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11 HERBERT ST - BUILDING INSPECTION PUBLIC PROPERTY DEPARTMENT w KI\R FIU-Fy DRISCOLL MAYOR M WASHINGCON SIRFEr•CAL Fj \{AnAcHLshm 01970 TEL-978-745-9595• FAx:978-740-9846 Q APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION, —� DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: J e Building: Property Address: I I -)4,rLert Sf j sa 1�,�7�MK4 0V=t-70 Property is located in a; Conservation Area Y/N Historic District Y/N l 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: raro ),ln k0s5owa4,-1 Address: 1 I He' r toe r't S + _Salevr-i MA 019 - 70 Telephone: 979 '"A A - 191 D 3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY Addition Existing III Renovation 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 l3def Description of Proposed Work: VIhyI S ��iln5 _L ✓75�� �GlU1/1 Mail Permit to: r What is the current use of the Building? - Material of Building? If dwelling, how many units? Will the Building Conform to Law?_ e Asbestos? Xh) LKIIpRr /V M -� Architect's Name C ,$ Yvv k-1 iP P� 'f ��'� �S - < �C- Address and Phone 102 Fl�r i c�a ��� PrW ( ) � 4U77 I — �L� U Mechanic's Name -- " Address and Phone Construction Supervisors License# HIC Registration# 4 6 O 7 Estimated Cost' Pro'ect�y� Permit Fee Calculation Permit Fee$ Estimated Cost X$7/$1000 Residential c t� Estimated Cost X$1141000 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 Xspecifications. Signed under penalty of perjury — - rg Date v l Pyo 6 0 N V v - - — W - a— "d — -- -- -- CrrY of SAt.E�t ' PUBLIC PROPERTY DEPARTMENT w,oaave►o.a�. N.ro. �3o�rnumiamwsnaar.sun��a-senmrn 1b:9 7&74s•tM*FAXS M7404M Constrnctlos Debris Disposal Aflldavit (tequiyred for all demoU=and rmovadom waft) In accordattcs with the six&edition of the State Building Cody 7W 00 secdm 111.5 Debris,and the pewviaiaas of UM a 4%g Sib Building Panrtit d is Issoed with the aox"on that dw debris=*Ing dos tMs wet abaft be disposed of is a properly Uaamad waft dlgmW hd ttl►as deIInad by MM a t u.s il0/1. The debris will be transported br. ,BP- f c.<.c k i Y-r c_ a 3) , i vv-o foams of baatarl I i The dcbria will be disposed of in: ctc�l( I'l " (aama o[Aeiu 36S Irsi -('�j �Je 06-: i i Tiprl !'1 m A o.)0 c�I T1 V O siaaseaa ��4• AS�f) All S, 2 data i CITY OF SALEM ra PUBLIC PROPRERTY DEPARTMENT KA1aERLEY DRWOLL MAYOR 120 WASHINGTON STREET a SALEM,MASSACHVsETTs 01970 TEL•978.745.9595 a FAx.978-740.9946 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly LFf� - D NyXA L Name (Business/Organizaeon/Individual): I fl v1C . Address: •rap so /c 1�I� y City/State/Zip:L4 c ul/Tr, cJ, FL 3 ,)7 SQ Phone#: 407-- SS, 1 — $-Ll O a Are you an employer?Check the appropriate b�. Type of project(required): 1.❑ 1 am a employer with 4. H I am a general contractor and 1 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 subcontractors have 8. ❑Demolition working for me in any capacity. workers' comp. insurance. (No workers' comp. insurance 5. El We are a corporation and its 9. Building addition required) officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 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 12.10 Roof repairs r insurance required.)t employees. [No wo�rk�e�rsr'77 13,�Other✓ SA COMP. insurance req""""•] I Id -Any applicant nut cheeks box 01 mutt also all am the section below showing their workers'compensation policy informadm t Haneowmn who submit this affArvit instating they an doing all work and rhea hum outside conhactas must submit a sew anidavit indicating suck. :Contractor dim shalt this box must attached an additional sheet showing the namm of the sub-connectors,and their worker'comp.policy inraneatlam. I am an employer that is providing workers'compensadan insurance for my employees. Below is the po/icy and job site information. /n� `i Insurance Company Name: C E i i __t_ Co-44 yL-1 Policy#or Self-ins.Lic.