45 FORRESTER - BUILDING INSPECTION (2) APPROVED BY T+IE
JNSPJ:CTDB ,PFIIDR TD A PERMIT B,EWG GRANTED
CITY OF SALEM
All
No. ,��` � � � Date
Is Property Located in Locati of
the Historic District? Yes_No /� Build
Y� ?PIf e
Is Property Located in
the Conservation Area? Yea No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace. Other:
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specffications: Fy
Owner's Name /
Address & Phone �y'y S P- 0+1
�
y = Architect's Name
Address & Phone 1
Mechanics Name
Address & Phone
Whet Is the purpose of building? C o y-e-
Material of bulirbng? If a dwelling, for how many families?
Will building conform to law? e /�
-J Asbestos? /l�
Estimated cost /60 0 city License M N P' Sfa N �� L�7i
Rome Improvement
Uc' I i ' r S gn t o of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORTS TO BE DONE
e
MAIL PERMIT TO: re.
11 d oc"-� S-
S,[z ) t IL'4 6/y3�
.t.
r •
NO.
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
2.0
APP OV�D
INSPECTOR OF BUILDINGS
• n
I • • I
Y'
3 The Commonwealth of Massachusetts
- 7 Department of Industrial Accidents
mcfe/Ialrestleaidaw
600 Washington Street, a Floor
Boston,Mass. 01111
Workers'Compensation Insurance Affidavit: Buildin lum lectrical Contractors
tee: Pf�kj��P dGo��,Kp��,E
address:�t,,tt J/�y ���/�7�i� /� X i . (� �5 �!// '7 / ) p [i
c�11/1` Pie *' ,4 state, ti zm 0�qY phone#41/'b�> 91V
work site location(full address),
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑_I-am a sole proprietor and have no one workin any capacity. ❑Building Addition
---- --❑-1-am air-employer providing workers' compensation-fit employees working on this lob - —
" ¢w
c . �,i a i� 'tom
f
,y
address
�`;e°''H`'£ y n s ? ""#:1t S, h a Y. at -+,� ♦ ° R r "' 1' f
cityTMI
i IF
ffi^
�} I am a sole propri or, eneral contracto or homeowner(circle one)and have hired the contractors listed below who have
the following workers' corn
company...,, `l�: y, � l egt 01U-T- �rV &4/}fy-
tp
address: . `6 3 Z #(OfL&14 Abe . ... . . ._.
I
S/� l Gil ctj�
company name:
address-, d.sx a t e."�` +.*`''�'�'xd %�".", 4 a ii n:4y r^ Y";.il
Cltr. x
-
# $ya9•nx> �.4;r trw*• h: e , oes-F '� x _.�7��
Failure to secure coverage as required under Section 25A of MGL 152 can had to the Imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment u well as civil penalties;in the form of STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of th*statentay be forwarded to the Omce of Investigations of the DfA forcoverage verification.
l des hereer the pains and penalties of perjury that the information provided above is true and correct
Signature Date -Print namfHIIP �IJUZov�f Phone# 60
official use only do not write in this area to be completed by city or town omcial
city or town: permil/license#
❑Building Department
❑check if immediate response is required ❑Licensing Board
❑Selectmen's OOtce
❑Balth Department
contact person: phone#; ❑Other
I
rc1'isN Sep,.Nxpl
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the`law",an employee is defined as 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 of
the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver
or trustee of an individual, partnership,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.
MGL chapter 152 section 25 also states that every state or Fo—cal6censmg agency shall-withhold-the-ismance-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,neither the commonwealth nor any of its political subdivisions shall 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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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 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.
City or Towns
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 fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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
Mce a Imesd aden
600 Washington Street,7ih Floor
Boston, Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406
i ,. '..,.- ✓die i0onc '�✓ ide� .
