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61 HATHORNE ST - BUILDING INSPECTION Zi7 6 CITY OF SALEM r: PUBLIC PROPERTY DEPARTMENT Xj?.&WJLfiY Dffisco 1 �5EM 01970 MAYM I20 WASHIWG M S rRFgr•S11 GPI NLk% Fi . II:L 978-73S-959S 9 FAX:9767i0-98d6 Construction Debris Disposal Affidavit (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code,780 CMR section I11.5 Debris,and the provisions of MGL c 40,S 54; Building Pemtit p is issued with the condition that the debris resulting from this work steal)be dispos ed sal facility as of in a properly licensed waste dispo defiled by MGL c 111,S 150A. The debris will be transported by: D�Sp6L (same of healer) The debris will be disposed of in ( me na of facility) C7eo�fflQl++O,,N ^ ml N (addrms of facility) sisnamm of pamlit applicant �20Q 7 due .tebr7.al7.Jut / CITY SALEm PUBLIC PROPERTY DEPARTMENT KISMERLEY DRISCOLL MAYOR T2o WASHING ON STREET•SA Eu ,mAAAcHt:sLrTs 0i97o TEL 978-745-9595 *FAx:978-730.99" APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION. DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY Y EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: Building: Property Address: (.t V aO-V o«e SA Property is located in a; Conservation Area Y/N Historic District Y/N 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Mow J Gnt? TLN \\erl Address: Telephone: cl g c1'lcl O A S 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sq Renovated construction or renovation of existing building New Brief Description of Proposed Work: rcn.da�\ kArJ ec\ ` kr-,SN0,A r\ew WAV\Vw-r — see cICMVA Mail Permit to: What is the current use of the Building? ra a\are\}} 1(A Material of Building? If dwelling, how many units? Will the Building Conform to Law? Asbestos? Architect's Name Address and Phone Mechanic's Name (Sn�VC1} RA G'^c c%)(\ 4 Address and Phone r) X Construction Supervisors License# HIC Registration# 104 SS2 Estimated Cost of Project Uk �0 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 Perm't to build tot labove stated specifications. Signed under penalty of perjury X Date �)- 8 Zo (J f 0 O � N o % F a > u Z u 1 CITY OF SALEM I' PUBLIC PROPRERTY DEPARTMENT KIMBERLEY DRISCOLL MAYOR 120 WASHINGTON STREET ♦SALEM,MASSACHUSETTS 01970 TEL:978-745-9595 ♦FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �R t} Please Print Legibly Name (Business/Organization/Individual): G6e n f\ 9(J IS\`_\V% �t1S1f VC—\I O.r� Address: e O- &)Y ICI U City/State/Zip: CS9 yt6\A MfN f'( m 1c Phone #: Ctl% °1 Q �C %(o Are you an employer? Check the appropriate box: Type of project(required): 1.Q I am a employer with 1 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. t �• ❑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 11.❑ 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.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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: L \ o A ke m yA udA Policy#or Self-ins. Lic.#{1n Q 31S-4 5 5°I b% -6 4 b Expiration Date: 5�td!(mc "1 y Job Site Address: U (" ca). O r p P q• City/State/Zip: cp�oqmpdo 1R 7o 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 S250.00 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 u t expl1ains and penalties o-perjury that the information provided above is true and correct Si nature: /t" Date: 'J.0 Q7 Phone#: 1 74 0°z7 Official use only. Do not write in this area,to be completed by city or town offeciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town 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 he`en 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-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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense 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 affidavii inust 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 Of ee 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 } Glenn Battistelli Yk Estimate Painting, Roofing, Siding & Carpentry DATE February 1, 2007 ,. P.O.Box 496 kx Quotation# 100 Beverly,MA. 01915 Customer ID (978) 927-8956 (617)-962 1235 fx( 978) 921-9202 Mrs Mary Jane Taglieri Quotation valid until: February 11, 2007 59 Hathorne St " Prepared by., Salem Ma 01970 Re: 61 Hathorne St Salem t 978 745 7997 978 979 0845 Ak . For every job we 1) If necessary, secure Building Permit fro City or Town. 2) A clean job site will be reasonably main t d at all times, 3) Contractor has all necessary Public Liability and Worker's Compensation. 