4 GARDNER ST - BUILDING INSPECTION What
is"Current usa of the Building? r� �� l I (�U►1�, US 1 _
Material of Suk*V? If dwellirrq.how many unnb7'
yyill by dicing Contbrm to Law? Asb"tos9
Ardlited'a Name
Address and PhoM
MedwWsName
Address and Pha+s /y
Construction supervisors Licstiseee a HIC Registration
Es*nded Cost of Projed i—L.a1 Pena Fee G mdfidon
Permit Fee i Ea treated Coat X$71:1000 Residential
Esttrnated Cost X$41151000 Carnrnsrda4 --- ----
An Additional$5.00 is added as an
Administrative dwge.
Make sure that all fields are property and ebb written to avoid delays in procusing.
The undersigned dose hereby apply for a Building Permit to build to the above stated
OOjV�-&UU2zD
spwAcadom signed under penalty off ury
Date
i III
ft
N
$
x
a. —
Eimrors x
PUBLIC PROPERTY
DEPARTMENT
V.MummumDrIs n."
wra. r-o W s-MW*
IMA04 wsuaasr„s o1970
APPLICATION FOR nM REPAIR RENOYAnoN_ CONsTRyc no&
Q&M0LTt'I0N.OR CHANGE OF USE OR OCCUFMCY_ FOR ANY EXLvM G
STRUCTURE OR BUILDING
O an INFORMATION '
Location Name: r #
Property —��_
Property Is located In a;Conservation Arm YIN Hlstorlo D4trld YIN
2.0 OWNERSHIP INFORMATION
.5.1 Owner of Land _
Name: t d- cV\y(IS-CJ KQ1 r l Ur Cl VA
Address: U a a r- '(\-W 5�4- �
Telephone:
3.0 COMPLETQ THIS SECTION FOR WORK IN E]IISIIlti3 BUILDINGS ONLY
Addition Exlsdng
Renovation ✓ Number of Stories Renovated
Change in Use New
ff
Existing of Area per tiaor(sf) Renovated
ovation
New
9def Description of Proposed Work:
-boAk Rc ovvv �o,�_ s ru c u rah R-1 f A)CAIV eS -+7
re n Sa cx' u-)OafO —
(11St��z c� Ciscn " (2- kS) r19 �^� C �a�2 Walls, X1uve�
-- -- ---Mail Permit to; ' v"K0 bmtn,tc+t)1 -c) "7a- Kpail t!3 Jf ,Wo bArn ,�iN +
' ✓�
11 Board of Building Regulations snd Standards
* rvlaor Ucettag:
Constructlon sups
l.lcen6. CS''88913' I
008
81.1511
i - 61t5 008 TF♦i 8897!.: t
. ssSU, P'DEMA
72 MOUNTAIN ST commissioner
WOBURN,MA 0180t' -
y._�—....�.. ✓/ee�-\ Board of�Bu�v
ildimng uRuegul4ati oo8/s a✓n�d a /tondards
a�
HOME IMPROVEMENT CONTRACTOR
Reglstration, 152706
Ezplratitm_:- 20/2008 Tr# 131639
PAMKO CONSTRUC r
TIONO PANY
SUSAN DEMACEp
72 MOUNTAIN S7�? �r� C:; w
WOBURN,MA 01801'`== Administrator
i
it
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,.vim n at 'w.r,ty
\L�l.a ldC w..9,tv::ot.iataT 3u:14]tAvtl4:u.tn.::sr.
Tta:~4&.m F.�97sJ�C.lraK
Construction Debris Disposaf Aftidsvit
(reyuinal fur all demlition and renovation work)
In mardanee with the sixth edition of the State Building Code.730 CUR section It t.S
Debris.wA the provisions of vtGL.a 40.S Sk
gWldifts permit A - . _ is issued with the conditioe that the debris resulting tins
this wait shall be disposed of in a property iicetlsed wags disposal tbcility as dented by MOL c
t 11. S 130A.
