50 FREEDOM HOLW - BUILDING INSPECTION (7) What is the Current use of the Building?
Material d Building? �"^r io�P, it dwelling,how many units?
W N the Building Conform to Law? (td::�2 Asbestos?
Ardited's Name
Address and Phony III III
Mechanic's Name 215�i
/9
Address and Phone yS
Construction Supervisors License HIC Registration 0
Estimated Cost of Projed�i�QL?l� Permit Fee Calculadon
PennK Fee i� Estimated Coe X$71$1000 Residential
t Esdmatsd Coe X SMS1000 Commercial----_An Additional$5.00 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 st 6d
specifications. Signed under penalty of perjury
Date 1
IL
a �
y y s
a
EPIYOFSaAA, LEiV -. -
PUBLIC PROPERTY
DEPAR"I'1biENT
►�.mFxsr o■�,y
Nwvae 130 W&*uN *Sneer•smjjKM..Suo&5wns0t970
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION
DEMOLITION,OR CHANGE OF USE OR OCCUPAxtrY, FOR ANY FJQSTING
STRUCTURE OR BUILD>Q11t
1.0 SITE INFORMATION -
Location Name: BulldlrV
Progeny Addrees - -
Property Is located In s;Coneavedon Are@ YIN Hkwft OW&k:t YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: —78 `78 Z — eel 6-17 7q7:- /IaL
3.0 COMPLETE THIS SECTION FOR WORK IN EXIBIINQ BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of I vf� Area per floor (sf) Renovated
construction or renovation Iv
of existing building ��(;�0,4 New
8[ief Description of Proposed Work: /
Cv✓n�e.- j fir 5�g1/ r rJ Lv Ci-»9�J lI t`I
c "I C�1 G FUG/O5• /� S %c LJ lTct 25 ��4-f—fli t e
— Mail Permit to: 15 o / �
!� CITY OF SALEM
PUBLIC PROPRERTY
'' DEPARTMENT
M%11,11'RE FEY DRM:ULL
MAYOR M.WA*iNGI*0NSTREhT 4 SAtE34,MASSACIIt Wrlsol=
'GILL.:978-743.9595 0 Fix:9M744C,9846
Workers' Compensation Insurance Affidavit: BuildersiContractors/Electricians/Plumbers
Al)[)IICant Information Please Print Leeibly
NaMC tHuciiic.WOrgattiratiotVlndividwlq: 5 L o,N
Address: S vt"` sk
C ityjstate/Zip: (�A. ®Phone (f: -78 "
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ I ant a employer with 4. �6 I am a general commtor and 1 6 ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors
?❑ I am a sole proprietor or partner- listed on the attached sheet. : 7• 0 Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp. insurance. q• Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercises!their 10.❑ Electrical repairs or additions
3.❑ I ant a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
Myself. (No workers comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] r employees. [No workers' 13.❑ Other
romp. insurance required.]
.Ally upplicaw tidal checka box 01 must also fill out the section below dtowina their wwkm'cumpenuaiwt policy inrinnuiwa
'Ilo naimnan who submit this affidavit indicating they are doing all work and that hire outside coutnon,mud sulanii a new amdavil indicting Hach.
zContracu=that epode this box must attached an additional shoat showing the nam of rho sub-coatraeton and their wohan'comp.policy information.
l an;an euployer that Is providing workers'compensation insurance for my employees. Below is the puiicy,and job sire
information. ���� �—�1
Insurance Company Name:__._ _
Policy 4 or Self-ins. Lic.#: we, !_O,q /-/.,_- Expiration Date: q
Job Site Address: SO 14" IUcJ ��I CityiSlatdZip: S4 ��m / 70
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of
tine up to S1,500.00 and/or one-year imprisonment, as well as civil pcnallics in the form of a STOP WORK ORDER and a fine
of Lill to S250.D0 a day against the violator. Ile advised that a copy of this statement may be forwarded to the 011ice of
ILis rsti�aeions ul'the DIA for insurancc coverage verification.