4) All work will be done to code. comments or special instructions: - e t O- Remove ttie existing kitchen cabinets and plumbing Remove sheetrock from walls and ceiling at same.area � . ainstall plumbing for the new bathroom Install new electric for the bathroom, new fan light;ne FI'pl g and lights over vanity Install new sheetrock and tape with joint compound o alis and ceiling. Install one vanity and sink, one toilet and one show, �t Install grab bars in shower area d Install new bathroom door, window trim and baseboa. rim Install new vinyl flooring in bath area Prime and paint walls and all wood trim Remove all trash from job site s TOTAL. -4 �2 If you have any questions contact Glenn Battistelli 97 27-8956 nsu and o ui uig 'egu ati ns`-/a/d�ars One Ashburton Place - Room 1301 lei Boston, Massachusetts 02108 Home Improvement,Contractor Registration _ - Registration: 104352 Type: DBA Expiration: 7/13/2008 GLENN BATTISTELLI CONSTRUE I -R Glenn Battistelli PO BOX 496 Beverly, MA 01915 << — ---- --- Update Address and return card Mark reason for change. Address Renewal I_'. Employment ' Lost Card 8-CA1 O SOM-05/06-PC8490 Boa2$Bu I mg eg 1Tat land .taadard, License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. 'If found return to: Registrat(�n Board of Building Regulations and Standards .� 104352 One Ashburton Place Rut 1301 Explrabnrt /2008 Boston,Ma.02108 F b1 GLENN BATTISTECLL TION Glenn Battistelli �= e w fit ,./ 11 BROAD WAY REAR-4 reverly,MA 01915 Deputy.Administrator Not valid without signature V3 ��I � s �e.�a�nmwouueall/'.y./�a°ouclueelk �1f;rk `�I�x� s��t.A1<r6f�'s ,1 ptyk -R �1,751°f�U /�i��QNNN��SIiSLt�f�OR LMG 2/8/2007 11 : 12 PAGE 002/002 LMG Liberty Mutual Group Libe tX PO Box 7202 mutU51 Portsmouth, NH 03 8 02-72 02 Telephone(800)653-7893 Fax(603)431-5693 February 8, 2007 JANE TAGIIRI 61 HAWTHORN ST SALEM. MA 01970- RE: Certificate of Workers Compensation Insurance Insured: GLENNBATTISTELLI PAINTING CO PO BOX 496 BEVERLY, MA 01915 Policy Number: WC2-31S-455968-046 Effective: 5/112006 Expiration: 5/112007 Coverage afforded under Workers Compensation Law of the following state(s): MA Employers Liability. Bodily Injury By Accident $ 100,000 Each Accident Bodily Injury by Disease: $ 100,000 Each Person Bodily Injury by Disease: $ 500,000 PulicyLimits As of this dale, the above-referenced policyholder is insured by Liberty Mutual Fire Insurance Co under the policy listed above. 'The insurance afforded by the listed policy is subject to all the terms,exclusions and conditions, and is not altered by any requirement, term or condition of any or other documents with respect to which this certificate maybe issued. This certificate is issued as a matter of information only and confers no right upon you, the certificate holder. This certificate is not an insurance policy and does not amend, extend, or alter the coverage afforded by the policy fisted above. If this policy is cancelled before the stated expiration date,Liberty Mutual will endeavor to notify you of such cancellation. t_L AUIJHORIRIZEDC,lttlnLFRESSEENNTT ATIVE LIBERTY MUTUAL INSURANCE GROUP This CeniLekisexmtd by LIBERTY=UAL INSURANCE GROUP..,peels such insmame asis affxdM by thox.mgxu u. cc: Insured: Producer of Record: GLENN BATTISTELLI PAINTING CO STERLING INSIIRANCE AGENCY WC PO BOX 496 P O BOX 493 BEVERLY, MA 01915 BEVERLY,MA 01915 21S2007 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 02/07/2007 PRODUCER (978) 922-6600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Sterling Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 306 Cabot Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 493 Beverly, MA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Commerce Insurance Co. COM Glenn Battistelli Painting INSURER B: Battistelli Painting Co. INSURER C: P O BOX 754 INSURER D. ,Beverly MA 01915- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED 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. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS A GENERAL LIABILITY WV1751 02/26/2006 02/26/2007 EACH OCCURRENCE $ 1,000,000 }{ COMMERCIAL GENERAL LIABILITY PREMISES Eaoccurtence $ 50,000 CLAIMS MADE F-IOCCUR / / / / MED EXP(Any oneperson) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JERO F LOC / / / / PD AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS / / / / BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY AGG S EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE It OCCUR F-ICLAIMS MADE AGGREGATE $ $ DEDUCTIBLE / / / / $ RETENTION $ $ WORKERS COMPENSATION AND / / / / TORV LIMITS OER EMPLOYERS'LIABILITY ANY PROPRIETOWPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? / / / /. E.L.DISEASE-EA EMPLOYEE$ K yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE Jane Tagliri INSURER,ITS AGENTS OR REPRESENTATIVES. 61 Hawthorn Street AUTHORIZED REPRESENTAAVFj Salem MA 0197-0 T (•/ ACORD 25(2001/08) C4LAtORD CORPORATION 1988 ft,r INS025(0108).05 ELECTRONIC LASER FORMS,INC.-(800)327-0515 Page 1 of 2