0007 HARDY STREET - BPA-07-222 PUBLIC PROPERTY
DEPARTMENT
KISRIFRLFY DR1SCOLL
MAYOR i20 WASHINGTON STRFEY♦SALEK NAZACHLSLI-M 01970
TVL-978-745-9595♦ FAx 97s.740-gm
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1 A SITE INFORMATION a V
Location Name: Building:
Property Address: ) 'E}A P 0.1 S;- —..-
S -or,Lt--�
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: -
Address:
Telephone: q _ 'b 5 IT-7
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation f Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to:
What is the current use of the B�uilding?/ 1 `�' q
Material of Building?31ti+ ( u(wW If dwelling, how many units?�L�
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost f Project$ a0 Permit Fee Calculation
Permit Fee$ �� Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date _CO -" c
N
O 7
r1
a
I. .� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOtL
MAYOR 120 WASHINGTON STREET a SALEM,MASSACHUSETTS 01970
TEL:978-745-9595 a FAx:978-740.9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (� Please Print Leeibly
Name (Business/Organuation/Individual): nFL e p�c- IQea P!2v*
Address: $ tC lit r a tt t, 1-f
City/State/Zip: Phone #: rf)b - S 3 S" — y 4 y &
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling
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 corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.[1 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information
t Homeownets who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contracton that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �+
Insurance Company Name: C0 L(L C V tC"-'J _VLA s „e -.-:j
Policy#or Self-ins. Lic.#:_ .0 3 06 1 d(spCt Expiration Date:
Job Site Address: ' 'b E— City/State/Zip: Qs rYi-C&-1
Attach a copy of the workers'compensation policy declaration page(showing 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$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 certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date 5�'l (e o (A
Phone#:_
Official use only. Do not write in this area, to be completed by city or town oy1cial
City or Town
Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under 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 on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL 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 who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL 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 contacting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es) and phone number(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.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled 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 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 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
CITY OF SALEM
r; PUBLIC PROPERTY
DEPARTMENT
KINGIESIEV Ue13COU S'nx 0 SALEM.v •c tuLyiTIS01970
NtAYOa 120 WAaaNGrON
may-978-74S-9S9S a FAX.973-7J0-984
Construction Debris Dlsposal Affidavit
(required for all demolition and rmwvarion work)
In accordance
with the sixth edition of the State Building Code.780 CM1t section 111.5
Debris.and the provisions of MGL c 40.S 54;
is issued with the condition that the debris resulting from
Building Permit N disposed of in a propady licensed waste disposal facility as defined by MGL c
this work shall be
s 150A.
The debris will be transported by:
.P
(same oQheuler)
The debris will be disposed of in
-- (name of fxiliry)
.� «.
(�dcass of Paeitiry)
i ,
/
mut applKaat
sisaawre o f Pe
date
ACO-MV. QERTIFICATE OF LIAWL- i Y INOUKIA UM 05 29/2006
vRo°UceR (G03) 883-5528 THIS CERTIFICATE IS ISSUED,AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE -CERTIFICATE
�0J,2RIVEASI pNSVRANC$-..AGENCY,,. INC.; `HOLDER- 'THI&CERTIFICATE^DOES 'NOT;'AMEN D,' EXTEND OR _
ALTER THE COVERAGE AFFORDED BY THE.POLICIES-
BELOW. .
11_6 MAIN ST
P O BOX 369 NAIL.#. .
NASADA - NH 03061-0369 INSURERS AFFORDING COVERAGE
INSURER A:NAUTILUS
INSURED
LONDONDERRYr MANCHESTER CONST SERV CORP - INsuRERB:AIG
DBA: OLYI+IPIC INSURER c:PROGRESSIVE
INSURER D:
15 TANGUikY AVE
NASHUA NH 03063— INSURER E:
COVERAGES;
THE POLIGE!i OF INSURANCE LJSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, POLICY EFFECTIVE PDUCY EXPIRATION
NSR IGEIMAQGRE�7,IJ
POLICY NUMBER DATE MNYODPYV DATE MIWOONY LIMITS
TYPE OF INSURANCE 4,000,000
AIERALUA13ILT' EACH OCCURRENCE $
DAMAGE TO RENTED 100,000
COMMERCIAL GENERAL LIABILITY PREMISES Es omirmnc9
OCCUR NC502722 12/09/2005 12/09/2006 MED EXP An one crson $
5,000
CLAIMS MADE 4,000,000
PERSONAL B ADV INJVRY S
GENERAI.AGGREGATE S 4,000,000
MB APPLIES PEft� PRODUCTS-COMP/OP AGO S 4,000,000
POLICY �i LOC
A X AU•-OMOBILELIASILITY 35190760 05/11/2006 05/11/2007 COMBINED SINGLE LIMIT S 1,000,000
(Es oWden0
ANYAUTO
ALL OWNED AUTOS / / / / 1perpe on) 1
(Pcr person! -
X SCHEDULED AUTOS
X HIRED AUTOS / / / / BODILY INJURY S
(PereCGdMl)
X NON-OWNED AUTOS
PROPERTY DAMAGE y
(Per acddenO
GA TAGE LIABILITY AUTO OILY.EA ACCIDENT S
ANYAUTO / / / / OTHPRTHAN EA ACC S
AUTO ONLY: AGO s
E%GESWUMBRELLAL.NBILITY / / / / EACH OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE S
q
DEDUCTIBLE / / / / $
RETENTION s 4
B WORKER4 COMPENSATION AND NC2791321 09/25/2005 09/25/2006 X
EMPLOYERS LWBILT' 100,000
ANY PROITD TORIPARTNEP/EXECUTNE E.L.EACH ACCIDENT S
OFFICEMdENBER EXCLUDED? - WAS / / / / E.L.DISEASE EA EMPLOYE E 100,000
If yes,ci Aidhe under 500,000
SPECIAL F TSOVISIONS Delm EL Ors EASE POLICY LIMIT S
A DIRER ];NLAND 1- RSNS IMB 1139E3 01/13/2006 01/13/2007
190,000
)ESCRIPTRON OF OPERATIONSn OCATIONSNEHICLES/EXCLUBIONS ADDED BY ENOORSEMENT/SPECIAL PROVISIONS
:ERTIFICATE HOLDER CANCELLATION
( ) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 - DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT
FAILURE TO 00 BO SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER,ITS AGENTS OR REPRL'SENTATIV S,
AU ZED REPRESE TI
d .
CORD 25(i001100) - - - - 6 ACORD CORPORATION 1981
�n:INS025(010Bpii _ ELECTRONIC LASER FORMS,INC..(800)S. A5e5 PPBC I or
✓� P�,z,,,�r�l� o�,/��aa4ar�ruee� "
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 080145
Birthdate: 10/26/1963
Expires: 10/26/2007 Tr. no: 8042.0
Restricted: 00
GEORGE VASILIADES. '
515 LOWELL ST
PEABODY, MA 01960
Commissioner
� p
..:. ✓lee.4{onima, d+veal�i o�.i�2rae4ac/xueeLG I
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 124356
Expiration: 6/12I2007
Type: Private Corporation
Olympic Painting/George Co., Inc
George Vasillado
515 Lowell st. _,�r,y��✓
m - Peabody,MA 01960. Administrator ,