10 GIFFORD CT - BUILDING INSPECTION (3) Salem Historical Commission
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970
(978)745-9595 EXT.311 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntim
Address of Property:
Name of Record Owner: Maureen Jacahyjajnkj Tnni Fournier Omit2)
Description of Work Proposed:
Construction of secondary egress in rear per drawing dated 6121106. Non-applicable due to being essentially
non-visible from the public way.
This certificate replaces the Certificate of Hardship dated 3116106(which was rescinded by the Commission on
6121106 at the request of the owners).
Dated: June 29. 2006 SALEM HISTORICAL COMMISSION r /
The homeowner has the option not to commence the work(unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings(or any other necessary permits or approvals)prior to commencing work.
8.0 PROFESSIONAL CONSTRUCTION SERVICES-,",
8.1 General.Cantractor Su ( LC�
Address: 0 1( ' (�
9"IJ
Telephone: — _ Fax: g— D—(0`D -
Responsible in Charge of Constructio n�)c�l
7.0 CONSTRUCTION DOCUMENTS -to be prepared by applicant
Item „ 4 as Applicable
7.1 Plans (Note 1 this page) Submitted Incomplete Not Required
7.1.1 Architectural
7.1.2 Foundation
7.1.3 Structural
7.1.4 Fire Suppression
7.1.5 Fire Alarm
7.1.6 HVAC
7.1.7 Electrical
7.2 Specifications
7.3 Structural Peer Review
7.4 Structural Tests & Inspections
Program
7.5 Fire Protection Narrative Report
7.8 Existing Building Survey
7.7 Workers Compensation Insurance
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note 1 Areas of Design or Construction for which Plans are not complete at the time of
this application must be identified herein. Work so identified must not be commenced unfit this
application has been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
8.0 COMPLETE THIS SECTION FOR NF. "CONSTRUCTIO[ ryONLY
For`Eids Buildings proceedao S"ftn 9.0
Number of Storiess-above `N umber of Stories Below
Grade Grade
Story Height FlogArea Per Floor
Total Building Height Totaj!_Buitding Area Above
above Grade w
GCatle
Total Building depth below, - 1 Total Building Ares Below'
Grade' .. . ::
Brief Description of Proposed Work
8.2 USE GROUP AND CONSTRUCTION Cum,F1GATIQN(Now Construdlon Only)
USF,O,RQU °'r j ' USE l3ROU $ t GORY CON8TItUCTiON
td as appilbt ) __ ( { t �1 CLASSIFICATION
B Business
E Educational 2A
F Factory F-1 0-2 2B
H Higi Hazard H-1 H-2 H-3 H-4 2C
K
I Institutional 1-1 1-2 1-3 3A
M Mercantile'} 38
R Residential R-1 R-2 R-3 4
S Storage S-1 S-2 5A
U Utility 5B
Mx Mixed Use Specify:
Sp Special Use Specify.
