5 FLYING CLOUD LN - BUILDING INSPECTION What Is aw cLw"use od a+e Building? ONS L�-�N
if dMieNirn&holly many
LUWW of Bua*q? Asbsstos?
Wit ats B O&V Conbnn 10 LAw?
Archftds Name ( )
AddrNe and Phone
L49dw ic's Name
Address sod Phone f/ n R7 00 2 _HiC Repatrstlon a
Cons^supervaars Lleeme
Ea*nstad Cant Of Project °=
E,*„„ted cc.t x s»sI000 R..id.nd•l
Permit Fee= Esffineted Coat X$iil$iOOG Cpm wdd------- -
-- --- An/ ddpfonal:6.fb is added es an
Adminalrove ehsrge.
MM tw all fields are properiy and agiby wrlaen to avoid do"in Womsi^a
The urde►,W d does hereby apply for a Building Permit to build to
apecNfaaons signed under penally of Penury
ate �� o
v �I
EITY"Op
h .
PUBLIC PROPERTY
DEPARn ENT
a..set�nesouu I X� ��
71L•V&746-FSN.Fit V&.14&%ft
D
1.0 S M INFORMATION
Lcca*m Nafnse
Address:------ -- ---- ------ - - - ----- ---- __ -- _ _--- - -
5 �LY�'✓Y� ci��p LynyF
Property is kxabd in a;Conservalon Ana YM Hbbfb obwd YM
2.0 OWNERSHIP INFORMATION-
Li Owner of Land
17~ww'
affw. C O G
ddress;
3.0 COMPLETE THIS SECTION FOR WORK 11V EYIa MNG BUILOINGs ONLY
Addition Existing
Renovation Number of Stories Renovated
Change In Use New
Demogdon Existing
Approximate year of Area per now(sQ Renovated
constructlon or renovation
of existing building New
Wd Descliption of Proposed Work:
� ePlflc� l�.T�Y1 EvY Cw Q� � cTr n�«I e��C��To f,
-- ---Mail Permit to: i'h -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT'
NA1"IttIV UllMOLL
sYtie 12d V/wsw%GTmsnitrr a Shim lt AgLu.-la.-*-rnso1970
Tutu.97t.745.9595 a FAx:97i740.9WA
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciandpiumbers
Applicant Information Please Print Leelbly
Varnelw..inl:�rors.ni�tiwllml�lmrott: .To�-il�l p�A,ry7-auras
Address: Dr0. (fir,x IWOlb.-
019�1
City/suteizip:� tuf a:
Are you as employer'Cheek the appropris box Type orprojeat(required):
1.Q 1 am a employer with 4. 1 am a general contractor and 1 6. Q New conanteaon
e Ittycctt(cull mWar part-tine).• have hired the sub-comractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet. 1 7. JQ Remodeling
ship and have no employees Theme sub-connaewrs have a. ❑Demolition
working for nw in any capxity. workers'comp insurance. 9. [3 Iluildiag addition
(No workers'camp, insurance S. Owe are a corporation and its
required] officers have exercised their 10.0 Electrical repairs or additions
3.Q I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152.j 1(4),and we have no 12.0 Ruof repairs
insurance rcquircd.j t employees.(A'o workers' 13.❑Other
comp inwntolec required.]
'Ally.p kluld lbe clads bag el man also fill sea the action bvbw Ygrioa their wakes'c aapolmaka pWiryr ioaammtion.
'tlueswwrmes who submit this amdsvit imucamst;they are doiaa as wwlt and than his atmaide comma s awat submit a new aradavis indimdina awh,
foturxvn the ohmic this box mums snacholl at.addmblrl Alms.howina the mums of au sub comaaan and thew wud me'ramp.pduy inhamadmi
mmmmmmmma
i um on employer that/s providing workers'compensadlen ltrsarancejar my employees Below/s the pulley andlob site
iufurwatroa.
Insurance Company Name: -
Policy is or Self-ire. Lic.0: _-- . .---.. Expiration Date:
lab Site Address: Cilyistaw/zip:
Attach it copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Fit lure iv secure coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties of a
Ape op to S 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 i2S0.00 a day against the violator. Ile advised that a copy orthis slatcawnt may be forwarded to the Office of
ILI%C.% hattons uI the DIAL for insurance covera4t: 1tirlfCatlan.
i do hereby certify u that the infarevatlos provided above is tr and correct.