l da hereby certify auder that psi d pet es perjury that the information provided above is true and correct
Phone 7:
OJJiciul use only. Do not evriie in this area,to be completed by city or town of/DciaL
City or,rnwn: Permit/License N____
Issuing Authority (circle one):
1. Board of Ilealth 2. Building Department 3.City/town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Gnduct Person:__ - __ Phone q:
Information and Instructions,
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
Ain eMployer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint 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."
biGL chapter 152, §25C(6)also states thug"every state or Total licensing agency shall withhold the issuance 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 compUance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"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 w ith the insurance
requirements of this chapter have been.presented_to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,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
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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Official
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 till in she permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pertmitilicense 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 or
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 tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l'hc Otlice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Deparnnent's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
OSlee of Investlgatlens
600 Washington Street
Boston,MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12C WA9 aXt::avS BEET•1Nti N.\tA MCU it a:i u:19/C
TFJ:97s•7454M •F.%t 97474COM
Construction Debris Disposal Af iidavit
(required for all demolition acid renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNtR section 111.5
Debris, and the provisions of M. GL c 40. S 54.
Building Permit N - . ._ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by M. GL c
111. S 1S0A.
The debris will be transported by:
6 2 vls s4/
game of hauler)
fhc debris will be disposed of in
Wane,of facility)
OMOZ-
..d:ros. of fiCady) /
- � `1 7 -
•.at.
08/01/2007 13:59 FAX 978 922 2328 CARMEN KIMBALL INS 0001 a
ACOR CERTIFICATE OF LIABILITY INSURANCE 0DAe TE ILBBDD/YYYYI
01/2007
PRODUCER (978) 922-0086 THIS CERTIFICATE LS ISSUED AS A MATTER OF INFORMATION
Carmen-Kimball Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
48 Beckford Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 73
Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIC 0
UiSUMD INsURBtA Liberty Mutual Ins- CO
Sheldon Frisch Development Inc- IusuRERe:
P O Box 811 INSURFRC:
218 Humprhey Street INSURER0:
Marblehead MA 01945- INSURERE:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REOUIREMENT,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 TYPEOFINSURANCE POLICY NUMBER DATE M IDOF E DALE�TION UNITS
GENERAL LAINUTY / / / / EACHOCCRRENM s
COMTORENTED
MOWAL GENERAL LIABILITYREEMMIGSEB ece S
CWMSMADE ❑0I / / / / MED EXP one f
PERSONALB ADV RIIURV S
GENERAL AGGREGATE f
GEII AGGREGATE
ppLRIIMpIIT.APPUES PER: PTOOUCTS-COMP/OPAGG S
POUCY JEGT LAC
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LINK S
ANYAUTO (Eaalv4em)
ALLOWNEDAUTOS / / / / BODILY INJURY S
8CHEDULEDAUTOS - (Per POWN
HIRED AUTOS / / / / BODILY INJURY f
NON-0YRBDAUTOS (Pw e=icl-a
PROPERTY DAMAGE f
(Pw emeenN
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANYAUTO / / / / OTHER THAN EA ACC S
AUTOONLY, AGG S
BRESSIUMB EUA LABILITY / / / / EACH OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE f
s
DEDUCTIBLE
RETENTION f S
A WORKERS COMPENSATION AND TfCI-316-32109E-0104 03/31/2007 03/31/2008 X TD LIMITS ER-
E PLOYERT LIABILITY
ANY PROPRIETOfwaRTNERE1ECUTNE El EACH acc®E+T f lOO,ODD
OFFICERIMEMBER E)(CLUDED? / / / / EL DISEASE-FA EMPUDYEE f 500,000
ffymSPECK .PRO wW� EL DISEASE-POLICY LIMIT f 100,000
fPEGIAL PROVISIONS DelPw
OTHER
DLBN:RPIIDN OF OPERATONSROCr-T10NSP41M ea eYn L tMONS ADDED BYEOORSEBIT9PECUIL PROVISIONS
Looat1=: 50 Fn dlND Hollow, Unit 101, Sn1HTA, NA 02970
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES M CANCELLED BEFORE THE
191PIRATON DATE TE11lOF, THE ISSUING INSURER WILL ENDEAVOR TO MAR,
10 DAYS WRIMN NOTICE TO THE CERIIRCATE HOLDER NAMED TO THE LEFT,BUT
City of Salem FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY NRD UPON WE
Building Inspector INSURER RS AGENTS OR REPI ENTATIVW.
