6 FLYING CLOUD LN - BUILDING INSPECTION (2) What is the current use of the Building?
Material of Building? It dwelling.how many units?
Will the Building Conform to Law? y 8 S Asbestos?
Architect's Name
Address and Phone_ l )
Mechanics Name f a h Q Jj+V T W P,� S
Address and Phone Q G flo
ConsUucdon Supervisors License it HIC Registration 0
Estimated of ied S U C0 Pemhit IF me Calculation
Permit FesC Estimated Cost)(S7/51000 Residential
Estimated Cost X$11/$1000 Commercial—
An Additional SS.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penally of perjury
Date /a V
N
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w \\la1Q,
o ai
v A o
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EIT..�OFSA= - -
PUBLIC PROPERTY
DEPARTMENT
wI.aSFxero DRUG L ('7 CyC 1
N�raa 1 W WA9*NGWw SWAT SubM,%rAttAd1{:StY[S 01970
Tla.97e-745.9S93•FAX 978-7404W
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
----- Property Address -------- -- -- — - ---- -- -- - ------- -- - -- ..._
Property Is located in a:Consiuvatlon Ares YIN Historic Dlabtat Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land '
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN t=mATrun BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
G1�t�1NG2 cxl Qe%-rH1Rc4y-\
---_----Mail Permit to: -
J -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTN EM
..u1n.r• aa..v►.
al�u• t.lC 7.%9tt w.anf W"•iutfl.lL►vpt»w et�1i.:9
Tn.~46+s9M•f.%m 96MMA
Construedan Debris Disposal AfAdsvit
(required fat all dandidan and renovation work)
In=Onb m with the duds edition of dw Stets Building Code,7S0 OAR section 111.S
Debris►and do provisions otrlGL a 40r S 54
9uiidiss Permit 0 _ is issued with dw condition that the debris resuldnS ftm
this waft shall be disposed of in a properly 11censed waste disposal ftility as defined by.%IGL a
t11.S Is"
The debris will be transported by:
AM A M S E
cane of ttsutM
rho dcbds will be disposed of in :
(,ramie ur fxtGry)
irr
RightFax H1-1 10/11/2007 3 : 51 : 35 PM PAGE 003/003 Fax Server
r � v
ACORD. CERTIFICATE OF INSURANCE DATE(MMIDDIYY) 10-11-07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PARENTE INS AGENCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
94 L.YNN STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
PEA3GDY,MA 01960
COMPANY
22'1'CN A AMERICAN ZURICH INSURANCE COMPANY
INSURED COMPANY
B
MACFARLAND ED
COMPANY
36 WASH]NGTON ST C
PEABODY,MA 01960 COMPANY -
D
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWTHSTMOING MY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED
BY THE
POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFF POUCYEXP
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM\DDWY) DATE(MM\DD\YY) LIMITS
GENERAL LIABILITY GENEP.ALAGGREGATE $
COMMERCIAL GENERAL PRODUCTS-COMP/OP AGG. $
CLAIMS MADE OCCUR, PERSONAL88ADV.INJURY $
O'NNIER'S SS CONTRACTOR'S PROT. EACH OCCURRENCE $
FIRE DAMAGE(Any one fire) $
MED.EXPENSE(Anyone person) $
AUTOMOBILE LIABILITY
ANYAUTO COMBINED SINGLE LIMIT $
ALL OWNED AUTOS BODILY INJURY(Per Person) $
SCHEDULE AUTOS BODILY INJURY(Per Accident) $
HIRED AUTOS PROPERTY DAMAGE $
NON-OWNED AUTOS
GARAGE LIABILITY
ANY AUTOS AUTO ONLY-EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGREGATE $
EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE 8
OTHER THAN UMBRELLA FORM AGGREGATE $
WORKER'S COMPENSATION AND
A EMPOLYER'S LIABILITY UB-0660L916-07 06-21-07 06-21-08 STATUTORYLIMITS X
THE PROPRIETOR/ EACH ACCIDENT 3 100,000
PARTNERSIEXECUTIVE INCL DISEASE-POLICY LIMIT $ 500,000
OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE $ 100,000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIRESTRICTIONS!SPECIAL ITEMS
THIS RI:1'LAIJ LS ANY PIIIURCERI'IPIC ACT ISSUE])10 1'HE CLRTIFTCAFE HOLDER AFFEc UII WORKERS L()NU'COVERAGE_
I UL W ORRI:RS UOMPENS.STION POLICY DOES NO'T PROVIDE COVLRAGE FOR MACFARL.AND ED.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE LANCE!LED BEFORE THE EXPIRATION
DATE
R ICH AR D 1.1 THEREOF,TY.E SSUING CCMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HCL DES LAMED TO THE LEFT,HUT FAILURE TO MAIL SUCH NOTICE SHALL
IMPOSE
5 FLYING CLOUD LANE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITSAGENTS OR
REPRESENTATIVES.
