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10 GLOVER ST - BUILDING INSPECTION
i APPLIMM PE l TO /PiF -4f,es ;n r.Fi cS d- 2t--POiNT�✓c LOGATM /CJ G'Lor/c� PER*NT(3RAWTED • �QVS f L� ffi �� APPROVFD dw,WMOF gPWM WlW#Ntr4ND APPROVED aw Ziff MPMW PM TOA.P�29= ORAWkD CITY OF SALEM .S� 1..J h IYmlo GW tYb YQa NO i tlw of .o &Amin Is Plowtj Loolm In Patmk to: WJLDNQ PEIMET APPLACATM POR¢ (Ckols whlolW*ar apply) Hoof fistoof. Ina1sM SWrO. PwisrW Dook. Shad, PLEASE PLLL OUT L.ElfI KY a ODYPI.EMY TO AVOW DELAYS LM 0 0� TO THE INSPECTOR OF BU LDING&The ' huaby apples for a wmk to bukd awwdhg to Mte► foNorwtp speoNwomm 0WWs Nome RiC t-ar j (rl , b o aP n AdituaPhom I /7 C�1 oOe)y Amhkaat's Name Address a Photr M@dw*s Name♦ Address a Phom Whl b�PuPM�el y� MIN"d � N a e9ar q,lOr law�M IOiMMt w bmem aeon b kw? EOrM100 MM cw UJ e�no UI • sorobfm of Appbft slum UNOM Tm P§ MLTY' DEfCRIpLLON OF WONK TO U D—O�-N of E INK MAIL 8 CITY OF SALEM9 MASSACHUSETTS V 9 PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM, MASSACHUSETTS 01970 STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380 MAYOR FAX: 978-740-9846 HOMEOWNER LICENSE EXEMPTION Please Print Date ,5 Job Location Home Owner Address Home Owner Telephone Present Mailing Address The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official, on a form acceptable to the Building Official, that he/she be responsible for all such work performed under the Building Permit. The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned"homeowner"certifies that he/she understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE zd2j4_& APPROVAL OF BUILDING INSPECTOR t See other side for state code r HOMEOWNERS EXEMPTION erformin work for which a Building Permit is The Code states that: Any Homeowner p S xem t from the provisions of this section(Section 109.1.1 —Licensing red shall be p s a person(s) f hire rem engages q provided that a Homeowner eng g P Supervisors); P of Construction do such work, and that such Homeowner shall act as Supervisor. the Many Homeowners who use this exemptendix Q Rules and Rn are unaware that egulations fey are or Licensing responsibilities of a Supervisor(see Appendix Construction Supervisors, Section 2.15). This lack of awareness often results in serious problems, Particularly when the Homeowner hires licens it weld with a 1 erased persons. in this case your Board cannot proceed against the unlicensedperson Supervisor. The Homeowner acting as supervisor is ultimately responsible. To ensure that the Homeowner is fully aware of that the her responsibilities, omeowner certify that communities require, as a part of the Permit Application, w this issue is a he/she understands the responsibilities of a Supervisor. On the last page form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. P yoo S R6Y GI3o� CITY OF SAL.sM, MASSACHUSMTs PuauCPROPI rDaPAM9NT l aD vAk Ni - n atma"' aaa►wow tiAI M MA61670 TaL(M)74a-Un UT.sw Rat ls701 