t,
9.0 CONSTRUCTION COSTS(See?80 CMR Appendix L)
Total Construction Cost suading Permit Fee Check Number
(1) =(1) x $0.001 ^
11 1")00 W V V'�/T,
F
UTHORIZATION OF STATE AGEN CCY FOR AGENT TO APPLY FOR BUILDING
IT (when applkable)
on behalf'of the au#mwb irg State
gency or Authority. hereby authorize. aDPly
for the building pem dt for project number,
Signature Date
1 SIGNATURE APPLICANT
10 S NATURE OF BUILDING PERMR
i Kq 00d
Name
73 Ib
Signature Date
12. Certificate of Occupancy required on completion of project? Yes No
Inspectors Notes:
C
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:r F
77
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CITY of SALEM
PUBLIC PROPRERTY
DEPARTMENT
r.u:ral of•'Aita9►
?ttt�a h1:7.�IN::JMsALR•�l@14>t��Y1t'.M elt tls�:4
'11Y:yp�7�s+tst!�f.�tt:97iJ�6lW
Construedos Debris Dhpossf Af idsvit
(required for all danotition and renovation work)
In mmdaneo with the shok edition of the Sate awmins Cody.7SO CblB section 111.S
oebris,sad the provisions of MGL a 406 S 54
Build%Pon A _ is issued wish the reargues that the debris rtaaltins!tots
this wort shall be disposed of is a property licensed wsste disposal &duty as donna by WL e
111.315"
The debris will be transported by:
more at hawdo
rho debris will be disposed of in :
'Ka �
(name ut faciAty)
� n�e�
49 ut taco t
In Z3
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
AArm'nrr.Y Dar OLL,
MAYOR 12c WAswt,�4:Totesnizr a SA
'rta_9711445.9593 a F.ax:97t•740Q9946
Workers' Compensation Insurance Afdavit: Builders/Contractors/Electricions(Plumbers
Appilgant Information PrintPlease Letibhf
Name IBuai MN )r1miratiavlmLvichnn: its
Addreas: O e A , it
City/StatwZip: 1`r� .t 4-b (�
tJ. m: _2 0 — Ce 33 — 43�3 0
Are you an empleyar'Cheek the appropriate boa:
1.0 1 am a employer with 4. ❑ 1 am a gencral contractor told[ F6. 0
f w consject(r coon d).employees(full antYor part-tine).• have hired the sub-contractorsA'ew coruaruction2.0 1 am a sok proprietor or partner- listed oo the attached sheer. = Remodelingship and have no employes Then stlb conaaewrs haw Demolitionworking for me in any capaci[y. workers'comp insuralceno workers'comp. insurance S• 0 We are a corporation and its Building addition
required] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption par MGL 11.0 Plumbing repairs or additions
myself.(no workers'comp, c. 132.§1(4).and we have no 12.0 Roof repairs
insurance required.]t :mploycm[No workers' 13.❑Other
comp. insursux r :required.]
•A�4 VpacwM tho duxks boa el mom alao all"dw arch"6cWw AMiva lbjk vwtaa'cump.n+ackm Puliry io6unasiaa
II
umwtwnsn who submil Mier attldavu indiouina Moy am dafna co wank mad MOa him Outside eamm"M am"a broil a tray&amdavil indiatrina ata►.
:Cantrxaos Ihm sksk MY box mur anaehad an addilimcl she[Acwity the nano Gray sad Ihm warren'coop.poiky Mfbmark a
I Gm um employer that 6 providing workers'companradon lossuranee jar my amploywm Below/it the policy and Job girl
NEW
IJJlYrmati/In. Ir[
Insurance Company Name: �AkA M 7W�C,7V( v ,
Policy!{o Self-ins.
Lic.#:l�IW�L60 11919/�J01_�-lJP_ D_ EApiralton Date: L ( � yy�Z0
Job Site Addresx:�V 07ITI[it t21 LJ('JU��- CityiStatVzip:Ga&r t J &_
Attach a copy of the workers'compensation Polley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A uf.MGL c. 152 can lead to the imposition of criminal penalties ofa
tine up to S1.500.00 and/or one-year imprisonment,.0 well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to S250.00 a day.tgainst the violator. Ile advi.wd that a eopy urthis slatcawnt may be furwarded to the Office of
Im.�ngmnmis ul'thc DIA for insurar• t vcragc vcrl tc
/Jo hereby certify a fury at the iajarmat/on provided obey&la true and correct
tii•vuurt' -- I)X
U/J/ciN/Yrton/)t As Not write/a fA/r area,to be completedby city of town of&.0
City or 'rown: PcrmiNl.lecnss M
Issuing Authurity (circle one): --
1. Iluurd urucaith 2. Building Department 3. City/romn Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: _ Phone N:
Information and Instructions
tion for their employees.