SALEM,MA 01920 AUTHORIZED REPRESENTATIVE
W ABolinder
ACORD 25.5(3193)
,w
CT-10-07 04:166pm FROM-E A SSTFEEV�ENS CO ` 1781-397-7 72� T-435 P 001/001 F-567
sI �� 10/10/0
..r.nucER THIS CPR C,LTIi IS ISSUED AS A MATTER OFLNTORINtATI
E A STEVENS CO INC ONLY AND Cf sNIERS NO RIGHTS UPON THE CERTMCA
HOLDER. THIS C"RTTFICATE DOES NOT A W4D, EXTEND(
ALTER TH2 COVERAGE AFFORDED BY THE POLICIMELO
389 MAIN S'1' BOX ' 188 � CONOAPnRS AFFORDV9G COVERAGE
TALDEN NIA 02148-5076'I COMPAN
I
_ A C13NSRikL INSURANCE
RED
COMPnW
;TOHN PANTAPAS s
COMPANY
P O BOX 4065 I C
PEABODY NIA 01960 COMPANY
D
THIS IS TO CERTIFY THAT THIi POLICIES:OP NSVRANCE LISTED BELOW HAVE BEEN ISSUED TO T i£!ENSURED NAMED ABOVE mit THE POLICY PERIOI
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR:OTHER DOCUMENT OATH RESPECT TO WUICH THi
CERTIFICATE MAY BE ISSUED OR MAY PERTAN, THE INSURANCE AFFORDED BY THE POLICIES DE'jCRIBED HEREIN IS SUBJECT TO ALL THE TERM`
�CLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED 3Y PAID CLAIMS.
u IrvFE OF iNSURANCC I I P ..!!�s � TN ULIfY NUMBER DATE IMMIDO/ Y M
LIMITS
Y'- AIGEN'ERALLUBILITY 7989264 I12 23/06 12T73707 1 GENEIALAGGREOATE s2 , 000 0 .
ix COM.ERCLALOENERAL LIABILITY ( PRODUCTS-COMPIOP AGO s2 , 000 0
CLAPAS MADE O[;CUR I PERSONAL!ADV INIIRLY I s 1 , 0001 0'.
OWNEa•S A CON'TRACTOk'S MOT ',I EA[R OC[LRRENCfi s 1 , 0 0 0[ 0,_ �I F�aEDWnGH IAgy orcfnl S 5o/ C
MED EXP Inny an�nm) s 5 , O'
VTOMOGILK LTA21LITY
P�nhY aI,TO I COMBRIED SINGLE LD4IT S
ALLOWNEDAUTOS
BODILY INII/RY S
SCHEDULED AUTOS
I,BiLD AUTOS aOD(LY INJURY
S
NON.OWNED AUTOS CPce XulunO
PROPERTY IAMAGE is
-- i
GARAGC LIABILITY n TOON"LY'EA ACCIDENT S
_ JnY AUTO
OTLIPR TITAN A UTDONLY
N
Ew[l1 ACCIDENT S
AGGREOATE s
.i, EXCESS LIABILITY EACREOATE R OCCUARPNCfi S
•—UMBRELLA IORM I AOO IS
I OTHER THAN UMBRELLA FORM 4
U OrN.I
WOR1 RS M COPENSATION AND�I I'D0.Y LIMITS EA
CMPLOKRS'LIABILITY
j_ EL EAC![ACCIDENT S
j THE PRO
PRIETORI I INCI, ¢L DISEASE-POLICY LMR 3
➢ARTPIR5+CXECCTIVE —
^OPPCCRSS ARE EXCL� EL DISEASE-EA EMPLOYE£. Is
OTIICR
)KSCRIPTIONOF OrERATIONS/LOCATIONS/ CHICLPSISPECIAL ITEMB
� I
I SHOULD ANY C P TIW &DOVE DESCRIBED POLICIES BC CANCCLLED BEFORE 1••I
:T RICHARD LI 9�Xl!I�IRATION D,TEITUrREOF, THE ISJWNC COMPANY WILL ENDEAVOR lal—
ASL_ DAYS Y RTI TAN,uOTICC f0 TJ(P[l$LELGA36aB W=NAmC1):7'D TIM,
5 FLYING CLOUD LANE BLS FMLVRe-03 Wol NOTICE SMALL IMrOSB NO ORLIfnTION-OBLIABIJ.II