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Ntonber.:S$ 040282
04L�T^ Tr.no: 23185
PHILIP GOUZOULE� f
50 EVANS RD 815
MARBLEHEAL)i 01 A6KI
��e 1%oo�+mearu�ea� o�./�ageao%�aeGO
Board of Building Regulations and Standards
HOME IM@(,tOVEMENTCONTRACTOR .
Re lstrafion 144872
s_ /1612006
PHIL GOUZOUL S
PHILLIP GOUZO
50 EVANS RD °H °` �! :- /�jjr.✓
MARBLEHEAD,MA0,1945h Administrator
%mentp: T4ZT0 MEMON
,'ACORD- CERTIFICATE Of LIABLIT IY IVa SURANCE °"'E'"�°°"""'
07/02/01
PRODUCER THIS CF'-RTIFICATE IS ISSUED AS A MATTER OF INFORMATION
B.K. McCarthy Ins.Agcy. Inc. CHIV AND CONFERS NO RIGHTS UPON THE CERTIFICATE
10 Centennial Drive HRtiLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Peabody , MA 01960 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
978 532-5445 INSURERS AFFORDING COVERAGE NAIC#
INSURED Highland Avenue INSURER A: The Travelers Insurance Company
M s San Man, Inc. INSURER B. Travelers Indemnity Company
32 Highl Saugus, MA 01906 INsuRERc:
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
MAY PERTAIN,THE INSURANCE AFFORDED BY 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.
INbKUU-LTR NSR TYPE OF INSURANCE PODGY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
DATE MMIDD DATE MMID LIMITS
A GENERAL UABIUTY 1680346R4376PHX02 08/02/02 08/02/03 EACH OCCURRENCE $500000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 5300 OOD
CLAIMS MADE O OCCUR MED EXP(Any one Person) $5 000
PERSONAL B ADV INJURY $500 OQQ
GENERAL AGGREGATE $1 000 000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1000000
POLICY F jE OT 7LOC
A AUTOMOBILE LIABILITY 1810394H97201ND02 08/02/02 08/02/03 COMBINED SINGLE LIMIT
ANVAUTO (Ea accident) $
ALL OWNED AUTOS
BODILY INJURY X SCHEDULED AUTOS (Per person) $500,000
X HIRED AUTOS
X NON-OWNED AUTOS BODILY(Peer racci ent) $500,000
INJURY
PROPERTY DAMAGE E25O,000
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANV AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
E
DEDUCTIBLE
RETENTION $ $
B WORKERS COMPENSATION AND 6KUB957X507003 01/13/03 01/13/04 J( I WC STATU- I OTH-
EMPLOYERS'UABIUTY
ANY PROPRIETOWPARTNER/EXECUTIVE E.L.EACH ACCIDENT $100 000
OFFICER/MEMBER EXCLUDED?
II Siwtler
E.L.DISEASE-EA EMPLOYE $100,000
PECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Phil Gouzoule Construction DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
50 Evans Road NOTICE TO THE CERTIFICATE HOLDER NAMED T E LEFT,BUT FAILURE TO DO SO SHALL
Marblehead, MA 01945 IMPOSE NO OBLIGATION OR LIABILITY OF ANY UP IN E INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001/08) 1 of 2 #42079 LEG 0 ACORD CORPORATION 1988
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (97B)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition
- — - of Building Permit-#----- - —;all debris resulting from the construction-activity--
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c a S 150A.
The debris will be disposed of at: SIT U G 0 mrt
Location 6f Facility
/ 1'311
as
giipUire of Permit Applicant ate
FULLY complete the following information:
P g
(PLEASE PRINT CLEARLY)
��lCi/ G a_Og�EG��z�u� _
Name of Permit Applicant
�/f(L G-n�Lt,�[x C�NSTit �Trb N
Firm Name,if any
'�s �Q��r���Lt1Jtt}� ��Ij OoK
Address, City & State
The above statute requires that debris from the demolition, renovation, rehab or other
f building or structure be disposed in aproperly-licensed solid-waste disposal
alteration o g spo
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.