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46 FORRESTER ST - BUILDING INSPECTION (2) EI`I'Y -- ' PUBLIC PROPERTY DEPARTMENT AI.MFM.EY DRISCOLL '/ MAYOR 13D WASHING ON-MEET#•SAI.LK 7&SACH 16-Is01970 Q7 FAIL 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: -rivh I Property Address: ZAU Fcr4-,�5-k-r s+4 7 et property is located in a; Conservation Area Y/N 0 Historic District YIN 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land I _ Name: PV-�ft Address: FV(Z�5'w SA� Telephone: 01 go -5jj YZ) 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING. BUILDINGS ONLY Addition Existing 3 Renovation Number of Stories Renovated 3 Change in Use New Demolition Existing Approximate year of Area per Floor (so Renovated construction or renovation of existing building New Brief Description of Proposed Work: - �Q,wi�e tnw��l-erL �� �ix�5 , ax{�-1��1✓S as.w .-k�s Mail Permit to: vuwt bm rxlmtsV `� 1 What is the current use of the Building? Material of Building? WLUd �40v"-� If dwelling, how many units? 2 Will the Building Conform to Law? �Q� Asbestos? tJO Architect's Name Address and Phone t Mechanic's Name Address and Phone Construction Supervisors License# 053�-46(0 HIC Registration# 13y 77S Estimated Cost of Project$ a 002 Permit Fee Calculation Permit Fee$ p Estimated Cost X$7/$1000 Residential p �0 Da Estimated Cost X$11/$1000 Commercial I Z� An Additional $5.00 is added as an Administrative charge. $ Make sure that all fields are properly and legibly written to avoid delays In processing. The undersigned does hereby apply for a Building Perm to build a above;s te/d �/ 1 specifications. Signed under penalty of perjury X / 1 ci Date �IO � o N akZ a 14 OJ ° b � CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT xaratntstr oatscoLL MAYM t20 VAaw4aro snw a sAaua,MAssAeetmm olwo Mm.V11-74t1"" a FAx:97tt•74MM Workers' Compensation Insurance AiHdavit: Builders/Contmctersmectlidanalptom6ers Applicant Name(BusioeworgamsenodlnmviAul): � l l 4\/ �JI� S 1� lV7 )e�GjS �C Address: wk City/Statt:lZip: �'`) of Afe you as employer? appropriate boss F[:]Rm trognit : 1.J I am a employer watlt 4. ❑ I am a feoerat contactor and Itrctioo employees(fill and/or pact-time).* have hired the sub-contactors 2.0 I am a sole proprietor or pa tneo- listed on the attached sheaf. t g ship and have no These workin f for me in any capacity. wow'ro ,have(No workers'comp.insurance 5. ❑ We as a corporstion and its 13 dition required) officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work risk of exmnption per MGL 11.Q Plumbing repairs or additions Myself.[No workers'comp, C. 15Z 11(41 and we have no 12.Q Roof repairs insurance required)t employees.[No workers' I3.Q Other COMP.insurance required.) ��y apptteamt dtr ahaela has s1 awe ale NI art the secdas halmre teotvb,s drdr amtlaa Hamemnsis who nthett dds aAWsw vdleatlw day=d0ia6 as oadt sod eta kb aotalds om mad suheu a new aflids„Y tCaaheelm ears cheek dds hoe=0 aaaehad a ddtdonst sheet Amiss da mate of the n twk, - sea ihstr wtloes'ammp try tatbttmtloa lam an employe►that lr providhq workers'eowpossadoe,Issuance for my essployeaa Below h the policy and fob.rha Information, 1� Insurance Company Name: Policy 0 or Self-in&Lie.N wC a�a " Expiration Date: i��/ Job Site Address: 17 C11Lt�S S� City/swamp:__ S l, A- 01920 . Attack A copy of The workers'compensation policy declaration pate(showingt� poliky number and a:piratloa date)6 Failure to am=coverage as required under Section 25A of MGL c. 152 can lead to the fine up to 31.500.00 and/or one-year imprisonment,as well as civil imposition of criminal Pia ofa of u m 3250.00 a day a penalties is the form of a STOP WORK ORDER and a tine p y f the violator. advised that a copy of this statement may be forwarded to the Office of Investigations of the D for' cov 0e verification. !do hereby eerdJy a d r the pa d naltiea ojperfary drat the In jorrnadow provldsd oboes h des and correct . l to D� O,Jfclof us*one% L)o sot write he thh area,to be completed by My or Iowa offlc&L City or Town: Pertnif/Lieenso N Issuing Authority(circle one): i. Board of Healtk 2.BuOdInR Department 3.Cityt?own Clerk 4. Metrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone q: Information and'Instructions Massachusetts General Laws chapter 152 requires all employers to Provide in the serviceorkre another under compensation Y for es ct ofbi% Pursuant to this statute.an employee is defined as ...every person an cont�a�totEiro+ express at imPloA oral at written." ,. P.association,corporation at other legal entity,or any two at more An employer is defined as"an individual, and ves of a deceased employer.or the of the foregoing engaged in a joint emterprie",and including the legal �association a other lo ees. However the r legal entity,employing amp Y receiver a tn individual,partnership,of an individu partnership, and who resides titerein.at the occupant of the dw Q of anothar whowho employs p�0o do maintenance.construction a�`we&on such dwafft bow" at on the grounds at building appurtenant thereto shall not because of such employment be thhold b be an empleyer' MGL eha;ew 152,§2SQ6)also states that"every stab or Weal Ikensisa agency shalt withhold tb"issuance or b operab s busiatua or to contract buildings is the commosweaitk far any renewal of a Beewea or permit �1'st"8 evidean et eomptlane"with the issurse"coverage sequin" Additionally MGL chapter 1���(7)status"Neither the commonwesith now any of its politicalwith the insurance pulormance of public work until acceptable evidence of comp liance � u o into any f the chapttract for er have bies.presented to the contracting autboM." Applicants the boxes that apply to your situatiou sud,if please fill out the workers' compensation affidavit completely,by checking _ necessary. suuub contisCtnr(s)name(e).address(es)and plane number(s)along withwith no a)of�sn the Limier Liability Companies carry ore Limitedco Litumance.