SALEM MA 01920 Ovi nxv IDYU II Twc coM'ANY. ITS AGENTS OR A�RFATNTAT •lI
_— AU'n IOPIeeD RE!do �Yave
QQ A
ACOR37.,cORkGRAT,ION 19s7
CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
nl4arat(t/.ti,r.r,
utwn. tee rwoaarlasrgnar a>a tss<kfa:aty earns 01l71
Tea.M74& % a ptx:tysaeovaw
Worker'Compotugdom Itsuranee AfWavtr. Buildervicamtncton/Eleaddalu/Phmbers
annlieatat Informadoo ��� t►.s � a ���
Nave luu ieessro se.ir d;e,Ytteh.rh.q: Ma H /V P AfxT FI PA S
AlJdtt�ts:_
City/stmwzip: QC-A(bo9�j,, ,ram 1� Ol°1 G ( t'booe 0: 97 R - S?o�-- —
Are yN est empleyer!Cheek the"__bossEWwkm* PWWY
'typo orprolea(►«I�od)1.❑ 1 am a employer with ♦.JM I am a Sco ataetor and i B O Now
employ-ca(ru11 a umor part.time). have hired theunlrutats
2.❑ 1 am a sole proprietor or partner• listed on the d shoat t 7. ® Remodeling
ship and hour no ampbyaan Themhe" & p Demolition
working for ma in any capacity. workero'comumm& 9.
(No workers'cuagL inserste" S. ❑ we am a corpn era!its �lyruwm addition
n quiredj offlema have sed their 10.❑Eleoaieal repairs or additions
3.❑ 1 am a horneown er doing all work right of examar MGL 11.0 Plumbing repairs or additiom
Myself (No workers'comp. c. 152,¢1(4), e have no 12.0 Roof repairs insurance tequiretj ► :MpleyeaL(wkers'
comp. uintil.l 13.❑OtherAlt:pplicad Nat etnaebe boa et ste alto"auNseeeide tvlsfib"o vm'amgeuw{ae PW WY inaYetuioe.'iN�:naw who Submit a1i atttdwk aey am daffy an wad am the.bite:C aeaii eaeuodawe WHO cohorts a aw aalJaail
umcattYa 00 chsa Nis baa suer anaebd m addnmol sheer.bowiq dM name of ode raksnaarmme aes Nair �'Nt ebb.
wwkm'emF Pdk7 wAwnmdm
/amr am ma plover that&prov/d►w;work"'coarOenranlea liunre/ree jer My earp/oyees Belpre a rAe Naz tracMmmmmm
Im%urar=Company Vantt
POlicy Y or Salr-ins. Lie.M - •- Edpinstion Date:
Job Site Adckcse: CilyiStrtu2np:
Attack■L'apy of the workers'compensation policy declsratiom palls(showing the policy number and cxpintiun date),
"ai sure to wcum coverage as required under Section 25A ul'MGL c. 132 east lead to the imposition of criminal penalties Ora
ri n¢up to S1.500.00 and/or one-year imprimtmncnt.AS well m civil penalties in the form of a STOP WORK ORDER and a riot
.If up to S210.00 a Jay agrinat tits violator. ire advised that a copy Or this statatnunt may be forwarded to the QIJIt:e at,
Ltr,�ng�unos vf d w DIA for racurarce covcrno vcrifdc.ttiun.