#:, /W L RC A 4 1A u S I6 0 Expiration Date: 04 G / G O 7 Job Site Address: /`i L°/ b2 r / S �r ep T City/State/Zip�few , M A O,It'7 O Attach a copy-Of 6it-workers`eatilpensatioti pokey 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 S 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 u to$250.00 a day against the violator. Beadvised Y B� seal 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 a er he pains aena/ties of perjury thatty the information provided above is brie and correct Siianature: �i cti . �h I ���ly✓ S /7a e r I ) Date, �Ll t/ Phone#: 13GO — OJJlcia/use only. Do not write in this area,to be completed by city or town oJJleiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/rown Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone N: Information and Instructions- Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation forctltutra ct floes Pursuant to this statute,an employee is defined as"...every person in the service of another under any 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]rouse having not more than thin apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,constntction 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,§25CM 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 subdivision shall of compliance with the insurance enter into any contract for the performance of public work until acceptable evidence have.been presented to the contracting authority. requirements of this chapter Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to Your situation end,if sub-contractors)narne(s),addresses)and phone number(s)along with their certificates)of necessary,supply L or Limited Liability Partnerships(LLP)with no employees other than the insurance Limited Liability Companies carry C) non insurance. If an LLC or LLP does have members or partners,are not required to carry workers' compensa • employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial The affidavit sho Accidents for confirmation of insurance coverage. for the permit Oro sign and date the license is being requested,ut the Department of be resumed to the city town that the application Industrial Accidents. Should ould 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 a riate line. City or Town Officials it is complete and printed legibly. The Department has provided a space at the bottom Please be sure that the affidav of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.which will beas a number. In addition,an applicant please be sure to fill in the permit/license number �edar need onl c submit one affidavit indicating current that must submit multiple pennit/license applications in any gi Y Y 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 he or.licenses.:A new affidavit must be filled out each as proof that a valid affidavit is on file,fanfuumr i ermr. - year.Where a home owner or titian is obtaining a license or permit not related to any business or commercial venture yea a dog licensee 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 you r cooperation and should you have any question+. 