7401MO STAWAT A L%W*IC; AL MAC Duposa or Dmu AFFIaa t b►amoidmsa dr piovtsiaas atTdti.a S!1►I alommtsdp dues a oomMm atai{dq�r .a•dslda�t Itos sa aoesOmsdaa aelbrlg► prm+by db SwIft Pamir&A ba dbpow dbe a popa ly somsa/=1164 rash dli Wd fir.r dvftWbrMM a M%SlJWL Theddd@wMbadgmWa[at NDi'T �►S�dz C �r� �°J swu PsrASgl-e" ,mg Laeadot a[Fsdligr a Doss . FULLY emipide dr h&**s mh msdm dP UM PRM CLEARED PI C r4 —T�T, � ycleau > Name of Ann d FLs Namsr itaglr AddrUk C'Iry as MW lb show su4 requires did dAm Dios 66 damobdM rmwado%rehab or odic WUndom olbul ft a mace n ba d quM S a peopaly6Iiee WW aoli&Wum diapow fwh ag dai M by MM dit S15ft and dW bandies pamib a B...an os mdko ft badoe of dW ho ft. � r � � ' - � . 1 l' t- tieparr�aeau M iasatsrrtat edactaenw Ufa of Invesdemdom 600 Wasumston Street Bostbm6 MA 02111 tewtttataslc0+ot✓/Ia Workers'Compensadon Inmranote Aiiidavk: BWMali Contractors/EledridanaMumben AmUcaet Ighmadom rMn Kitt I.aMQW Nadu • EAR-IN ConSir%/Cllo) .j CvvTiS 'DRA5oty Address ` 1 3 g oTTT Sr city 1 SMI--e'er VK4 of47o-lla2 Phan* q?iss- 7U�- t47S An oa= CbWk tbrappteprlate bees 1. I sea a �— 4. 13 1 am a 0eaessil aootracttr ad 1 6 Type N� eagbym(62 mitt PING OW bove Mod the e m 2.Q I am a sole ymy iem, or pasmm- *W an tee aoached sheet t 7. ❑ Rawddi" ship andhave no cupbym 'use mob-convocom have E. ❑ Demogdm woddg fbr ma i•szW apacigr S Q Wei omgL ieao� 9. ❑I�tihlr"adddim Db wookeo � aory , "ma Mile • l0 Q Eleetrirat tusks or additioaa oflioea have esWdS d their 3.Q I e meowner doiet all wo* �of� m�D 11.Q Phm bioi sepses or add&m myz eK 1*rookess'comp e. 13%11(41 sed we have no 12.Q Roofrepaks iasotnowIMod IId.) �(Pb[PIn ' 13. ffomR R-tPI4Q 540.SI rHamowmnv& nbmka rtma�..n ftym daft wo*mddm Mmoo" =mtsubmakamm.mdrbftadns= a &Conmwo s fbr art abbm met tortod m add d=W mbw Abe a,a offt.sr.e.ws.a**svem r omp ponor idbrnn*a on I ass ANssspAgw dim b proms MwAsrs'esaspsasaNm fasanssm fw xV a xpfi m Bdvw b As peft and joAsfat hmm=mCmWWNamm E4fM F4, t Iy f ftft a or SeWiss.Lie* 0 o S ©� 9 Exabodoa Deem ! I l 4 / o lob site Aaasaa I A C lo"C r S f— City/Smt: S 1+1 le,M/ `Ntq. 019X3 Attach a copy of W workers'composatloe polley deeluidem pap(shawl"the ponq mmuber and upbudon date)6 Pasilme m soma corn e s requh soda Sesdoa 23A of m e. 132 can lead to tee haposi a ofcsimioal penalties of s Hoe op m SI SW.00 md/ef 01pyew mipnsoamed,a well AS chnl pewhiet is the fbsm of a STOP WORK ORDER and a due of up io$00.00 a day apinst tee violmor. Be advised the a copy of ibb smomem may be fotwmdad m the ofilm of btnestipaaas ofthe DIA Im immmoe oovasp vaiHadoa I As AarripCPO aadtr Act paw adpam6ts ofpvjwy AW die laJtrwadsa paw&bow b pat and awreca Peane�: R7S- ��u- 1u 7� Olkid Mat m6t Do ad*v*As IAb arse,to be eewpldtl fy sfd or mm s,Q W Clay or Towns Persomewe 0 lsnd"Am6orky(drde ona)s 1.Board d aeaM 1.BuMal Department 3.Cityfrowa Clark A pbdrk Impeetor I tlombl"Inspector 6.otber Coded Persom Phone th Geoaal yaws chapter 152 mquva an aoployaa to pov*wpkas'aampansamo of unu �..