3B HALSEY WAY - BUILDING INSPECTION (2) C) The Commonwealth of Massachusetts
Department of Public Safety
\l.w> ichtrw•tl.State dullalmti Code 17SO CMR)Seventh Edition
City of Salem
Buildinx Permit Application for any Buildin other than a I. or 2-Family Dwellin
(rhis Section For Official Use Only)
Iluilding Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block• and Lot I for locations for which a street address is not available) 1
X3 $ NotITeV L1� 50 1CV1 A
No. and Str Clq• /Town Zip Ctide Name of Building(if applicably)
SECTION 2:PROPOSED WORK
If New Constructiun check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration O 1 Addition ❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Arc building plans and/ur construction documents being supplied as part of this permit application? Yes O No
Is an Indrpertdent Structural Engineering Peer Review required? w Yes ❑ No
Brief Description of Proposed Work:
0 A An r fM1QA
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing MR40
No.of Fluors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(.sq. ft.)and Total Height(ft.)
SEC 70N!t USE GROUP(Check as a lleable)
A.- Assembly A-1 ❑ A•2r Cl A-2nc❑ A-3 O A-4❑ A-5❑ B: Business ❑ EEducational
F: Facto F-1 ❑ F2 O H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4Cl
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R•
IS: Storage S•1 ❑ S-2 ❑ U: Utility O Special Use❑and please descri below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA. O IB ❑ IIA ❑ fle ❑ IIIA ❑ file ❑ IV Cl VA ❑ VB ❑
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
\Yater Supply: Flood Zone Information: Sewage Disposal: Trench Permit: DebdD
Public❑ Check it outside Pltsad Lune❑ Indicate municipal ❑ A trench will nut be License
required Cl or trench or I'nraw❑ ur mdunufr Lunn: uron stir system ❑ hermit t.enclosed ❑RailraaJ right•o(-way: Haurda to Air.Vavigation: ( onturt..tonIt\t.I \pphcot'le❑ 1.�Iruclun•withum aopurt appnaach.tree.' I. their rea ivw comlea liuild cncL Heel ❑ NL•s❑ air.No❑ Yes❑ \o
SECTION B:CONTENT OF CERTIFICA rE OF OCCUPANCY
1-,lilnm d ( •aln ____ L�a/:roulat.i, rt re,.,Con,irucw-n: (kcupant l.o.id per l lan-r'
IAa.• Ihrburl.Lnti:annainenSpnnCler?t.h•in': �pa•cialSopulalions:
SECTION 9: PROPERTY OWNER AUTHORIZATION
.Name.md Addressol Properly Owner ^ SAIQ /(/^^A
r: ISC _ W
Name(Print) .No.and Street lily/ rows Zip
Property%h%ner(lmtact ntorm.mon:
.. / �Oyl ten vctnn"11'i�Owilt ` �t.SH� . pits
'X\ Title Telephone Nip. Ibusin ..) Telephone Nip. (cell) a-marl addra�.
If applicable, the property owner hereby authorizes
Name Street Address Ciiv/Town State Lip
to act on the +ru pert%owner'.behalf, m all mailers relative to work authortzed by this building ermit a p lication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is k". than 35,t1W cu.it.of enck.sasl. ace and/ur not under Canaructiun Coninsl then check hen Candlup Scafiun I0.1)
10.1 Relifistered Professlonai Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
A CC IAJk j d (OM/)An V 1. TNC
Cump AKJrck, MYAairked C S 9 S$ 19
Name of Pe . n Resprmsible for Construction License No. and Type d Applicable
19 Rerli Ave OJ 04?
Street Address City/Town State Zipy.
01
- -�599 _- nnrr �/f sklJ r b j ro %t rAr�, nc l
Tele hone No.(business) Telephone No. cell —Te-mail address
SECTION 11:WORKERY COMPENSATION INSURANCiAFFIDAVIT(M.G.L c. 1S2.I 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION lb CONSTRUCIION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) -f
1. Building f Building Permit Fee a Total Construction Cost x_(Insert here
2. Electrical f appropriate municipal factor) f
rg "T
Plumbing f
nical (HVAC) f Note: Minimum fee.f (contact municipality)
nical (Other) f
Erich>w check payable to
ost f (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
ng my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
n is true and accurate to the bbestt of my knowledge and understanding.
rew M `elA(kQ� G�9i//�id 1////�"1 rrr�;dchj` 6P 9nt.Ind .� m nafne �I' rule relephune.\'.+. Dale'
�Q^ll�rc)i fl✓0. _Nt�n�tA]� D
S6rv1 \Jdre.. Crtci Tonyn Sh t Lrp
)umcipal Inspector to fill out this section upon application approval:
\am )ale
CITY OF SALEM
PUBLIC PROPRERTY
DEPART'�IENT
A
�jwH•�F��
',1 11:' ACN\)1I.m.;oN SCNI:I r45,\1I \t, %1.\ii\I I .
Construction Debris Disposal Affidavit
(retluired fior all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it - _ 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 MGL c
l It. S 150A.
