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11 GALLOWS HILL RD - BUILDING INSPECTION 9 Oda Mo. d� IBPMWMLoorWa N.w wa awe+bpospeftLeoftilm ;� w.a�w�laawl ra---N°— MULOrq NIM ff APPLI M POW (Groh whialwwr app4►) Roaf� MiMaY BialYp, CMw" Do*, SIMd, Pool. run MLOff LEOW.,a Cq1 U MLYTOAV== AV&Oi MOO"" TO THE R&%C=OF MD"IIL The undMeOW hsr*Y aPPW for a PFM* 10 bM aooW** to the lollowirp NOW&Nam Lv Ad*M 6 PhM+a ArdlraOCa Name / 1 Aftm l Phom . MaChwift NMaa AONW• Phone .- < �✓nv Uzi Ufta 60 p.pona eurmro9 wr w a arm ���„^n aorwrw,W ft=.rall ��. -� a w" ImINPMVM=t X us. / t3'7q a APPIi01MK aowr umm-11 E PENALn Of PWW OEECR fwM OF WORK TO of DONE g /ff.'S�L`mFit//- lilJ�f DNE*'' INS �n11—�iaq�,y��� iqvs)g�i, szf S& wo m -ro - zy ,4c i rru 5TmeArI6 MAIL P i..�( D �QAlO1L�F s% � � "oe MZ/ - 7 • APPLICATION PWAW To FOR Sfi LOCATION / J� PEFW A ,N l% 1,4 2e aF Mxcrros f 4DCITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RO FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOvICZ, JR. TELEPHONE: 978.745-9595 EXT. 380 MAYOR FAX: 978-740-9846 Salem Building Department Debris Disposal Form In accordance with the provisions of MGL c40 S 54, a condition of your Building Permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter in, S 150 A. The debris will be disposed of in: (Location of Facili tY)-['#o rytrl 0q Signature of Applicant /4 V%1111 Date The Commonwealth ofMassaehusetts Department of Industrial Accidents Offree of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dla Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information ,P Please Print Leeibiv Name(susi ss/ror nizationil mdoal): 11�r.�Jia�' 1Nstni�Jr 97&1 Address: �1,0 TR�PIr S3' City/State(Zip: C.MmA) Phone 4D(oj9 Are you you an employer?Check the`approprlate boar' d project aired 1.�t am a employer with' -a 4. ❑-I am a general contractor and I Type e 1 (required): employees(fan and/or-p�.• have hired the sob-contractora 6: ❑�New construction 2.❑ I am a sole proprietor or partner- listed on the attached sleet 2 7. Q Itemodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity., workers' comp. insurance 9, ❑ Building addition(No workers'comp.insurance 5. ❑ We are a corpotanon grid 10❑ Electrical sus or additions required)_ officers have ext=chsed they" 3.❑ I am a bomeowna.doing all work right of exempti=per MGL' 11.0 Plumbing repairs or addition myself [No workctu'.comp:. c. 152,§1(4%and wehave'no 12.❑ Roof repairs insurance reyyaed j t. employees (PTo,wotkas' ; .. : 13.❑ Other - COMP.insurance regnii4j ;Any applic®t that checks box,#1 must sled 5A ottttite"on below showing%cir'%wUp'conWepapon policy ro80.nne ian:- t Homeownm who sub"dams affidavh indicating they an doing all work and then bug outside cos6actm must suUnit a new affdavd indicating such. tCoauactm dust check this boit'n"attacheden additional"sheaf ebowmg the nape bfthe"su&oonEiactotsend floe wo,km'coeV policy mfomwhom I an;etr employo that!s providbi;worhers'eompensadon buumnCe for myenoloytes+ Below is thepo&y and Job site information. Insurance Company Name: L4 9&-?y MA tifix- Policy#or Self-ins.Lic, M IA)(tL-1�,?jj-jg43JV-611— Expiration Date: `fi 2q-0 Job Site Address: l! U1¢ItewlC-lam City/Staftg4: -Yrtc M, 1)l4 76 Attach a copy of the worker'compensation policy declaration page(show ing the policy number and expiration date). Failure to Secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year mrprisonmen;as well as civil Penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby fY 4 f pedury that the Information provided above Is true and correct Si tire: D Z Phone#: -7,fi f /-0060 0fflel l use nubs Do nag wrks in Air ana,to be completed by city of town q,pul City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cltyfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provid.c