28B FEDERAL ST - BUILDING INSPECTION -pL-#M WT-gE fLc&4M+u APPROVED BY 741E
msP�rsaB MWR 70A.>r14F UNG GRANTED
CITY OF_SALEM
NO. DamJ
i
is ply In umatioa of
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Sulam "JW APPLICATION FOR:
Permit to:
(Circle whfohe w apply) Roof, ROW, InsWl Sidfnp, CwWrw:t Deoh. Shed, Pool.
RepaidReplace. Other
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS.
The un Wagned hereby applies for a permit to build arxordfnp to the fo WMV
specificawm.
Owner's Name M 4 7-1— G o!' IV i�E-GL
Address & Phone -�g13e_�o�
Archilea'a Name 1� /M G
Address & Phone 15 L 1
Machanics Name Ri c tl A r o J7/,11/10/Say ,
Address & Phone 9 11'1I9blSon( I 111,= 1 sr) 37 3 - 1Gc/5
who is to PUWU m bWltlkip? e"f�
MAO"of b A*q? I a dwoov.for how many%man? cu-r b
wo b AWQ=tonn to law? Asbaooa?
Edn wd coo 10, ? ad My LIMM r iV A sMM LiWW tr
lDs�� 5o iwr�t
Uc. 0 11
X
Somh#of Applicant
UNDER THE PENALTY
OF PEMRY
DESCRUSTION OF WOW TO BE OWE
041
MAIL PERMIT TO: rc,1jAr 0 J AM'106onl ve
1M 6f S$'
NO.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
APPR I
INSPECTOR OF BUILDINGS
NEW SALEM II CONDOMINUM ASSOCIATION
28 B FEDERAL STREET
SALEM, MA 01970
November 16, 2005
City of Salem
Planning & Community Development Department
RE: Building Permit Application
To Whom it may Concern:
Beth Anne and Matt Cornell have informed us that they will be
remodeling their unit #8 at 30 Federal St (mailing address 28 B
Federal St Unit 4).
The Cornelis have represented that the scope of work is:
• Update kitchen, work to include new cabinets, counters and
sink.
The Cornelis have informed us that the work shall be done by a
licensed contractor and under a city building permit. Attached is a
copy of the contractors "Certificate of Liability Insurance"
After review, the New Salem II Condominium Association takes no
objection.
Regards,
Douglas Ho per
Board Member
New Salem 11 ondo inium Association
Date:__ _L _ -
10-20-05 12:I9PM FROM-home depot Salem +9787401417 T-421 P.001/001 F-490
YPI Gf"MIDOryWY)
A s x Fowler Troy C 912s 01 Agency 9tJ1FlCA7EI8IsSIEDASA MATTE / 5
200 Perk Street ONLVANDCON NOPr1GIiJSU ROFINR]RMATbN
HOLO�'RI Jac J3RTIRCA IGM PONTAMCERTIFICATE
North Reading, L91 01864 ALTB2TIgCOVg{AGEAORDMB,.HEPOUCI� NDOOjry,
IrauR® INSURERS AFFORfaNG COVJ3IAGE
R a Construction INSUR6i A. Hartford NAIC 0
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3 Madison Ave, INwRetE IAa aAve CodSi
Groyelaad, MA 01834 INSIRER C:
INSlRER D:
OOVI3RAGE5 INSURFRE
THE POLICIES CF INSURANCE LISTED BELOW HgYE BEEN ISSUEp TO THE INSURED NAMED ABOVE FDR THE POLICY PERIOD INDICATED,NOTWf7}i57ANDING