AUTHORIZED
RFJ�IEf e/ram/
Salem MA 01970-
ACORD 25(2.00108) ®ACORD CORPORATION 1988
*n BNS025(MDBIM ELECTRONIC LASER FORMS.INC.-DDD)7T/-OBIS Page T oil
1
CG DS 01 10 01 A S P E N
ASPEN SPECIALTY
POLICY NO.: GLOO1297
REFER TO POLICY NO.: GL000301
COMMERCIAL GENERAL LIABILITY DECLARATIONS
ASPEN SPECIALTY,INSURANCE COMPANY H.T. BAILEY INSURANCE AGENCY, INC.
99 HIGH STREET 20 MALL ROAD, SUITE 100
BOSTON, MASSACHUSETTS 021 1 0-23 20 BURLINGTON. MA 01803
NAMED INSURED: SHELDON FRISCH DEVELOPMENT, INC.
MAILING ADDRESS: 218 HUMPHREY STREET
MARBLEHEAD, MA 01945
POLICY PERiOD:FROM 04115,07 TO 04/15/08 AT 12:01 A.M. TIME AT YOUR MAILING ADDRESS SHOWN ABOVE
IN RETURN FOR THE E T OF THE
PREMIUM, AND
STATED IN SUBJECT
THIS POLICY.
ALL THE TERMS OF THIS POLICY, WE AGREE
WITH YOU TO PROVIDE TH
LIMITS OF INSURANCE
EACH OCCURRENCE LIMIT S 1,000,000
S . 50,000 (AnV one premises)
DAMAGE TO PREMISES RENTED TO YOU LIMIT $ 1,000 (Any one person)
MEDICAL EXPENSE LIMIT
PERSONAL & ADVERTISING INJURY LIMIT $ 1,000,000 (Any one person or oganization)
$ 2,000,000
GENERAL AGGREGATE LIMIT $ 1,000,000
PRODUCTS COMPLETED OPERATIONS AGGREGATE LIMIT
DESCRIPTION OF BUSINESS
FORM OF BUSINESS: Corporation
BUSINESS DESCRIPTION: CONTRACTOR
f ALL PREMISES YOU OWN RENT OR OCCUPY
III LOCATION NUMBER ADDRESS OF ALL PREMISES YOU OWN RENT OR OCCUPY
1 218 HUMPHREY STREET MARBLEHEAD MA 01945
// Board of Building Regulations and Standards
f15 I� HOME IMPROVEMENT CONTRACTOR
1�; Registration: 104546
Expiration: 7/14/2008
Type: Private Corporation
SHELDON FRISCH DEVELOPMENT INC.
Sheldon Frisch
218 HUMPHREY STREET,,,,\,
Marblehead, MA 01945 Deputy Administrator
.�:a., ,p¢g,ebrnlaro�trl(f G� /Lr.;rzr:i,
BOARD OF BUILDING REGULATION c S.
d License: CONSTRUCTION SUPERVISOR
Number: CS 051135
a4"'r Birthdate: 07/14/1955
r Expires: 07/14/2008 Tr. no: 28501
_ Restricted: 00
SHELDON W FRISCH
PO BOX811
MARBLEHEHEAD, MA 01945
Commissloner