workers' compensation for their employees... Pursuant to this statute, an employee is defined as"...everyperson in the service 4f another under any contract of hire, express or implied,oral or written." An employe i$defined as an individual,partnership,association,corporation dr other legal entity,or any two or turn of the foregoing the engaged'in a joint enterprise,and including the legal representatives of a deceased empinYa.or receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the and who resides therein,or the occupant of ili4d ` owner of a dwelling house having not more than three apartments construction or repair work on such dwelling house dwelling louse of another who employs persons to do maintenance, or on the grounds or building appurtenant thereto shah not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that„e ery state or local 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 compliance with the insurance coverage required.,, Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth rot any of its political subdivisions shall he work until acceptable evidence of compliance with the insurance enter into any contract Eor:the performerce of Pub requirements of this chapter have been presented to the contracting authority:" Applicant Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-coutracmr(s)name(s),addresses)and phone numbers)ur along h their no employees other than the of insurance: Limited Liability Companies(LLC)or Limited Liability Partnership (L1 ) members or partners, are not required to carry workers' compensation insurance. If an LLC of LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial ould sip Accidents for the city or t n that the a lication for the permit overage, Also be sure r license being requested,not the Departmiffidinvftmthof d date the affldsivIL no a ed to the city or town application required toa workers' In returnas regarding die law or if you comp mationidenta Should you have any qaestio at the number#stud below. Self`named companies should enter their , tier lease call the Department . coa�ensa poliwy P self-insurancelicense member on the ' to lure. City or Town Officials 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 as a reference number. in addition,an applicant Please be sure to fill in the permit/lcense numb which will be applications in any given year,need only submit one affidavit indicating current that must submit multiple permit/license 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 firnue permits or licenses:.A new affidavit must cm filled Out ene� year.Where a home owner or citizen is obtaining a license or permit not related:to any busiaeas of commercial (ie. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office 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 Department's address,telephone and fax mamba: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia OWENS CORNING • - .■■■..■■.■■■■■■■■ m YWOEM A■a■■mo■■m■■m■E■■.■.■■■■■■■■..■■■■.. ■■.A■.■■.■■■■■■■■■■.■e �l . .A■■■om■■m■■■ ■■■■■■■■■■■■■.■.■■.■ ■■■.■■■■■■M■■M■E■ME■.. ��M■■■■m■■m■�.■.■■.■.■■■E■■■■.■■■ ■E■■■.■■■■■A■E�ocom®®ram■■ �lllnelle■s■■■■ ■.■■■■.D.Fitu ■■.■■. ■■■■■■.■■■■■■■■IMA■■■■OE■�Oim.■1■■■■■■■ .■..■■.■■.■■■.■■■■■■■ MAMMA■■■■■■■■■■IA■ MAMA.■ tl:■..■■.MEN■ ■■■...■E!■ falii■■..■■■.■ ■■■.■.■■■■..■■■I■ MAMMA■E�dm■■■■■■■■■ ...■■.■■OI.I�O�I.wwM■■EM■E SEEM■■.A■.■a■MOI. ■■SERA no■■■■o■■.M ■p■M■.Sii�IrYO■m■■■mom NORM■■■■AA■■■■Mil■■M MAMMA.�IIEMMEE■■Sol[■■ ■■■MEN■.■■.■.mom.■mom ■■■A.■E■E■.ENE■OIm.M■■E■■Ill®®■■■■OM■NSIMdl a..■■■ ■iMM9i'Zi sic-0 ONE ■AM■■MEAN■m■ERA■�o.ME■E■■■O]BEN o.■SEMEN■■■■■mom s■M■.O mom■mMEN m■■.■■O■■M■■MEMO M�■M.■E.■ gloullm !!■■MEOEM■■■■■■E■mMr7Oil MA■■■■■m ■ME■■MEMO■■■■■■■!m ■■m■■EM�©wommmg MEN■■■a .MAMA■MO■■■■.