i ANY REquIREMENT,TERM DR CONDITION OF qNy CONTRACTOR OTRER p
MAY PERTAIN,THE INSURANCE AFFORDEp 6Y THE POLICIES DESCRIBED HER ry STBUBJEGT TO ALL 7ryE TERM$ I CW CERTIFICATE
AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS BHOWry MAY HAVE LAMICH THIS CERTIFICATE TE
IN 6EEN REpUCEO 8Y PAIp CLAIMS. MwAY C TjQNISSUSO F S
OPAlEAAL LIABR.RY POLICY NUMBP,R PoUCYEF R R1UOY er ATON
A COMMERCIµ GENERµ DAB"Ltly 05 LIMITS
S8ANF7078 5/28/05 5 28/06 nMD�RR i 1 000 000
CLAMS MODE OCCUR / Br11so rFa Rclahn ''.i
300 Pauc JFL 0000�MEWfAnvaa 0 D�PFRON&A RV-ZlROATLIMT APPLES PER; 1,000,0000E URY
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1 Lot! POGucTB. 2,000,000
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ALLO'ANEDAUTOS ICONASNEDSINGLE UMIT S
A SCHEDULED AUTOS OOMCCZM6294
ODDLY INJURY
HIRED Autos 8/28/05 0/28/06 IPAtpa" $ IDO,000
NONPMED AUTOS
BOD7LYuRY i
((iPobt 300,000
OARA PROMTYDAMAGE
+PAR AGO*M S 100,000
ANYAV*rIL(TY YAUTD AUTOONLY-PA ACCIDENT S
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InsurBM0e verification IALPROVISIDNS
CE RTIFICATEMOLDER
,t CANCELLATION
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EpOREE/r LU�Y / DATETNMMP,THEI53U1ND fN&URDI WILL IiNDEAWR
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ACORD25(2007lOS)
ACORDCORPORA'IYON 1088
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
4'
120 WASHINGTON STREET, 3RD FLOOR
MINB SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
(Location of Facility)
Signal of Applicant
Date
The Commolswalth ofMassaeauserra
Department oflndus&W Accidents
Offim of Inwsdgadoxs
600 Washington Sired
Boston,MA 02111
HwKwass.;ot✓dia
Workers'Compensation Insurance Affidavit: Bugders/Contractors/Elecbidanslftmbers
" Please Pint Le eribly
A Hcan Informati
Name
Address: 0/2 a
City/State/Isp' C� �o�e �A/D //L�ASS�/ri( Phi PhaOe#: 7�- 3 7 3 /0�l5
Are you as employer?Check the appropriate box Type of proles(required):
1.❑ I am a loya with 4. ❑ I am a general eonvactot and I 6. ❑New construction
w an/or parbtme)•• bate hued the ached sheet.
? ❑ Remodeling
®/ p listed on the attached sheet t
2, am a sole proprietor or attner- These sub-contractors have 8. ❑ Demolition
ship and have no emploYea wow. romp. insurance. 9. ❑ Building addition
working for t>x in any capacrty. S. ❑ We are a corporation and rb 10.❑ Electrical repaus or additions
(No worlcerp' comp.insurance officers have exercised their
an rrgnired] �. work right of exertion per MGL
11.❑ Phurbing repairs or additions
3.❑ I am a homeowner mg
myself. [No workers' c: 152,11(4N and we have to 12.❑ Roof repass
insurance o worrequirker to ces. [No workers
t Y 13.❑ Other
comp.insurance required.].