The debris will be transported by:
tna,w o,tuulM
fhe&-bds will be disposed of in
(naRl/tui tx,t,ty)
ilk I
J
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wHln:'RIF.Y URtd:aNl
Mtrot 120WAsa_*4TE tSUWaSALEKWASAIUa.IST1N01970
TkL:97$.7e3-9S91 o FAX:9M740O911e6
Workers' Compensation insurance Affidavit: Builders/Contractors/Electrielans/PMmbers
-Applicant information Please Print Legffly
Name tor..imp.•s7slOcyani:ariorvinu�v�gJuop:
Address. ' / 2 tgk(, 1�\�/(y7�1�J I�'�r, n
citylstawzip: IA-Y) Urn �119- O (1D1 Pboe0: 7&I-93�-yy9�'
Are you as employer'Cheek the appropriate box or project"ryw coed <rotildrao:
1.❑ 1 am a employer with 4. ❑ 1 am a general cootrWW and 1 6. O New construction
employcest(full and/or part-tine).• have hired the sub-comractors
am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have on employcoa These stb eonaserors have V. ❑Demolition
working this am: in any capacity. workero'comp, insumnim 9, 0 Budding addition
(no workers'comp, insurance S. ❑ We an a cogxxxtion and is !0.❑Electrical repairs or additions
required.) officers have exerciacti their
3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myselL(No workers'comp. C. 152.¢1(4),and we have no 12.0 Roof repairs
insurance required.) t cmploycaL(No workers'
13.❑Other
comp. insurance tc uirtxL
9 i
•An)+Wh"s eas elaxka boa et meat also as w the Maim trcktw taotriaa tbetr wakwa'cwspesaatioe putiey iaiiamiaioa.
'1lwnwwrsm w1l u bmil"anldo,18 indicating they are doind an work and thas him outside moraaon mwl.uhnll a new awdevil"aline rasa.
=C roan this chsk this boa muss aaaehed m addiUaml,duvet showing ma name stew sol4oatiosom and their wurken'cmV.policy intbonwim,
l am on employer-that Is providing workers'compensation Insurance for!try employees, Below/s this puBcy and fob site
iuforarrrtiow,
11tsurance Company Name: __ _
Nolicy,Y or Self-ins. Lie.0: _... EApiralton Date:
Job Site Address: Citylslawzip:
Attach a copy of the workers'compensation Ptlley declaration page(showing the policy number and expiration date).
Failure to xxure coverage as required under Section 25A of NGL c. 132 can lead to the imposition of criminal penalties of a
r,ne up to S 1,500.00 and/or one-year imprisonment,as well an civil penalties in the form of a STOP WORK ORDER sad s fine
of up to S250.00 a Jay against the violator. Ile advised Mat a copy of this slateawnt may be t'urwarded to the Ot ice of
I n\'�1lhall UllY aI Lhe DIA for witicance covdraye verification.
l do hereby ra ify undler,nthe pains and penalties a r/ury/hw the information providpe�d be is true and correct.
tie•:rtri.r- _ V° ` � Ql Date• 1775 .
U/Jlri�wise ua/y Do eon write br rhkr area,to k completed by c4 or town o,07i ild
City at Town: _. PermitiLlecese
Issuing AWhurity (circle ate):
1. Ifuard of health 2. Rudding 11cparnncnt 3.City/town Clerk 4. Electrical luspcetor 5. Plumbing Inspector
6.Other
Qnllact Person: ___ Phone p•
1
I
Information and Instructions
Massachusetts General Laws chapter 152 requim all employers to provide workers'compensation for theit cmploytsa
pursuant to this statues,an es1111feyeor is defined as"...every person is the service of another under any contract of hue.
eapress or implied,oral or written."
An ertpfoye►is defined as"su milividnal,Partnership.aaocrsteE-corporation or other Icgal entity.of 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,parmarah*anoeiarion or other legal entity.employing employees. However the
owner of a dwelling house having not time then three aparmiems and who resides therein air the occupant of the
dwelling house of amdwr wbo employs Persons to do maintenance.amatruction or repair work on such dwelling house
or on the grounds or building appurtenant thaem shall not because of sutcb employment be deoned to be an employer."
AtGL chapter I32, §25C(6)also states that"every stab or local licensing agency shall withheld the issuance or
renewal of a(lees"or Permit to operate a business or to construct buildings,I.the cetameaweallh for any
applicant who bas met produced acceptable evidence of compliance with the insurance coverage required"
Additionally.MGL chapter 152.;23CM 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 with the insurance
requirements of this chapter have been presented to the contracting authority.-
Applisasa
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary.supply nub-contraetot(s)name(,),addteu(es)and phoHIe numbeKs)along with their canificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employers 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 aMdaviL 'Res affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Iadusmial Accidents. Should you have any questions regarding the low or if you are required to obtain a workers'
compensation policy,plesse call the Department at the number lined below. Self-insured companies should enter their
.elf insurance license number on the appropriate line.