The debris will be transported by:
C L13
(name of hauler)
The debris will be disposed of in
-- (name of facility)
(address of facility) //J�p��_���
signature of pefffilit applicant
7 by lio
date —
Irlu i.�rl d.c
;
- CITY OF SALEM
PUBLIC PROPRERTY
`y`• n
DEPARTMENT
hl\II;F KI IN DKISCt n.1.
\..I.,rt m 12C WASHING ION 5 MELT • SALEM,M.\SSACI It SL I s 01970
11:1.:978-745-9595 0 P:sx:978.740-784L
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A inlicant Information �tr Please Print Legibly
Name 11311siucss/OrBanizatiorvindivi(lual): �fC�AJ1('� U �6 M✓/R nq F
Address: 9 aurJ, f AllC
Cily/Stare;%ip: ✓iIP22 r 411 A U1b�I Phone t'.-: l7) 1 q D S9 9
Are you an employer! Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and I ft. ❑ New construction
m alo ces full and/or urn-time).• have hired the sub-contractors
I Y ( F 7. ❑ Remodeling
2 1 am a sole proprietor or partner- listed on the attached sheet.j
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
To workers'core insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.) officers have exercised their
right of exemption per MGL t I.❑ Plumbing repairs or additions
3.❑ I :un a homeowner doing all work S P •
myself. [No workers' comp. c. 152, y 1(4),and we have no 12.❑ Roof repairs
insurance required.) t cmployecs. [No workers' 13.❑ Other
comp. insurance required.]
•AIq:ylplicanl Ihat checks box 01 musl alas lilt out llm action below showing Iheir worlom'eumpensation puliry infornutiun.
I lomeuwnem who ssibmil this affidavit indicating they arc doing all work aml then him outside cuntmetom must submit a new al'rdavit indiubng such.
C'onlnlCpna that check this box must altachcol on additional.twat showing the mane of the sulr oontmctors and their w'urkers'comp.policy infnanation.
i am ati employer titat is providing nvorkers'compensation iosurrtnee fa•sty eutployeea•. Below is the pulfe.y und%ob.cite
information.
Insurance Company Name:---.- _._. ...._..----........----
Policy S or Self-ins. Lic. *: .._. _._..___._ Expiration Date:
Job Site Addrusst Cityistate2ip:
Attach it copy of the workers'compensation policy declaration page(showing the policy nurnber and expiration date).
Failure to sccurc coverage as required under Section 25A uf:`IGL c. 152 can lead to the imposition of criminal penalties of a
fine up at S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. 13c advised that a copy of this statement may be forwarded to the Office of
Invesli�ations ul the DIA for insurance coverage verification.
t do hereby certifyyuuuder the pains and penalties of perjury that the information provided above is rtyte and correct.
Si ,llol ////t /'/'� j Date, 7 /� 9 /Iy
F
al m.ce only. Do oat writeiu this urea, to be completed by city or town of)ic•ial.or'fmsrn: Permit/Liccnse'�.ng Aulhorily (circle one):
ard of llcalth 2. Building Department 3. Cilyoffcocn Clerk 4. Electrical Inspector 5. Plumbing Inspector
hcr -- - -
Costae 1'cnou:. _.__ _. --- 1 hone S:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. -
Purxumit to this statute,an employee is defined as".:.every person in the service of another tinder any contract of hire, "
express or implied, oral or written."
An 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 in the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
IIGL chapter 152, §25C(6) also states that"every 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 wbo has not produced acceptable evidence of compliance with the insurance coverage required.
.additionally, hIGL 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 with 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-contractor(s)name(s), address(es)and phone nurrber(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 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.
['lease be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current
policy information of 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
the Of lice 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 number:
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
TAe Commoflweallh of Aassachusells
Department of Industrial Accidents
-_ Office of Investigations
600 Kashington Street
Boslon, Massachusells 02111
Affidavit of Exemption for Certain Corporate Officers or Directors
Friday, January 20, 2006
_ Pursuant to the provisions of MGL 152,Section 1(4)as the amended by Ch. 169 of the Acts of 2002 your _
affidavit has been reviewed and the Office of Investigations has determined the following:
NOTE: It is your obligation to submit an approved affidavit to your insurance carrier in order to
complete this process.
The affidavit was approved O approved date t/20/2006 Attached please find your approved affidavit
li The affidavit was rejected ❑ rejection date
Your affidavit was rejected for the following reason(s):
❑ The i affidavit was not signed by all Corporate Officers or Directors. We have enclosed another fo
rm please provide
all signatures required and resubmit.
❑ The affidavit is not an original (THIS FORM CAN NOT BE REPRODUCED ONCE IT HAS BEEN SIGNED)
❑ Information provided does not match the Secretary of the Commonwealth Corporate records.
❑ The affidavit you submitted is an obsolete form of the Department. We have enclosed the appropriate form..Please
complete and resubmit - - -
❑ Corporation is not listed with the Secretary of the Commonwealth as a valid Massachusetts corporation.