�....,.- pmsua s to":ionise. m enpfsyst is dct3sed a".••evay pm=m its novice of anoda under MY conna of bits; CXPM or aVhed'pal or writtea- Ai mqpbyW a dellmd as"as bdividaal,pwwcnbip,anciado%eorporA&M df otba kpi entity.or aq two or more of the apt is:jot t adapia4 sad bcldui tbs kptd repaaltdva of a deceased m4bYc&err the recdver or tropes of as bW&i i,pxmft a odadoa ar other kpl amity,empbft cmp*m However ft owtta of a dwelliopbouse haviep Wt mm sift tatee spstmeals aed who raids eack6 ar der ootstpst of the dwcMr4 bonne of ssoder who MVIOYe pintos:to do mmse auM Weasdm or xp*work as sod dwelling house as do ira'un�or bmildmp appertesast Aaaa don ass beanie of ad aepbymMbe deemed to be s aaployer. or ' . MGL cbxpIW 15%J25QQ ales states that"every stage er Idled tleessP apd04 dsW wltbbw the lsasaaes or renewal of a mama or Perak a operate a hadaas er su tsntrnd bo@dbp is the comma swank for sap ypreast who bar aeee nt prodnee/ vb"evldeaee sf coaiBsaot wYh the!winos ewer IV requlfet" MM d VW ISL 12M a Addidoaany. m"Neitba the commoaweald mr any dill pal"subdivisions doll cow into say o.Md tlx the p W jb mssca ofpblio wont nosh aoaplbl evideae of ampsom widk the inpkmmu asaraaoe of this ebapsar bavebem PoWd 114 tb cmncded as&oW AffAppreaW e tau act the wo>iters'eompaamsdou affidavit aomples*,by ch eddp sac bore that apply o Yasr shmutIoa ors,it neeas y.supply )nam(sl addrea(m)and phone mmha(f)au*wilt tick eadficom(a)of bu ram Umbel LisbMW COMPal"(lam of Limited LidAW pnmastipa aly)wilt no employees other tins the membeta err parmas. are>nt tetptued 1D cony O0 iomtttloe If su LLC or LLP dos!sere cmpbyea,s po&T is regafied. Be advised that this affidavit mty be sibmiaed to the DgMIMmt of bdeilrld Aocidead fog easdrmsdas of iMYmr M cvvaape. Ala be wrs is dp aM date the aAldavlR IMuffidIVUSIMM be umnadlo&ecilYccwwzdmt*eappgcadnfxdwpamkw%mmbbftfcquMAsdftDqwummof Industrial Aaidcm% Should you bve g�reprdisp the law a i[yon Oro regpeed to abtda a wortOs' oompcmadonpeyay,plea+e an the DMOUNat A tha nimbus NOW bbrw. Solt-o ved eompaim donid Omer deli seK imueoe_noemn::saber an tat:sppopiale lino ay er Town 0fadats Pkac be sure dot sae affidav8 b aompkta sad printed koly. Tao Depatmeot be;provided a tonne at the bottom of the affidavk for you b iffi out is do evaa sae Office of Imratiptiom ba to coumct You reptdiop the MOSCUL pkae be sue uo ffi in the pamaWaeme mzha wbkh will be used a a refacwt mU*W. ID addidoa,Be applicant that mnt submu maltWlc Pamir*="sppksu m m any pivm ycw,need only submit one afdavit iodicatiup current policy mfpmaooa(if neeamy)ad under"job sine Address-tie appNeas sbonid writs"an loadom is (sty or town}-A copy ofSW affidavit tact hn ben offieiW stamped of maned by the ay or Iowa may be provided to the applieaet a goof that s valid dfidtvit it oa>)l et those pamis err bceswa A new affidavit moat be t311ed out ad ycw wbae a bome