■■.■■ ■■■.■MEMO■■.■■■■IE ■o■■■■■■mM■.■■1■■IOli �A■■E.■■E■a■■A■.■■� f►ia.■ MAMA■SEEM■.■■■■■I■ A■A.■■■m■O;:m�.■I■'■G■I■I¢.IOm■mm■■M■■■■E■..■■■■M■ NEE.■■NEE.■■■■MMIS�M■■■MA■■■L''� ■■i■,■.■1■1GA.■■mmwwMM■■■mM SEEN■■. 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Oi I Shed ZSSBIZ8I8L NO.ISOH 9NINHOD SNW @E0:01 900VOI W acoRb_ CERTIFICATE OF LIABILITY INSURANCE BAYST i "o6/8/2 PNOO THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Raplansky Insurance Brookline HOLDER THIS CERTIFICATE DOES NOT AMEND.EIREND OR 114 Harvard Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Brookline MA 02446 Phone:617-738-5400 Fax:617-738-8214 INSURERS AFFORDING COVERAGE NAIC0 HSLa® HstERA: Norfolk i Dedham Group13993 87y Late Basement system W HSLRER B: e St 960 1 Ocvepps Corpinq Bioishinq t 960 Tu &02021 Captors !IIL Demo- HSUER E: COVERAGES TE POLICES M HSIRNJCE LISTED BELOWI w BEEN WiEu To TIE to ED ILM.EOABOVE FOR TW POUCYPERIOD MICATED.NOTMMSTNOW ANY PEOUPDENT,7EWA CR OOPMON OFIHYCONIRACTORORER DocLwe f MTRLRESPECT M VMCHTNISCMWICATE WY BE LS$UM M /MYPERTAH TIE WSLRANCENTOPOEDBY TIE POLICIESDESWKIN IS SEXCT TONI RE TFTd.6.E)MBIONSNO COI )fT0*OF SlA1 POLICES.POOREGATE LYTS SIgMH WAY KAYE OEEN REWLTD By PND aAj S. L1R TYPE OF HSIRNICE POl1L1f N(RaER fWTE M,yOOA'Y) DATE MNDMY) LL Ge6ML WBLRY EAO+OcamlE+cf j62000000 0 C001CRCK GBERAL LIAELIIY PRELIISES EeomPiaae 0 aNNS WN]E ❑DDaR LEDEIVIAq"+ j A X Business Owners R0309626 02/10/05 02/10/06 PERSONAL a XW KAM GQETW.AGfIEGATE GERLAGOREGATELOWAPPLESPEA PROOIICTS-COLvwP G POLICY T& D Loc AVTOWB{E NIBtRY COk0*ED SffG E LINT ANYN1f0 IE,iIWO.V t ALL OAYEDNNOS 5!!®IAEDAUMS BODILY NARY t (Pr Pam) IaEDNROS N011 OW EDAUTOS BODILY HARP { (FW Kdbfi) . PROPERTY DNWIE { Ipw udd m CARAGrETJIBLFIY AMY�Vf1D NROCf1Y-EAACCIOEW { OTFIERTLWI EAACC i AUTO MY. AGG { EltCE55AAB11HLA IIPBLfTY EACH OCQ%ENCE { OGLTA RCWA6 WLDE AGGREGATE i OEilIICTmf ' REFDOM IT - S a ftoy SCOIferTy NO { EMPLOY9tttYa{RY TORY LHRS ER CIRIVE E1.EMAI ACCOQO t S ONOrO PROVIS1016bIpIv EA.DSFASE-FAexwyEE i OTHER E.LOTSEASE-POLICYLDAT i OFSGHVTgNOFOPEIGTgI6/LOGigNS/YENClES/IX(rIKpNS AOOED BY EFDORS(�EtYT/SPECYY PROYLSgHt CERTIFICATE HOLDER CANCELLATION $I D MTY OF TIE ABOVE DESCRa(�POLICIES 8E CANCELLED BBORE TIE Fp'IRATgN MTET/OE -IEISSLOC.MURERVMLENDPAyORTOWL 10 DAYS MAI((1131 NOTICE TO TIE CER1 "TE!OLDER W&IED TO 114E LEFT.BUTFALIRE TO DO SO SHILL DPOSE NO OSLIOATIM OR LKSILfTY of ANY NHD UPON TIE HSIFEFL ITS AOEM OR REPRESENTATTYEl 1TVE AC 0 ACORD CORPORATION Igoo BOLA International Evaluation Report B Pt/o A �6 ,� I - 11: 1� - evaiue#ion>scope � � : , condition of use Research Report Complancewtthttiefallowmgcoest This report is limited to applications and 21 24 BOCAtVati6nalu7ldutgCq'e�1999 products as stated herein. BOCA-ES intends that this report be used by the code official to Skchon$03 2 Clas$rficahou,t ° ' a txx determine that the report su bject complies with ■°Secnofi 803:0 Ca , and caret hlte the code requirements specifically addressed, MANUFACTURER tvall eovotittgs x ',�i provided that this product is installed in accor- r dance with the following conditions: a Seenon d96 Y�ternatiue tgatenaLs OWENS CORNING andegmpirient , • OWENS CORNING Basement Wall Finish- ONE OWENSCORNINGPKWY MTM• Seenon2603Inlenorirm; ste nba ementa rs intended for bcations.Otherasgations TOLEDO,OHI043559 Sechan 1301?1 Scope(Energy " are outside tha cope of this report DIVISION 7—THERMAL AND s n; ,��=,t,, 3 `.�`� . ,. ; j ■ The maximum permitted area of the PVC MOISTURE PROTECTION I99&lnternq?rb One dJtd t �r moldings shall not exceed 10 percent of the l amnFy Dweftrng Code at aggregate wall and ceiling area of the room. Section 07200—Insulation ■ j Secton 3L$ tWa�l Ltd celmg't � ■ Installation of the Basement Wall Finishing aflame sptead ualeft} , an SystemTM shall be in accordance with this DIVISION 9—FINISHES ■ S�enon3l$2Sinoke-dcye!