U/J&itd asr us/Jt /Jo not write/a ebb area,to be camp/ecnl by e/ty or town a/Jlriai
City or"rawn: _- PL'rmittlJcernse N
Issuing Authority (circle aim):
i. iloard urllealih 2. Building Department 3.Cityrrowa Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: — Phone q:
J
Information and Instructions
\lassachusetts General Laws chapter 152 requires all employee to provide workers'compensation for their employees.
Pursuant to this statut0.an errtupbyw is defitted as'...evwy person in the service of another under any contract of hire.
.%press or implied,oral or writtem."
An ssepfoyer is deflo d as-as iatirvidaal.pasmanibip,associatim corporation or other k-&W entity,use any two Or mom
of the foregoing ematiesengaged in a joist enterprise,and including the legal representatives of deceased employer,or the
aid"or other legal entity.employing employees. However the
receive a dwelling
o individual,parsaership." and who insides therein.or the occupant of the
notions of a dwelling house having not more than three apartments
dwelling house of another who employs Persons to do maintenance.cwtstuctim or repair work an such dwelling house
or on the grounds or building appurtenant thereto shall not became of such employment be deemed to be an employer.'
AtGL chapter 152.¢2SC(6)also states that"every state or beat licensing ageaey shag withhold the issues..or
renewal of a Ikeass or permit to operate a business or to contruet buildings is the eommoawca"far any
applleant who has ant produced acceptable evidence of compuzow with the Insurance coverage required."
Additk malty,MGL chapter 152,$23C(7)woes"Neither the commonwealth trot any of its political subdivisions shall
enter unto any contract for the performances of public work until acceptable evidence of compliance with the insurance
requirements of ibis chapter have been presented to the contracting authority.'
Ap lkants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary.supply sub-connector(s)namc(s),addcesa(es)and phone number(s)along with their certificatc(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees odter than the
members or panners,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
lndusmiul Axidens. Should you have any questions regarding the low or if you are required to obtain a workers'
compensation policy,please call the Departtttent at the number listed below. Sel&inmtred companies should enter their
se1P insursnce license number on the appropriate time.
City or Town Oflfelab
Plcasc be sure that the affidavit is complete and printed legibly. The Department has provided a space at the b m.
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 peratit/l case number which will be used att a reference number. In addition,an applicant
that must subunit 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 of
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 ham owner or citizen is obtaining a license or Permit not related to any business or commercial venture
i i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I'hu Otii:c of Investigations would Ire to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of IndusaW Accidents
Oak*of Ievariip da"
600 WashiagM Strut
Boston, MA 02111
Tel. 11617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
Revised 5-26-05 www.niaw.gov/dia
k,idhtFax H1-1 10/11/2007 3 : 51 : 35 PM PAfE UusrUus rax :Dtxvcl
I �
ACORD. CERTIFICATE OF INSURANCE DATE(MMIDDIYY) 10-11-07
�HcoucER THIS CERTIFICATE IS ISSU PD,%S A MATTER OF INFORMATION
ONLY AND CONFERS NO R GHTS UPON THE CERTIFICATE
- <LN'IT': 1 NS AGENCY HOLDER. THIS CERTIFICA E ROES NOT AMEND,EXTEND OR
YNN SlREE1- ALTER THE COVERAGE AF FORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
AP()DY.NIA 01960
'I COMPANY '
f t'N A Uv ERIC.xN Z.IIRICH I?SU�2.ANC.E COMPANY
'N•-„RED COMPANY
B
-ART.AND LD
COMPANY
W ASH]N,J'FON ST C
:,BODY, MA COMPANY
D
vrRAGES
TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIE POLICY PERIOD IN OICATED.NOTWITHSTANDING AN Y
4L-MENT.FL-RM OR CONDITION OF MI Y CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY E E IS I3UED OR MAY PERTAIN. THE INSURANCE AFFORDED
LS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CON DITIONS OF SUCH POLICIES. LIMITS SHOWN 0 AY I NAVE I3EEN'REDUCED BY PAID CLAIMS.