owner qf ddsaa b obsisdop a)lama or permit nm reltad to say bu bm ar cowmen w veamre (is .s dog Namur pa ak a boa Ima ere.)raid paws is NOT r gabid to affidsvvit Tie Office of lavcs ipdona would bike to d mk you is adva+a for your coopaadn ad shone you have any quaoons, pkae do not bcdM to pive as s Cut The Dcpaanmt's address,tekpbm and 69 number The Commonwe"of Massaehusoas Dgwmmed of Industrial Amideab Oflloa dIavesdpdtm 600 wsshiagian Stm d BostaB.MA 02111 TeL #617-7274900 ext 406 of 1-MMASSAFE Fax#617-727-7749 Revised 5-26-t)6 wrwar.mass.gov/dia Farm DECLARATIONS PAGE 1 CONTRACTORS ADVANTAGE SPECIAL Family Casualty Insurance Company POLICY NO. 2005XO639 e Glen=New York NAME OF INSURED AND MAILING ADDRESS: AGENT NO. 2591 OFFICE NO. 2591 CURTIS DRAGON UGONE-JOHNSON AGENCY DBA EARTH LANDSCAPE FARM FAMILY INSURANCE 6 ABBOTT ST 10 S MAIN ST STE 208 SALEM MA 01970-1102 TOPSFIELD MA 01983-1834 978-887-8304 REVISED RENEWAL TRANSACTION EFFECTIVE 04/14/05 POLICY PERIOD FROM 04/14/05 TO 04/14/06 12:01 A.M. STANDARD TIME AT THE LOCATION OF THE DESCRIBED PREMISES THE NAMED INSURED IS: INDIVIDUAL BUSINESS OF THE NAMED INSURED: LANDSCAPE GARDENING (INCL. XCU) t LOCATION OF DESCRIBED 6 ABBOTT ST PROTECTION CLASS IS: 03 PREMISES NO. 01: SALEM MA 01970 CONSTRUCTION IS: FRAME PREMISES 01 BLDG 01 BUILDING MATERIALS / EQUIPMENT STORAGE BUSINESS PROPERTY COVERAGE: LIMITS OF TERM ADDL/RTN INSURANCE PREMIUMS PREMIUMS BUILDING 0 0 0 BUSINESS PERSONAL PROPERTY 6,250 54 0 BUSINESS INCOME AND EXTRA ACTUAL LOSS SUSTAINED NOT EXPENSE EXCEEDING 12 MONTHS INCLUDED INCLUDED BUSINESS LIABILITY COVERAGE: BUSINESS LIABILITY - PREMIUM IS SUBJECT TO AUDIT BODILY INJURY/PROPERTY DAMAGE 300,000 PER OCCURRENCE 600,000 AGGREGATE 300,000 AGGREGATE FOR PRODUCTS - COMPLETED OPERATIONS HAZARD MEDICAL EXPENSE 5,000 PER PERSON FIRE LEGAL LIABILITY 50,000 PER OCCURRENCE CODE DESCRIPTION PAYROLL TERM PREM ADDL/RTN 97047AA LANDSCAPE GARDENING (INCL. XCU) 39,800 641 219 91340AA CARPENTRY-RESIDENTIAL PROPERTY 0 0 218CR THE LIMIT OF INSURANCE FOR THIS BUILDING SHALL BE AUTOMATICALLY INCREASED BY 02 ON AN ANNUAL BASIS DURING THE POLICY PERIOD. -ACTUAL CASH VALUE (ACV) - BUILDING OPTION DOES NOT APPLY. DEDUCTIBLE: $500 DEDUCTIBLE APPLIES EXCEPT WHERE NOTED IN THE POLICY OR ENDORSEMENTS. COUNTERSIGNED BY: BF 30 05 01 98 INSURED COPY PROCESSED DATE: 06/09/05 E P Farm DECLARATIONS ' PAGE 2 CONTRACTORS ADVANTAGE SPECIAL Family Casualty Insurance Company POLICY NO. 2005XO639 1ps. Glenmont,New York OPTIONAL COVERAGES_: LIMITS OF TERM ADDL/RTN INSURANCE PREMIUMS PREMIUMS PESTICIDE/HERBICIDE - BF 30 09 01/98 100 TOTAL ADVANCE PREMIUM 795 1 OTHER FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY WHEN ISSUED: BP0002 01/87 BF 30 06 01/98 BP0006 01/87 BP0009 01/87 BP 10 04 04/98 FI 99 02 02/03 BP0419 06/89 BPO108 06/89 THIS DECLARATION PAGE WITH THE POLICY, FORMS AND ENDORSEMENTS COMPLETES THE POLICY. BF 30 05 01 98 . INSURED COPY PROCESSED DATE: 06/09/05 r �, �I