Atassachu atts General Laws chapter 152 requires all employers to Provide
rson in the service another under any contact of hi
Pursuant to this statute.an ewpfoyee is defined as'...every Pc
eapress or implied.Oral or written.
an eae/ ayes is defined as"ns M*Vm usl.pstesersbip.associaMm'cotporatwo at other legal cnaty.or any two or more
Of the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased employer.or the
�asoeiatioa or other legal entity,employing employees However the
receiver er t welts of o individual,having Dormers d and wbo resides dmein.ar tit oocupan of dw
owner of a use o a bouss who
having mat mace tins thin re"H teats or re work on such dwelling house
dwelling houss of another wfto employs persons to do maintentnce,cywwttction Pint
thereto shell nag because of such employment be deemed to be an employer."
or on the grounds a building appurtenant ,
MGL chapter 152,ii25C(6)also atatet that"wary state or toes)licensing MURRAY shag withheld rite Issuance or
rate a business or to construct buildings ld tint coomonweakh for any
renewal of i Iteene or permit to operate with the insurance coverage required.'
applicant ly, has net ter 15.Produced
accept"widow of onution of itt Political subdivisions shall
Additionally,MGL chapter 152,;2SC(7)ants"Neither the coauwwealeb not say
enter into any contract for due performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
out the workers' compatsacon affidavit completely.by checking the boxes that apply to your situadoo And.'(
Please fill o
necessary. set sult.c°nwocrar(s)na nc(s),adriesa(es)and phOOe numbers)along with their certificate(s)of
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employers other than the
members red to carry workers'competition Insurance. If an LLC or LLP does have
employe or policy i ors net rerpti ent of Industrial
employees.a policy is required. Be advised that this Affidavit may be submitted to the Departm
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Ilia affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Deparmtent of
Industrial Acj;ideats. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,Please call tie Department at the number bated below. Self-insured companies should enter their
self-insurance license number on the appmpdste line.
City or Town Offlclsa
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 evem,the Office of Investigations has to contact you regarding the applicant.
1-1ease be sure to till in the q rmiuliccnse number which will be used as a reference number. In addition,as applicant
that must submit multiple permitlliceast 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 ldxarlona is (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 ew.)said person is NOT required to complete this affidavit.
he Otiix of Lnvestigations would like to thank you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Depaftment of lndustrial Accidents
Odtes of lavesdpda"
600 Washington Stfteet
Bostm%MA 02111
Tel. N 617-7274900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
Rcvi.cd 5-26-05 www.ams.gov/dia
10/23/2007 12:25 7815937260 DUFFY INSURANCE AGCY PAGE 01
DATE(MMIDOIrfm
CERTIFICATE OF LIABILITY INSURANCE IO/23/2007
imouCER 791)S93-1200 FAX (781)593-7260 THIS CERTIFICATE IS ISSUED AB A MATTER OF INFORMATION
Duffy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
317 Vroa"v ALTER THE COWRArw AFFORDEDBY T E POLICIES BELOW.
Nyoma Squire
Lynn, MA 904-2602 INSURERS AFFORDING COVERAGE NAIC#
wouRn sg a n Tng III ntraccTng IVtces LLC INSURERIC AIN Mutual Insurance ioTlpany 0062
P D lox 1111 INSURER B:
Marblehead. MA 0194S INSURER C: -
INSURER D:
INSURER e:
THE POIICIEOP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NgMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
qNY REgUIR ENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIRI RESPECT TO W THIS CERTIFICATE MAY BE ISSUED
MI1Y PERTAIHI THg IHSURANC6 AFFORDED eV TH6 POLIC166 DESCRIBfiO HEREIN IS SUBJECT TO AI 1 THE TERMS.
