inulr
� f RC Re,ldellllal Routine
felcphone \\S Re,ldrlllwl \%wdurr .ind 11thnc
il` Rc,Ideml•lt SOLd I-.art 8uuune \Ir jhNlt lml,�l Lln, li.y
D Rcadenll.11 Ucnedllwll
5.2 Re catered Honte Im rovement Coll n tractor 0110
csrn
HIC I . 'alic o�i1C Rce sutra Na A D Rr ulr win \umber
Sf aww oo /f amp Z 312
F,poauon D;ur tl
Sl gnawre -- telephone —
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (N1.G.L. c. 152. § 2506)) {
Workers Compensation Insurance affidavit must be completed ;old ,uhmitted with this application. F:ulure to plu,Ide
this affidavit will result in the denial of the Isstm ce of the building permit.
Signed Affidavit Attached? Yes .. NL -. . ❑ __
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES [FOR BUILDING PERMIT
1. _-'•-"A!Ar� COH ii. ' L _as/pwner of the subject property hereby
authorize
IC * �5�2✓✓�-r1 � s.�ke724- _---_ ;u act can my behalf. in all m•tters
j :C!ativ to '.vork it this d by this building permit application.
@Flature of Owner Date —
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
/ i
as Owner or .Authorized Agent hereby Jrclare
that ihe'smre meats and information o the tirregoing application ore true and accurate, to the best of my knowledge and
behalf.
Print ne
Sig a ure of Ow x Authorized Agent - Date
_(St med undo airo and nalties of cru I
NOTES:
I. An Owner who obtains a building permit to do his/her own work. or :cat owner who hires an unregl,lered contruclnr
(not registered in the Home Improvement Contractor (HIC) Program). will teat hace acresN to the ti hiri:Lion
program or guaranty fund under M.G.L. c. 112A. Other important information on the HIC Pro mun and
Construction Supervisor Licensing (CSL) can be found in 780 C'MR Regulations I IO.R6 :md 1 I0R5, respecotel y. i
When ,ubNtamial work is planned, pioclde the Inlormuuon below:
Total flours area (Sq. Ft.I (including garage, fimshed basenlemJatrtcs, decks w porch)
Gross living area ISy. Ft.) Habitable room count _ ---__---
Number of fireplaces :Number of hedroom,
I Number of hathiounts Number of hall./hash, __-
f�pe of heating vstem Number of Icck.,/ por;hcs
i\'PC of cooling ,„(CM — —_ I:nclo,ed
, "PUt:d Prtr�eU! Square Footage- n1:IV be ,IIbNIIIaICd tor "Total Prr rICCI
yy CITY OF SALEM
PUBLIC PROPRERTY
DEPAR"I'''vTENT
Il v'8 '43.9;v5 P\Y: 'i78 '4.- 'r:4,,
Construction Debris Disposal Affidavit
(rcLluired lur all demolition and renovation work)
In accordance w ith the sixth edition of the State Building Code, 780 CNIR section 1 11.5
Dcbris, and the provisions o1 MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal 13cility as defined by MGL c
l l I. S 150A. A
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(nainr o(I'aeility)
(adders, ul IacililVl nq.
V i
,ignamre of porn t applie
,late
CITY OF SALEM
/ = PUBLIC PROPRERTY
, ;sji
ma
DEPARTMENT
, t.
�._
,I kilt;K:F% :)KIS(,q l
x �s,A 12^-W Ai"I.N(:i 0-N Sraetrl' • SA rxt,Ivt.s�s.ua n G197�
t
11,t.:978-745-9595 • P.vx. 97%-74C-9846
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/PlumbersPlease Print lv
-itoA
ilicant Information
lnucioc`sstigrganiratian/lndty uluall: «s'Trwrn�
Nillne
Address: SS 611,1 s � t
t�». . 7 n4
City'S[atc;%ip: r uruw- Phone
. re uu all employer? Check the appropriate box:
rype of project(required):
4. ❑ I am a general contractor and I G. ❑ new construction
I. I :Ip o employer with v _ have hired the sub-contractors
ell (full antl7ur part-un[a). 7. ❑ Remodeling
2.❑ I at,, a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees Thaw sub-contractors have S. ❑ Demolition
workers' comp. insurance. 9. ❑ Building addition
working for me in any capacity. 5. ❑ We at'a a cntporution and its
INo workers' comp. insurance 10.❑ Electrical repairs or additions
officers have exercised their
rcgl,it homeowner
] right of exemption per MGL I I. Plumbing repairs or additions
3.❑ 1 ys a.LNO workers'
doing all work c. 152, §l(4),and we have no 12 Rourrepairs
myself. e r air d.] cuntp. employees. lKo.work ers'
insurance required.] 13.0 other
comp. insurance required.-)
,,,pbcant nm[cl•.ccks box dl nIDDr:11Da IIIt Ullr 1111'4:UIUII IN:luw ilWwitiV Itivir wotke1Y cumpens:aioti pulicy inliumatium
' I lumauwners'who submit box
rl t1 mush indicating They am doing all ssvra aiul dten him outside cunrrncrurs must nutm,it a new afrjava indiutmg.uch.
(' t , rs that 9 k this box muni jowhed.m additimul,tuna h a the am of'he sub.oniracwrs and their wur4en'comp.policy informariun.
I ant an employer that is proriditig workers'currrpensnuon insurance for iruy employees. Below is the p olicy and job site
infonoation.
In,urance Company Name: ---_. .-
Expiration Date: '
I'olicv 4 or Selr-ins. Lic
. 21R ttViC11.,4 L- -S T . - . ..- City;Slalei"Lip: `7rTcc'r"s bri ll} a) ti7b
Job Site Address.