POLICY EFF POLICY EXP
.7t TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE(MMlDD%YY) LIMITS
GENERAL LIABILITY - GEt EP.,1L AGGREGATE $
COMMERCIAL GENERAL PR( DUSTS-COMP/OP AGG. $
CLAIMS MADE OCCUR. PEFSOIIAL&&ADV.INJURY $
OWNER'S&&CONTRACTORS PROT. EACH OCCURRENCE O $
FIRIi DF,rJAGE(Any one file) B
MEI I.E:''PENS'E(Any one PCIS..) S
-,UTOMOBILE LIABILITY
ANY AUTO COI IBIP I'iED SINGLE LIMIT S
ALL OWNED AUTOS BOI IlLY',INJU RY(Per Pe con) $
SCHEDULE AUTOS BOALY!INJURY(Per Accident) $
HIRED AUTOS PRO PE 17Y DAMAGE $
NON-OWNED AUTOS
GARAGE LIABILITY II
ANY AUTOS AU"OO,NLY-EA ACCIDENT S
OTI ER ITHAFI AUTO ONLY
EACH ACCIDENT $
AGREGATE F
c XCESS LIABILITY
UMSREI LA FORM AS 3R( CURRENCE
OTHER.THAN UMBRELLA FORM AS 3RE I G ATE $
NORKER'S COMPENSATION AND X
EMPOLYER'S LIABILITY UB-0660L916-07 06-21-07 06-21-09 STATUTORY LIMITS $ 100,000
'HE PROPRIETOR/ EASH NCCIOENT
°1A RTNER S/EXECUTIVE INCL DI';EAaE-POLICY LIMIT S 500,000
')FFICERS ARE X EXCL DI';EA',IE-EACH EMPLOYEE $ 100,000
OTHER
DI: .CRIPTION OF OPERATIONSILOCATIONSNEHICLES)RESTRICTIONS/SPECIAL ITEMS
RUPLAI L,ANyI'NJUIL('PKCUT.'AMISSIILDI()T T3E I.ILLRFTC ATE HOLUFI' UFECTING WORPEIIS lVh1Y COVEN AG7�.
Width Rs'I'UMI'L N 5.ARUN POLIO Y Df)ES NO I TRU VIDE I VE R AGE FOR M4l FMLAND LD
It v:TIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE AEO`r'e DES-iI BE]POLICIEC EE CANCELLED EEFORE THE E`PPATION
I( HARI)I. TH P.ECF,THEISSUINGCOMPANY Alu ENDEI=VCR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HCL OFF 1.=.C1ED TO-HE]EF i,DDT FAILURE TO MAIL OUCH NOTICE OH_'-
- I'L.Y1 N,i E.LOUD LANE NO OBLIGATION OR LIAEILTY OF]JY'i iND UPON THE COMPANY,I T S AGENTO OR
REPRESENTATEVES.
A1.EM,M.A 01920 AUTHORIZED REPRESENTATN E III
W A Bolinder I
A'.ORD 25-5(3193)
III
9�
Aor ,,�
o ui mg u1.0 ors an eg an ar s
One Ashburton Place - Room 1301
Boston, Masq'achusetts 02108
Home lmprovemen �ntractor Registration
Registration: 141492
Type: Individual
N _ s Expiration: 4/26/2008
JOHN F. PANTAPAS
JOHN PANTAPAS m — ------P. O. Box 4065 ° ----- -__-- -
Peabody, MA 01960
Update Address and return card.Mark reason for change.
DM-CA1 6 50M-04/04-G101218 Address I. Renewal Employment j] Lost Card
-....,1'7- maneeaea/b( o��/ roaacluoselk
Board of Building Regulations and Standards
t€€. Construction Supervisor License
4- . . f Lir CS 87003
/2009 Tr/R 7838 I
R tri"
ti
JOHN F PAN,TAP
' PO BOX 4065
PEASODY,MA 01961
Commissioner _
s
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
n.V 5e\I Rf' 1a1a'1 L
\L\N 12C 1.\9,4W';JKS?E[T t ui 11�N\VLU iM�lll1 ii�
Ta:Y7Nas•'1Slf •F..,c e7ea�6�1eK
Construction Debris Disposat affidavit
(reyuimd Cot all demolition and ramation warlt)
In accordance with the sixth edition of the State Building Coda.73o C1UR section 111.S
Debris`and the provisions of vtGL c 406 S S*
Building Permit N _ . _ is inua Milt the condition that the debris rmddng horn
this wait shall be disposed of in a properly licensed waste disposal facility as defined by%IGL c
l 11. ! 130A.