;Any to &PPIiiimwom that cbecb bent a mug den all out tha section ndoing below work andand then 1me�Andea�d' coutrrtm mug abi a new�iil it iodicding wch
riomeownma who wbrmttlda et5davit indieatma &u&ey duma
tcontncka do check one box mug attached m edditiond ehcet ettowma the torte ofthe wbwohactaa and tlxc wmtets'onntp.Policy infortnNiott
I ow os employer titer it provlding workers'eaapensadlon Insurance for my employees. Below fs Me penny ea djob sbY
brforara*a
insurance Company Name:
Policy#or Self-ins.Lin# O��" 'r G D O I D Expiratii'onnD..ato:C+�il� '4 3�/,G, — G
�, r n G] i S City/Stave...,.: S�L ---/
Job Site Address: r t r r rr number and expiration daRe}
Attach a copy of the workers'compensation policy declaration Page(showing the pocky
Failure 10 secure coverage as required under Section 25A of MGL c. 152 can lead to the impositan of crmmai Penalties of a
fiat up to$1,500.00 and/or toe-year it FbOumeat,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 violdor. Be advised that a copy of this statement may be forwarded to the Office of
htvcst pdm of the DIA for insurance coverage verification
I do himby eer�Jy under 1� lM °jam HMIs Aka i�rjornrerlon pravkied abars fs Artie and correct
D —
#. — 3 5�
Ogleki use wdp Do air wrke/n Ala arrt,A°be toaWkyed b•eAp or Anew ofikiai
City or Tower: Permw1jeense N
issuing Authority(circle one):
s actor
1.Board of Health 2.Building Department 3.Ckyrrowa Clerk 4.Electrical Inspector S.Plumbing Ins p
ti.Other
Contact Peri Phone#:
1111Va IllK6aVal NIiW 111Aa.1 U%,baVllv7
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employee.
pursuant to this statute, an employes is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or wrttoea."
An vnpfoysr is defined as"an individual,partnership,associatio%corporation dr other legal entity,or any two or mine
of the foregoing engaged in a joint eatesprise,and including the legal representatives of a deceased employer,or-the
receiver or.uw tee of an individual,Partnership,association or other legal entity,employes employees. However the
owner of a dwelling house having not more than three and who resides therein,or the ocatipint of the
dwelling house of=other who employs persons to do maintenance,construction or repair work on such dwenling borne
or on the grounds or building appurtenant thereto shall of because of such empbymeot be deemed to be an employer."
MGL chapter 15Z 125C(6)also states that"every state or local licensing agency shall withhold the lanamee or
renewal of a license or permit to operate a business or to eosstruct buildings in the eommosw,ea th for my
applicant who has not produced acceptable evidence of Compliance with the Insurance coverage required."
Additionally,Mid,chapter 152, 125C(7)stales"Neither the commonwealth or any of its political subdivisions shaft
enter into any contract for the performance:of public work until acceptable evidence of oanpli nce widi the insurance
regaircmmts of this'chapter have been presented Io the contracting authority."
Applicants
Please fin out the workers'composation affidavit completely,by checking the boxes that apply to your situation and,if
aaesaary,supply sab-eonUactor(s)nuai (s),addoess(es)and phone numbers)along with,their certificates)of
ice. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employees other than that
members or partners, are of required to cam we*='compensation insurance. If an LLC or LLP does have
d. Be
employees,a policy is require advised that this affidavit may be submitted to the Dcpartniest of b&w&W
Accidents for cmf'amation of insurance coverage. Also be sure to sign and date the affidavit- The affidavit sbonhd
be yearned to the city or town that the application far the permit or license is being requested,not the Department of
Industrial AecWmtL, Should you have any questions regarding the law or if you are required tu obtain a workers'
compensation policy,please all the Department at the number listed below. Self-ins red companies should enter their
self-insurance}icease number on the appropriate hme..
City or Tower Offidals
Please be sumo that the affidavit is complete and printed legibly. The Depati ment 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 we to fill in the pumidlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permiNicense applications in any given yen,need only submit one affidavit indicating entrant
policy information(if necessary)and under"Job Site Address"the applicant should write"all batons in (City or
town}"A copy of the affidavit that has been officially stamped or,matked by the city a town may be provided to the
applicant as proof that a valid affidavit is on file fa future permit or Iiceoses. 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
(ice a dog license or permit to burn leaves etc.)said person isNOT required to complete this affidavit
The Office of Investigations would Bite to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to'give us a cal.
The Department's address,telephone and fax am6w.
The Commonwealth of Massachusetts
Depmtment of Industrial Accidents
Office of Investlgatlol>r
600 Washington Stt d
Boston,MA 02111
TeL #617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-2ti OS www.mass.gov/dia