°aped s report and the manufacturer's installation manual. Section 09540—Special Wall .:� - E` ■ tSecnon�1$3 TestWg g irr ■ Basement Wall Finishing SystemTM shall be Surfaces installed over cast-in-place concrete or concrete masonry unit walls, or wood or EVALUATION SUBJECT description metal stud framing. Supporting structural systems shall conforming to code require- OWENS CORNING Basement Wall Finishing ments for that system and are outside scope BASEMENT WALL FINISH SystemTM is an alternative to conventional wall of this report. SYSTEMTm framing and gypsum wallboard.The Basement a The electrical wiring in the chase at the Wall Finishing SystemTM consists of PVC bottom of the Basement Wall Finish Sys- support lineals,base, batten, and cove mold- [emTM shall conform to the requirements of ings, and rigid pre finished fiberglass panels. the code and is outside the scope of this Panels are prefinished with a fabric cover. report. Basement Wall Finishing Systent''M is primar- ily intended for installation in residential applications. Refer to Figure I at the end of items requiring this report for illustrations of the Basement verification Wall Finishing SystemTM. The following items are related to the use of the The Basement Wall Finishing SystemTM shall report subject, but are not within the scope of be installed in accordance with the manufac- this evaluation.However,these items are related turei s installation instructions and this report, to the determination of code compliance. Installation typically consists of either me- ✓ Concealed electrical,mechanical,orplumb- chanical fasteners or adhesive fastening or a ing components shall be inspected prior to combination of both to the supporting sub- the installation of the Basement Wall Fin- strate. Thermal resistance (R-value) for the fishing SystemTM panels to verify compli- fiberglass panels is 11. ante with related code requirements.Evalu- Basement Wall Finishing SystemTM panels anon of these components is outside scope PRINTED AUGUST 2000 meet the requirements for classification as a of this report. Class I interior finish as tested in accordance ✓ Framing supporting the Basement Wall Page 1 of 2 with ASTM E84 and also has demonstrated Finishing SystemTM shall be inspected prior that it will not spread fire to the edge of the to the installation of the panels to verify Copyright©2000, specimen or cause flashover in the test room in compliance with related code requirements. BOCA Evaluation Services, Inc. accordance with the testing requirements Evaluation of this framing is outside scope specified in Section 803.6(2) of the BOCA of this report. A Participating Member National Building Code/1999. of the NES, Inc. Page 2 of 2 Research Report No.21-24 Information submitted product Identification ■ haegrexTm Testing Systems,Report No.73143,dated April 17, All OWENS CORNING Basement Wall Finishing SystemsTM 2000,containing results of physical testing. manufactured in accordance with this research report shall bear ■ IntegrexTM Testing Systems,Report No. C423-99065, dated the following identification: August 19, 1999,containing results of physical testing. ■ "See BOCA Evaluation Services, Inc. Research Report No. 21-24" ■ Omega Point Laboratories,Report No. 130W 103216a,dated 4 May 14, 1999,containing results for fire testing in accordance hit with ASTM E84 for rigid fiberglass wall panels used in All Molding Basement Wall Finishing SystemTM. Snaps Existing Foundation Wall ■ Omega Point Laboratories,Report No. 16218-106644,dated PVC or Interior Partition April 13,2000,containing results for firetesting inaccordance Support ` with ASTM E84 for moldings used in Basement Wall Finish- Grid ing SystemTM. ■ Omega Point Laboratories,Report No. 13060-103213a,dated 2.5'Glass t June 7, 1998. and Report No. 13060-104470a, dated March Fiber Board `. 