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 otRce of Investigations. 600 Washington Sheet Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mLss.gov/dia I�Irl11 Job No.: 6aao yyp ' Seem Hunts Im(aowment Products,Dec. Lkaue ROCD0012598 SEAM Y8 P.O.Bar 522HO♦Longwood.R 327512-229 vow ... Location: A\lO l Ty KOSSO kit A N Siding we�w Name ;� Phone:Rea M 77Y�Mb Sus. T2c-Ver- Address: // atcf for C-.A « Cdy: Ste le on 3.: -Zip: Q1!?7� Wye•the owners of Die prwMaea dosofroed below,hereinafter relermd to as'Pu chasee other to contract whh Seals Home Improvement Products hereinafter referred to as'Caltradof.to furnish,deliver,and Shadings for installation of all materials necessary to dro W,the premises loomed at swrvlIL (Sheet) (Ckf) (Sees) (Zip) Aomdlog to the following spealcnWta: NOT INCLUDED INCLUDED SPECIFICATIONS PREB%•'n6 1. O ❑ Obtain all necessary Permed end asnrrenms 2. © ❑ Impact suMPm in work area-ranee Worm wood.reps,most, ,am wood whore necessary in work Ma ea 11911M rmt decking or rands,and atnpwml members. 3. ❑ Remove E+aaag eldti4 Trpa: 4. Fr art wale on bridl blodi,meal or Nuoco areas:LocatWn: 5. Cans and east emend a1 windows$doors in work area as nemmery. a ❑ Inside appoved mn-oorrwiw wester strip. IUSIILATION: 7. ❑ Instal I sualion on 110 l mess to be Met with'3W 6U4' polyg(yrdna kuumm.(dma are) CUSTOM TRIM a ❑ Custom Vyea-Mad aluminum feeds aymem: Color. G',W M 9. ❑ Remove and rmVecN6apom of smarg gulWrhg. 10. ❑ taus,sa0p move a Mara p -vkryl soffit arms rolstl below. wnfl,sNedN❑Ater OPkatpnmMaMm51*61r (dack")Com_Patem: 11. ❑ C. Vyna-Igad akamtulb'/date boards: . �i wn , Color: Site: 12. x Ju coca trim: La91rsw Aja inure. r. TS Cu WMowa/dilslmiaslheadere with Vyrq-Rlatl eWmNum: d:aP0 r COW: C wI,, fa �, Remove aMJoeda�ex®drg slam WridoDalawN ❑ Custom wmP door swings seen Vyna-gad aluminum Location Color. tor. ❑ custom wrap garage door shgladauds wm Vym-wetl aluminum: 17. El em Rove and minded atom doom cam 18. ONute comer pow: Color: 19. ❑ Clip locking system: Location: SIDING: 20. ❑ Instill m r Oklat❑pks stir goner Solid pip.( oar) k Tyloplibroomild 1 Ymlkal S - COLOR:.. PORCH _ 2t. ❑�p Pork lnragoa: _Color: gvnTruc �Z2. ❑ PaPL:PmtL. CAN: . -. 23.-�❑ Pant boors: CaWr. Ct EAra UP' 24. ® Clem up and emorel of ad job msted dabi ; 2S ® ❑ Each job Is over-dapped b mid delays.Remove espfm materials and mgtmk. WARRA MPynmpe: 26. ® ❑ maidlmoers warmly send upon corpel4m. rocs a9��: No 9IcCAli Ai Work art t0 be done: _NO DRIP WOE COVERED-NO PAINT APPLIED yVtO \zsip O ec- Ad Of the elbow check bold and don lvork rot to ba dons'semipn lame been radswad all explained W me. NOTE:THE WARRANTY PROVISIONS AS STATED ON THE REVERSE HAVE BEEN EXPLAINED AND VINE UNDERSTANO ADDITIONAL PROVISIONS AND WARRANTIES ARE STATED ON REVERSE AND ARE PAIR OF THIS CONTRACT. Flame,read the following vandal undsmbrldmga and agreements with pmsmta lllnnott be binding.All un type arid fifitial derstandings writing In this Contact. log• spa end sgreanwn et loft Torte in Puraeua hdtltte:x The TOTAL PRICE W ate Labor A Materiels(itrktdtg eery eppk:ebb dlwdmt)b $ /�a-.gp U Down Paymt S car .00 L:t6 rectPrice $Beene Payable$ Saba Tax 1 %)$pksa sTerms: Credit ❑ (Subject m,the eppeval a tom Credit Daparbnent) Collect Price $(79 Cash U (Fell laymen Payelbe M Installer upon completion)Fmdad by: Bank: - city St