SUCH
EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AODREGATfi LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAIMS.__._ _
n'P6OF INSURAMDE POLN)T MUYBEII E Cr QPIRA UNITS
OSMS LUVALRT Cr-
a TO-RENTED
f
CbNMeRCIAI OENEPAL LIABILITY DAMAGE f
CUTIM6 MADE a OCCUR MED E%P fAAY anP PPnan) f
PERSONAL 6 AOV INJURY A
GENERAL AGGREGATE f
BENT. ORCOATC LMTA IN PER: PRODUCTS-COWIOP AGO f
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ALLOWWrOAUT09 BODILYINJURY f
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S�YSDULEP AUTOS -
M RED AUTOS BODILY INJURY f
J N-OMEOAUTOS (Per AcuawD
PROPERTY DAMAGE f
(Par P ftnU
CMA GLIABILITY- AUTO ONLY-EA ACCIDENT f
ANY AUTO OTHERTHAN EA ACC 6
AUTO ONLY: AGO 6
QDEABIYMBRPLIA LIAPWTY EACH 0CC,JRGFWF f
OCCURCLANS MADE AGGREGATE f
f
JeDUCTIBLE If
,ETOMON f _... . .. f
VWCSOI1916012007 06/01/2007 06 01/2008 X CSTATUTA
-
JUPLOYERtLABSUTY FACHACC10ENT 6 100,000
A ANY EXCLU Y_ ELECUTNE E.L.DISEASE-EA EMPLOYE 6 10D DO
Y aYswall,••INm EL DISEASE-POLICY LRR, 15 500,0
SPECIAL P VISION Wiw
OTHER
}.
[DUCRIPTION OF OPERATIONS 1 LJICATTONSI VEHICLES I E%OLUSIDNB ADDED BY EMOORSENENT ISPECIALPROVMRINS
E " 1It QEJRO
SHOULD ANY OW THE ABOVE DEBCRmED POLICIES BE CAHCELLEO BEFORE THE
EXPIRATION RATE T REOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL
1 DAre E TO THE CBRTW=TE HOLDER NAMED TO THE LER.
Cl t of Sal em BUT FARURE H NOTICE ALL KPOGE NO OBLIGATION OR LIABILITY
Bui: ding Department OP NI X61N R OR REPRQENTATiVEB,
Salim, MA UTNO NTA
ACORD 25( W108) FAX: (978)740-6537 I B)ACORD CORPORATION 1968
'- Bm"°B XRmls n and 3v ba
HOME OAPROVEMEM CONTRACTOR
Re9'straH06:. 134220
E�Wiralloo ;-1��07
OSGOOD PAINTING SERVICES'.;
PATRICK OSGOOD - -
56 BRACKETT PL
MARBLEHEAD,MA 01945:'.':•= ��-..
Adm'aiatrator--
9� &m~4
Board of Building eqqulations
One Ashburton. Place,-I�m 1301
Boston, Ma.02108-1618
License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 05l28l1973
Number: CS 091643 Expires:05/28/2009 Restricted To: 00
PATRICK M OSGOOD
PO BOX 1111
MARBLEHEAD, MA 01945
Tr. no: 91643
Keep top for receipt and change of address notification.
',CAI G 60M-04104 Gio1216
l
i CITY OF SM ENI, NA LASSACHUSETTS
• BUUMLNG DEPARTMENT
120 WASHINGTON STREET,31O FLOOR
TEL (978)745-9595
PAX(978) 740-9946
KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIF.M
DIRECTOR OF PUBLIC PROPERTY/BuumtNG CO`L6RSSIONER
APPLICATMI#FOR THE CONSTRUCTtCK REPAgf;REWVA' ICON.CHANGE IN USE OR
OCCUPANCY.OR DEMOLITION OF ANY BUILDING OR STRUCTURE
This Section for 010d 1 Use Only
64i1ding;Inapeotor:, !� �� fir-J , , 3I8� ='
Esf6nalbsProJecl calms: Start / l
Conwnents:
t.0�urE INFORMATION
' Location Name. BWIYlrV.
Rep"Address: I O (- d CtxD�-
Assessors Map Sk)dc LoWarcet '2& — OS(o I —80 1 f- .S�O 2
ORMATION
2.1 Owner o1 Land
Name: ID i for t 1 v S
Address: 10 (mot jrGr CCL)-f-1-
45;a 2.Yh O (R -) U
Telephone: G I O-1 L44 — s8
2.2 Owner or lessee of buUding of sauetan
Name: _ I
Address.
Telephone:
3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name:
Address:
Agency Project Number.
Project Manager Name: �� TeL