/JY htrcby r.rfi/y YYJei/he pr 'as Ya nY/ es Y/prrjary/kat//to I/IjYnwW/oaOnpru/erl YOovY y�y YaJCorrerL
D/JJcid mj;f am Jt Oio cow wnl/i/w/his orr^to At compAmed by elly or Atarw o,0&/YL
City or Town: Permit/l.lecam g
laming Aulburily (circle one).. _-
1. lloard of llealth 2. Building Dcpartutcat J.City/foea Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Of her
Cmllact Person: _ Phone p:
Information and Instructions
l32 ttgaires all employers to Provide workeW compensation for their emplayuaa
press:- l to thi Gunetal Laws chapter is the service of anchor under any eonttaot of"
Pucsuarst m this atatutR as egptspw�s is defined aa'...svery pats°°
e�prsss implied.oral or wrwted
amaiis,iar►aaspatat m other leWI ewity,ar'wy two a mom
aPthe foresoiasts ensetped a iadirids�0�►b��lefl reptesentldvcs of a deceased employer.Ibwever the
receiver of ttteetsa of as in&Must.patewrsbip.asswAanaa of adwr kp1 entigr.amplaYiat eata°1 eW of dw
_ and wba tesidsa derma or dw oom.
owner at&bouts Of aaothar who employs pow"0 do 0w'�O�Oa' or repair be
to such, rya lltas
dwcnwg amPlOY�
or on the grounds ar btu•ter dwress Aa w becann of esta "
AtGL chapter 152.f2SC(6)also stows that"aves7 ataM of Meal t{eeadat aOwY w er
a operate•bptsom w a ee sstresd ball/`bp Is thill i csvwar rpntrec.
resewal at a Yaw or).crack evldaw of wmpraon shall
SPPNCBM tabs W sat prod'ssaptaWa not�of its PoKdeal subdivieieas
additionally.MCI.chapter 152.;2SC(71 st&"wHaither tbs eomoaoweadL
enter into any eaearaot fir
the Patformancs of pubbe week mW acceptable ev_ulanet of cataPliaaea with the insurance
Mpkemems of this chapter bave bism presented to the C°�Os authority.
ApplMaNa
Pleass fill out dos workers' compensation affidavit compleftly,
by Checkingthe boxes that apply to your silttacw and.if
tteeessery.a+PP1Yity a)name(4 addtesslea)and pboas number(s)aloes wieb dWr cmeificate(s)Of
Coralissins LC)or Limited LSfMlity Pasoaershtpa lu P)with ao emPlayaaa other rhea the
tnaurertea Limited act tMuitad to csttY Workers,aatnV 6md06 insurance. if an LLC or LLP dose haw
mernbms Of Pones u go advised dot ibis aM&vit may be wbraitted to the Dgmbnmtt of industrial
employees.o policy foq of irturraneo eovmsso. Ababa sun to sip sad date the iMilaviL The affidavit should
Accidents for confirmation licattaa for the permit at license is being requested, sot the Department of
be recanted to the airy or sews that the app the hew or if you an enquired to obtain a workers'
lndustrisl Accident. Sbould you have any quatioas regacWrts below. SsU insured companies should enter their
compensation poltay.plan°call die Dqm moat td number Used
self.insurasa license mmnber on the
City or Tows Ofllelsk
_.....,.... ...__. . .. .. ratite/to tb the Depaessotct hat provided a space at the batto4-..
Pleax be sure that the affidavit is complete and p" i 17:
of the affidavit for You to fell out in the event the Office of Investigations hasto contact you regarding the spplieoeu
p,trmit/licettse number which will be used as a referencesubmi number.
I,l,.aso be sure to till is the one affidavit indicating currant
that must submit multiple 1permir/lieamo applies tiome in any given yeeru�should wfits"all locations is_.-(city or
policy information(if neeessary)and under"Job Site Address"the app
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may,be provided to the
each
affidavit is on fiN for future).men affidavit
cm n(led seeds(venture
where a hams owner or cinaen is obtaining ea
applicant>r Proof that s validobtaining a license«NOT requu not Belated to any businessor
to complete this JAdaviL
t i.e.a dog license or permit w barn leaves ea.)acid person
IN;0111Wc Of InVe%ti•Vtiuns would like to thank you in:,Jvance for your cooperation and should you have any questions.
lease Ju not hesitate ro give us a call.
The pcpaomenc's address,telephone and fax number
The COMIZOnwealth Of MassaChuxm
Depataneot of Industrial Accidents
Omee of[nwadSM&M
we Washilloos Street
Botloon,MA 02111
TeL 0 617-727-4900 ext 406 of 1-877-MASSAFE
Fax N 617-727-7749
cviacJ i-?G-US www.ingS vv/dig