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.
Plcaso be sure to till in the permtit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 that
applicant as proof that a valid affidavit is on file for future permit;or licenses. A now aflidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commerciil venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I'hc Otii:c of Umvesrigations would like to thank you in advance for your cooperation and should you have any questions,
plcase du not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Depacmnent of Industrial Accidents
Oilkt of Iavestilgade"
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
,tevi%ed 5-26-05 www.mau.gov/"
1
DESANCTIS INS Fax:7819335645 Oct 1 2007 12: 14 P. 01
OF ID DATE(MMroorYYYY)
-CORD_ CERTIFICATE OF LIABILITY INSURANCE PANIKO-1 09 30 07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Ctls Insurance AgCy, Inc. HO�AFR.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
DeSan ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
36 C•,ct Pura
Woburn MA 01801 ?
Phone:781-935-8480 Fax:781-933-5645 INSU RSAFFORDINGCOVERAOE NAIC#
INSURED INSUR A: NGM Insurance CO an
i v
INsuIi�R B:
Pamko Conrtruttion :CO., IN c:
72 Mountain Street wsuRER D:
Woburn MA 01 01 INSU e
I
COVERAGES
THE POLICIES Of INSURANCE LISTED BELOW HPVE BEEN ISSUED TO 114E INSURED NAMED ABOVE'..F,,ttO,,RTHE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPE�.1 TO WHICH THIS CER(1FICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREM IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REOUCEO BY PAID CLAIMS.-
POUCY NUMBER DAYS MM/D0 DATE MMIOD/W LIMITS
LTIS TYPE OF INSURANCE EACH OCCURRENCE $1,000 OOO
OE ERAL LIABILITY
% COMMERCIALGENERALLIARILITY
A MPP3612B O5/ 8/07 65/18/08 PREMISES(Ea nomrwm $5D0,000
MED E)Q�(Any one person) $10,000
CLANS MADE a OCCUR
PERSONAL A ADV INJURY $1,000 000
GENERALAGGREGATE $2 000,000
PRODUCTS-COMWOPAGG $2 000,000
GERL AGOREGATE LIMIT APPLIES PER:
PRO-
POLICY JECT LOC
AUTOMOBILE LIABILITY (Ea
SINGLE LIMIT $
(Ea Soodenl)
ANY AUTO
INJALLOWNEDAUT'OS BODILY - $
W persoon))
SCHEDULED AUTOS WD
HIREDAUI'OC (Perwd eM $
(PerewdeAq
NON-OWNEDAUTOS
PROPERTYDAMAGE $
(PVAxlderrH)
AUTO ONLY•EA ACCIDENT S
OTHEGARAGE LNU;ILITY TKAN EAACC S
ANYAUTO AUTO O
AUTO ONLY:
AGG $
EACH OCCURRENCE $
I E ESSIUMBRELLA LIABILITY
AGGREGATE $
OCCUR �CWM$MADE $
$
DEDUCIBLE $
RETENTION
TO RY LIMITS ER
WORKERS COMPENSATION AND EL EACH ACCIDENT $
EMPLOYERS'LIABILITY
MY PRQPEMBEREXCWOE�CUTNE EL DISEASE-EAEMPLOY $
If yes.tlesolbeuMBf EL DISEASE-POLICY LIMB $
SPECIAL PROVISIONS beJpvt
OTHER
pESCMPTON OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY EHDORSEMENT I SPECIAL PROVISIONS
EVIPENCS OF COVERAGE
CANCELLATION
CERTIFICATE HOLDER
SALEM-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE fiXPIRATOH
PATE"MV.OF,THEL4SUINGTNSURERWUMDEAVORTOMAIL 30 DAYSWRITTEN
City of Salem NOTHCETO THE CERTIFICATE NOLDFR NAMED TO THE LEFT,BUT FXLURETO DO SO SHALL
Attn: ITOyOe IMPOSE NO OSUGATON OR L,,SLTTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRE FTTVE&
Salem MA 01970 p REPRE$ENTAnvE
41 ®ACORD CORPORATION 199
ACORD 25(2001106)