(LLPan)LLC or LLP does have emembers at partners,am not required to is required. Be advised that this affidavit may bempensation submitted to the Department of Iaffidavit Accidents for confirmation of insurance coverage. Al"be sate to sign and date the a9ldsvit. The affidavits old be returned to the city or town that rho application fat the permit at license is being requested,sot the Industrial Accidents. Should you have any mwtu We regarding the law or if you are required to obtain a workers' Policy-pleas"call the Department at the number listed below. Seif-insured compw im should enter dim compensation Po li»a self-innaancs license n1IIObor on the City or Tows Officials a at the bottom fete and printed legibly. The Department has provided a spat Please be sure that the affidavit is comp Office of Investigations has to contact you regarding the applicant. of the affidavit for you to fill out in the sevva mber which will be used as a reference number. In addition,an apPH and Please be.sate b fill is the permi llcationt in any given year,need only submit one affidavit indicating current that must submit multiple necessary)�°sewder lJob Site Add<eas"the applicant should write"an kw4dona in__(City or policy information( or marked by the city or awn tray be provided to the town). A Copy of the affidavit that has been officially stamped fturc Panda at licenses A new afud+.vu must be filled out each applicant as proof that a valid affizen i u on file for license at�t not related to any business or commercial vantum year.Where a home owner at eitizes is obtaining leaves etc.)said person is NOT required to complete this affidavit (i.e. a dog license at permit to burn ou in advance for you cooperation and should you have any questions. The Office of Investigations would like to thank y please do not hesitate to give w a cedL The Department's address,telephone and fax number: The Commonwealth of Massat hUMUS Depattio W of IndnsaW A=dbmb ()Me of InvesdVdons 600 wa411110oa seat BMW%MA 02111 Tel. #617-727-4900 Cd 406 tx 1-&77-MASSAFE Fax#617-727-7749 Revised 5-2&05 www mampv/dia ACORQ CERTIFICATE OF LIABILITY INSURANCE oziioi2006 PRODUCER (978)887-4900 FAX (978)887-2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennett Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 16 South-Main Stlreet ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC# INSURED Port City Builders & Remodelers, TIC INSURER A: Western World Insurance Co, 2 Martel Way INSURER B Safety Insurance Company 39454 Georgetown, MA 01933 INSURERC: A.I.6 INSURER D: NSURER 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. INSR DD' rypE OF INSURANCE POLICY NUMBER DATE MminriffyiPOLICY EFFECTIVE POLICY EXPIDATE IMMIDRATION LIMITS GENERAL LIABILITY NPPI011009 01/04/2006 01/04/2007 EACHOCCURRENCE $ 1,000,00 TCOMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ rJQ QQ CLAIMS MADE aOCCUR MED EXP(Any one person) It 1,00 A PERSONAL B ADV INJURY $ 1,000,00 GENERAL AGGREGATE It 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGO $ 1,000,000 POLICY PRO- JECT OC AUTOMOBILE LIABILITY 2432700.COM 01 03/09/2005 03/09/2006 COMBINED SINGLE LIMIT ANY AUTO (Eaaecldertl) $ 1,000,00 ALL OWNED AUTOS BODILY INJURY X SCHEOULEDAUTOS (Per person) $ B HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE It (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY'. AGO $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE It OCCUR CLAIMS MADE AGGREGATE $ It DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC292-62-09 01/16/2006 01/16/2007 WCSTATU- I I OTH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,00 It yes,descbbe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT It 500,00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Evidence of insurance AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 PDF created with FinePrint pdfFactory trial version www.r)dffactory.com - Board of Buildin? Regulations One Ashburton P ace, m 1301 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 07/01/1969 Number: CS 053486 Expires: 07/01/2007 Restricted To: 00 WILLIAM T CLOUTIER 162 AS]I ST W Nl WBURY, MA 01985 Tr. no: 3179.0 DPS-CAI Co 50M-04/05-PC8698 Keep top for receipt and change of address notification. gx, -COo>)GLL04cuw.2ll�, O v 1'/.(/JJl6c✓LIIJP.Cfd BOARD OF BUILDING REGULATIONS nf,", License: CONSTRUCTION SUPERVISOR fx 4 + Nor Number: CS 053486 * ' Birttidate: 07/01/1969 - Expires:,07/0112007 Tr. no: 3179.0 Restricted:-00 WILLIAMT CLOUTIER 162 ASH ST W NEWBURY, MA 01985 Commissi CTIY OF SALEM PUBLIC PROPERTY DEPARTMENT 1°"�os�me► ,�a. �sw�owaa�ss�.sKn�x..�oawa+sm�a. Ilk M7464M 0 PAS M?4&" Consumcdoa Debris Disposal AMdavit ooq#"sw lz dsaomm sod neowatea woe* 2=Wmo wilt dw&& a,�t CW%730 CWM seedon III.! ��'ad*A PMVtdGW_ ie toe/��eomGle��t td da6eU addoAoea t3v�Iteeredt d otiw s D��►Hoeostl wsrse dlspoest Adugt>.deQeed by A[t8.s �Overt sbsll De disposed I u,s IJOA. Ths debris wiu be trsmpod"bye Cl�u ) hge (eerr.afbmwl The debris wid be disposed MIR INM� (same of&GAW