Other:
Investigation/SWO ID#
McClaskey & Company, Inc. Affidavit ID#
448 Reverre Beach Blvd. 121978 Revere, MA 02151 L 7 v
us99 -;p PAS 0144984444.10
t -
" 02219236 Mp16830905-001 00001
'"r"� BRANCHS4 CONNECTIWT OFF NONE
RENEWgE EFF 12/01/2009
4mlk
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ZURICH
MARYLAND CASUALTY COMPANY
PRECISION PORTFOLIO POLICY - COMMON DECLARATIONS
PRECISION AMERICA
SERVICE PROGRAM
This policy consists of the declarations as well as the coverage forms and endorsements
het listed on the Forms and Endorsements Applicable List
NAMED INSURED AND MAILING ADDRESS 1 . . �
AGENCY NAME AND SERVIC.ING ADDRESS t
MCCLASKEY 8 COMPANY, INC.
448 REVERE BEACH BLVD. EDNARD F. SENNOTT INSURANCE AGENCY , INC.
REVERE NA 02151 PO BOX 457
TOPSFIELD MA 01983-0657
(978) 887-4900
BRANCH NAME AND SERVICING ADDRESS r.
POLICY PERIOD
CONNECTICUT OFFICE
' P.O. BOX 10197 FROM TO
a3 JACKSONVILLE, FL 32247-0197 12/0.1/2009 t2 01 101_A
(800) 800-3907 12.01 am
1201 APA
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BUSINESS ENTITY: CORPORATION
POLICY PREMIUMS
In return for the payment of the premium, and subject to all the terms of this policy,
we agree with you to provide the insurance as stated in this policy.
This policy consists of the following coverage parts. This premium may be subject to
� adjustment
PREMIUM
Y, COMMERCIAL PROPERTY AND GENERAL LIABILITY 4 490.00
TERRORISM PREMIUM
$ 10.00
TOTAL ANNUAL PFU=-MIUM 8 500.00 MINIMUM PREMIUM #,
S
Countersigned by
Authorized Representative to
Includes copyrighted ra-1-6e1 nl Insurance Services Office, Ine., with '
COMMON Copyright, Insurance Services Office, Inc, 199 p.rmia r.
=d 955007 Ed, 09-02 Copyright, Maryland CesoaIt, Company, 195
INSUREDrS COPY �'!�' 10/22/20019
f"D4JCY'NOWwia
+4il
^ D PAS 01449844 02219236 pyf M016830905-001-00001 NONE
W'ANCH S4 CONNECTICUT OFF RENEWAL EFF 12/01/2009
ZURICH
PRECISION PORTFOLIO POLICY
COMMERCIAL GENERAL LIABILITY DECLARATIONS
PRECISION AMERICA
SERVICE PROGRAM
This coverage part consists of this declarations form, the common policy conditions, and
the coverage forms and endorsements indicated as applicable on the forms list
M.
:'[ :FM'Y1FI INNti �i 1 Y
' Some of these coverages are sublimity or are subject to aggregate limits. Refer to your
policy to determine how they apply.
a I .
GENERAL AGGREGATE $2,000,000
PRODUCTS AND COMPLETED OPERATIONS AGGREGATE $2,000,000
EACH OCCURRENCE
41,000,000
TENANTS LEGAL LIABILITY $1,000,000
MEDICAL EXPENSES - EACH PERSON $ 10,000
PERSONAL INJURY AND ADVERTISING INJURY $1,000,000 R
HIRED AND MON-OWNED AUTOMOBILE LIABILITY $1,000,000
ri
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COMMERCIAL COAL LIABILITY
9S2008 Ed. 3-00 INSURED'$ COPY 10J22/2009
!!
,; 3.1.1
Massachusetts Department of Public Safety
Board of Buddm_ Rc_ulations and Standards
Construction Supervisor License
License: CS 95819
ANDREW MCCLASKEY
19 BURDITT AVENUE
HINGHAM, MA 02043
Expiration: 625/2012
('.umnissinn.•r Tr#: 31180
` McClaskey & Company, Inc.
448 Revere Beach Blvd.
Revere, MA 02151
617.290.4599
mcclaskeyco @ comcast.net
Sonja & Dominic Cucinotti
3 B Halsey Way
Salem, MA 01970
July 25, 2010
Contract
Reference: Sliding Door Replacement
Slider
Furnish: 6'0" x 80" sliding glass, pre-hung door with screen, low-e glass: $1,625.00
Labor to remove existing door and install new door. Remove and re-install
existing door, frame and moulding as necessary and in keeping with condo
association aesthetic requirements. 550.00
Materials : Fasteners, shims, moulding as needed. 35.00
Total cost: $2,210.00
Sincerely,
McClaskey & Company, Inc.
Please note: McClaskey & Company, Inc. is not responsible for the repair of existing
plumbing, electrical or structural failures/deficiencies. McClaskey & Co. may repair
such deficiencies on a time and materials basis at the clients's request.
Andrew McClaskey, President
Sonja Cucinotti
. .
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