Attach it copy of the workers' compensation policy declaration page(showing;the policy number and expiration date). ,
1'ailw.e u)secure coverage as required under Section 25A ul`lGL c. 152 can lead to the imposition of criminal penalties of a
ring up to SI,500.00 and/or one-year imprisonment, As well as civil penalties in the ['arm of a STOP WORK ORDER and a fine
tement may be furwardcd to the 011ica of
of up to S250.00 a day ;tgainst the violator. Ile advised that a copy of this sta
:Tlk amens of the MA for inuirar,ce covcragu verification.
/do hcn•hy echo titer!l pains wid penalties ujperjary that the irrfortnation provided buv is true and correct.
ii :ca urn: _.
--iyat•:
t
rht,1:e ,:
/-8�
Official use only. Do not write in this area, to be cunipleted by city or town official.
.. Permit/License d.- _ ..
lssuing .%uthurily (circle one):
ncnt 3. Cityi 1'ow it Clerk 4. L•'Icctrical Inspector 5. Plumbing Inspector
I. Board of l lealih 2. Iluildin., Dcpar[i
Other
Phone ti:
Contact Tenon:-_ - ._.
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 its"...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
,rt the toregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
recetver or trustee of an individual,partncnhip,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."
.`iGL 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. NIGL chapter 152, §25C(7)states"Neither the conumonwcalth nor any of its political subdivisions shall ti
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." `
Applicants -
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, ;f
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
Lie 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 till in the permit/license number which will be used as a reference number. In addition, an applicant
that most submit multiple permit/licenw 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
I 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he i 11icc of Investigations 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
660 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
z, ;ncd 5-1e-05 Fax # 617-727-7749
www.mass.gov/dia
Sep 03 08 02: 12p Ryder Insurance 7819639274 p. 1
ACORQ CERTIFICATE OF LIABILITY INSURANCE DA09/03/200
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Ryder Twimmce Agency,hw. ONLY AND CONFERS NO RIGHTS UPON THE CER'YIFICATE
247 North Main Street Suite 201 HOLDER.THIS CERTIFICATE DOES NOT AMEND,IEXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Randolph,MA 02236X
rnom,so; 791_-963-0390 FA.CM: 78I-963-9274 INSURERS AFFORDING COVERAGE NAICif
tNSVNED INSUHEk A. PROVll?I;NCEMUfLIAL PIIU?TNSUR,
RICIIARI)CONLEY iNSURCRD. i-1A_RTFORD .,,.
23 S'I'OUCI I'IY)N STTtTET 1N.,uRLRc'. ,,.. .....
sTOUGI ITON,MA 02072 _
INSUHEHtr .-
INSURER E',
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE DEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITMGTANOINC
ANY RCOUIREMENT,TERM OR CONDITION OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MA"BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED DY 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.
INk GOL TYP 5 F P041,GPR'FPCCTIVC OLICY FXPINATION LIMIT.i
POLICY NUMBER OA E MMffiCIYY D TP MMQDIYY
A GCNCRAL LIABILITY CPP 0066701 03/19/2008 03/19/2009 CACIIOCCURRENCF S 500,000
�eRCMIi FTORCNTCD
X COMMERCIAL GENERAL LIABILIi FRCMI3CS(C;t9fF9L^.11[^Ly �(I�iI nOn
CLAIMS MADE - OCCUR MCD EXP(Any one perun)_ 5. _. S,O(IU
P' kRONAL6 ACV INJURY f 500,000
_ GENERAL ACCRCOPTE f SOO,000
.._ .. .. _........
OEN'L AOGRFGATC LIMRAFPLIES I'EH PRODVCTS,CAMPoOP AG S_._.__.SCO,000„
PRO
C LDIiOY ,IhCT I LOC
AVTOMODILC LIABILITY COMHINF.D SINGLE LIMIT '$
(EA accident)
ANY AUTO .—-
ALLOWNEDAUTOS BODILY INJURY S
(Par pnrcnn)
I
GCH LOLLED AUTOS
' 141RCO AUTOS tlODILY INILIRY S
-- (Par ccidonQ
I NON OWNED AU TUN
PROPERTY DAMAGE �
GARAGE LIABILITY AUTO ONLY.FA ACCIDENT 15 _
...� ANY AUTO OTHER THAN CA ACC f
AUTO ONLY.
ACC 4
EXCESSIUMORCLLA LIABILITY EACH OCCURRENCE
OCCUR UCLAIMSMAOE AGGRCGATC f
_ S
OE000I'1RI.F. .----
RETF,NTICN 8 $
WORKERS COMPKNSATION AND 0439L80 03/23/2008 03/23/2009 TOrNLIMITS .,-- E'H
EMPLOYER 5 LIA0141TY F.-EACH ACCIDENTANY f 1(I(J,(11J0
OFFICCRIMCMBC XCLLUt.I17 IIVE
C I.L pIaFASE-EA EMPLOYEE y UIO,000
u YYeP de.�Ilbe Ana L.DISCAUL-POLICY LIMIT T 500,000
5 IAL I'HOViwoNS bnlow
OTHER
DESCRIPTION OF OPENATIONS I LOCATIONS I VEHICLES I EXOLUSIONS ADDED DY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
TOWN OF SALEM SHOVLO ANY OF THE ABOVE DESCRIBED POLICIES DG CANCELLED BEFORE THE EXPIRATIO
TOWNING A.LEM DEPARTMENT DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYSWRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,DUT FAILURE TO DO 50 SHALL
120 VASHINOTON STREET, 3RD FL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSL PER,ITS AGENTS ON
SALBM,MA 01970 RDPRIESENTATIVES.
AUTHORII REPRESENTATIVE pp
ACORD 26(2001/08) O CORD CORPORATION 1988