24, 1999,containing results for fire testing for full-scale room Panel with comer testing in accordance with requirements contained in Facing PVC Section 803.6(2)of the BOCA National Building Code/1999. Cove Molding ■ OWENS CORNING Product Literature, dated May 1998. PVC Support Lineal ■ OWENS CORNING Submittal Sheet for Basement Wall (top, bottom, Finishing System(BWFS), dated April 2000. vertically every 48") ■ OWENS CORNING Basement Wall Finishing System Installation Manual, dated January 2000. application for permit To aid in the determination of compliance with this report,the PVC following represents the minimum level of information to Molding accompany the application for permit: Vertical PVCBatten Molding ■ The language"See BOCA Evaluation Services,Inc.Research Base Report No.21-24"or a copy of this report. • Plans indicating the aggregate area of the room and the area of the PVC moldings being used. Figure 1' Sketch of Basement Wall Finish SystemTa ■ Plans and specifications of any electrical, mechanical, or Showing Typical Components plumbing items installed within the wall system. 'THIS DRAWING IS FOR ILLUSTRATION PURPOSES ONLY.IT IS NOT ■ Details and specifications of the supporting construction to INTENDED FOR USE AS A CONSTRUCTION DOCUMENT FOR THE which the system is to be applied. PURPOSE OF DESIGN,FABRICATION OR ERECTION. NOTICE TO REPORT USERS This report is subject to annual certification.Reports that are not certified shall not be used or referred to.To determine the status of certification of this report,contact BOCA Evaluation Services,Inc.,or consult the latest edition of the BOCA International Product Evaluation Listing published periodically in the BOCA magazine. This report is subject to the conditions listed herein and to the specific product,data and test reports submitted by the applicant requesting this report. Independent test were not performed by BOCA Evaluation Services,Inc.and BOCA-ES specifically does not make any warranty,either expressed or implied.as to any fmdings or other matter in this report or as to any product covered by this report. Evaluation reports are not to be construed as representing aesthetics or any other attributes not specifically addressed nor as an endorsement or recommendation for the use of the report subject.This disclaimer includes,but is not limited to,merchantability. Please contact BOCA Evaluation Services,Inc.,with any questions you may have regarding this report.Additionally,please contact us if you have any information on the performance of the product described herein which is contrary to this report. 4051 West Flossmoor Road•Country Club Hills, IL 60478-5795 telephone(708)799-2305 a fax(708)799-0310 e-mail: boca-es@bocai.org•http://www.bocai.org . � fie -U� o��m•o�u��+� ��/Ga6�ac/�iu6e�6 Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 137943 Tvpe: &mpI meat Card Emiafim lr4=7 OWENS CORNING BASEMENT FINISHING DANIEL WALSH 960 TURNPIKE ST. - CANTON, MA 02021 Update Address and return card.Marls reason for ehaog Address Renewal Employment O Lost Card nPSCAJ 0 SOM-0410Hi101216 Board of Building Regulations and Snadards License or registration valid for individot an only HOME IMPROVEMENT CONTRACTOR before the expiration date- If found retorn to. Repistr>t(on 137913 Board of Budding Regulations and Standards One Ashburton Place Rm 1301 - 7 Boston Ma.0210E `,_� `_ 1Dc,E Suppianldd Card OWENSCORN03.EA EMEN CANTON,MA02021 Admiwbalor Not valid without signature