The debris will be transported by:
& m s r
(own a hart+`)
rho:kbris will be disposed of in
. taamrut'f�,cuy)
)CT-10-07 N:i6PM��+R®FROM-E A STEVENS CO IM a97 71721ii T 435 P 001/001 F-5S7
A .:; 10/10/0
vvnoucEa - THIS CERTII•'IC.LTij IS ISSUED AS A MATTER Oz iNFORITIC I•�
ONLY AN•D C<INI*RS NO RIGHTS UPON THE C£RTIFICA'I'F
E A STEVENS CO INC HOLDER. THIS Cl-
ONLY DOES NOT AbffiND, EXTENWO
ALTER TF02 CI)V]:RA6E AFFORDED BY THE POLICUMELO1
CONWAI•ITES AFFORDEVG COVERAGE
389 MAIN S'I' BOX 'I188 —.—
DIALDEN MA 0214 8 -5076I COMPANY
A c7NII %L INSURANCE
. iRED COMPANY
JOHN PANTAPAS a
I I COMPANY
P O BOX 4065 C — —
PEABODY MA 01960 COMPANY
' D
I
THIS IS TO CERTIFY THAT THE POLICIES OP INSURANCE LISTED BELOW IIAV E BEEN ISSUED TOT-IE INSURED NAMED ABOVE FOR THE POLICY PERIOI.
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WI11Cf1 THi 1
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DEijCRIHED HPRE]N IS SUBIECT TO ALL THE TERM`
IBCCLUSIONS AND CONDMONS OF SUclP POLICIES. LIMBS SHOWN MAY HAVE BEEN REDUCED 3Y PAID CLAIMS,
POLICY E➢VECTive PDLH'YE RPIBATIONI LIMITS
BR IT TrvE Or INSURANCE vQLICY NUMBER OnTE(MM/DO/YV) DaT c A,M/DDIYYI
•�. ,I,ceN6RAL:,.alury 7989264 12/23/ 06 12TI,�07 GENERALAGGREGATB s2 , 000 0
00MMERCIAL OENEML U•BILITY PRODUCTS-COM➢IOP AGO s2 , OOO C -
PERSONAL @ AOV INJURY 151 , 000 0'_''I q
J CLAPIS MADE x OCCUR
E•CH OCCUREENC6 $1 , 000 0�.
Ow NER•S @ CONTRACTOR'S PROT --'
i PaEDAMnCRIAnyoccEnl $ 50 0 ,I
MED Ex,luny oti prom) $ 5 1
JTOM1tOBILE LPABILITY I� !�'
ICOMRDftD SW-
LE LLMR —
ANy uiRO I Ali •`.
ALL OWNED ALTOS ( BODILY IrvtURY E
1iI (PeP Persen) 1
1 r,SCIIEDULED AUTOS
BOD(LY INIURY S
,=t10iED AUT05 �� I rycr xndum)
.,:NYD AUTO5
j PROPERTY DAM ACE i
—I
I I
AUTO ONLY EA ACCIDENT S
G•R•GE LIABILITY
1 M'AVID OTtIPR THAN AUTO ONLY: _
—_ EACH ACCIDENT S
_ AGGREGATE S
i £ACM OCCLRRPNC6 s
I 'E%CE95 0•niL1TY 5
UMBAELLP YOR
AGGREGATE I
—I M i � -
OTHER THAN UMRRPLLAFORM U'S
OIH-
i .1'ORY LPt IT
RxMDLO`TRS' IABIL TVON AND EL EACH ACCIDENT S
TSIP PROPRIETOR/
INCL EL OISEnSE-DOLICY LWR 3
—I.PAATNLRS,E%ECL'TIVG C
�II EYL _— EL DLSDASlL6w EMPLOY6i. 8 1
, Occ:CCf:S AFE�J I '
' oTllEa I I
I
)6SCRIPTION OF OPERATIONS/LOCATIONS/ EHICLPS,SPECIAL ITEMH
I I
1
SHOULDD ANY
C➢ TgQ ABOVE DES[a1BED rODUBS BL CnNCCLLEO BEFORE"i••,
RICHAF'ZD Li sx".TION D,TE I THEREOF. THE ISSu,NC CO:MPnNY WILL ENDEAVOR TOIr
DAYS V iVTTEN NOTICC TO 8J�C1BSlF7�M136+MOI+DYR Ny''°IE�l�Tt Otr'
T 5 FLYING CLOUD LANE BL'4-FAILVRE 03 SUUP F16TICE SIULL IAfrOSz No OBL1fnTI0N'.OXIADll: I
. ..I MIA TH
A 01920 Orf'AxY Sam, I x cOMPAnr ITS AGENTS R 6rAPATvr•n�T
uflIOR12ED PET .TSY4
F-M
®sGURID cdxkBPATIO INYh