IMP,** C M mIPCN N foeery he lMs ooelogrsanrPAmes roducts WmhasM Qpreat prkbmwe W*for one(1)year, e this is a crest transaction,the agreamanl for ands is WmIned In a sWamis document whkk Is incorporated heron by mmmnce arrd m de a part neraol.W the undersigned are hereby aumcrid g Seem Home Impmwmem Products to verily and nw w my/ou credit retold with an independent credit repomng agenry and release them from ad eability Incurred hum vmdven ns ent osions or epors. LL� IN WITNESS WHEREOF Purolanerts)have hewn sigma thine rratel ens /Odaya ..e 0VCMQ ,ao O/o end acknewsdpe receipt a a true copy of 0tla Combed and unless Omenvise specified,4 is utlerslood tWt tare owner is ready for this work to begin. THIS MESSAGE APPLIES TO DOOR-TO-DOOR SALES ONLY.You the Pumheaer(a) may cancel this Emnssetlon any time prior to mMnigM cif the third day after the date of this transaction. See accomparrying notice of cancellation form for en explanation of tAis right. SP .anme b. sov...01 Ott F.Ntmert.)�w. %aaw.la�t_. i. 6VawITTm 9Y:eegr®�tetNe pay p,t Ma Mail F ( ear ro ors, ff /o OG wCEP1EP en<ieviyw6Y�weab9welwm.Im.wmwr Pyacn irc. any wmv.. .. I ozso .nor.owns -r^ ,:/fF: (cr:rrnee:urrcrzr(l rf ((rJ.uric/rkie�� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: i.48607 = Lx1joduon: 10/11/2007 Type: Public Corporation SEARS HOME IMPROVEMENT PRODUCTS INC, ALERED NYMAN JR. 1-324-FL-ORH3 _ LONGWOOD, FL 32750 — � � Administrator Cr, d/2006 15:02 407-757-8536 PERMITS LICENSE-- DEFT PAGE 03 +CORD CERTIFICATE OF LIABILITY INSUR:ANt:E r 1014 03118 006 LOWON COWAMES THIS :J1T6 0A I muQSAS A TTEM P INFORMATION 525 W.Mmm4,Sd1E BUD ONLY AND,CA]NFEI 5 NO MGM" UPON THE CERTIFICATE CHICA00 D.60661 R.TH i`211 E FII OA7T DOER NOT F gKbF.XT$ND OR (312)9"D0 DIED dY T1 EL_ INSURE RD AFFORDING COVERAGE Gears Ho dl . 10fi2163 d10/o Baas Hmm lmp vv&7W t RoMft,Irc, e• u!$1cJm. N AR1:R IA MaIVITIont BS"1778 33U Bozo rip R4. Re, "— mm EsWft,IL60179 .-- C7 THE POLICIES OR NBUIRAMCQ LISTER OELOW HAVE EEEN MSUEO TO THE INSURED W MED ABOVE FOR T IE POLICY PERA]D INOMATfR1.NOTv1ETH0TANDE1p UIR ANY R60EMENr, TERM OR COWFWNOF ANY COHIRACT OTHER DOCUMENT IMRi RRVECT M WIFOCH THIS CERTIFICATE MAY EIS ISSUER OR NAY PF3QTAIN.THE RMSVRANCB APFORPED SY THE POLICIES HEREON 18 EULIEOT TY ALL T►E TERMS.MWLUGIONS AND CONDITIONS OF SUCH O Olt Nan 0 CLAIMS I�CTY�qFayy E oiiimM TION coma"LIABILITY F A X OiemAmitA Lmv HM023729303 0411 200E '14MIMD7 F ded CLARA MADE IE COMM EV 4 r $.000 000 6f3/ETULAOGREDATE a 5 L PAITAPFI RR, I S 000 000 AUltWO461 LUArISY "— A X ANYAIRO ISAMS219953 04MI2006 (oVOI2017 IelOm=Nm) tELWn A 5,000.000 ALL OVAM AUtW aONBD1AEDAUTOa RUN nY a XX�' IJIXX NAiEDAUTps N0014 M1W AUTOS W Rya;Uj Y a XXX70CXX OARAa4 LIANam IpPNOP zpl m R6 A xA7QIXXX A AM,AVm DOLLY- AC Six$5,000,000 04/01/2006 O1M12D(7 OCCUR ❑CLAma W= NOT APPLICABLE eACN OOOURR >: XXXXXXX e Deouc7m E ❑Fe = X)DDO= flBNpN a a A �R�ROwCN41MavAm WLRC4434096D(CA)(I .) 04M12406 Oro012DOI X No a A SCFC4434m72(1011) O) 04101200E (WADI 000.000 B DOTSTr 9 WLRC44340959 04101200E OL101200' LL DINA9E• IODO (: ATo A NAgdegmA T."IIy 9.IR,¢5.000,GOD 04M1pA06 dbD1200i SJ,A lS.000. R to"am—IN8 1E9CWFTpM ar0AD1A110NarLgwneNLNaMIGI,DDA'�SUgpN¢ADDaOR pgDyN� --� Aleva w,NymAn,Jr-,41"m ACT3COt253e IOCAkd 8 1024 PIDNdaCcn I pwin mW,Langw,,d,pL 327S( mld Am d W.Nym a,jr..Limns,4CINC12495r 0 bon"®1024 Flsrldn Central Padr..W,Longwood,FL 32750 224Ws2 Bows Hemp Impmveffew pm&xN NTOWDANY an TIIE AlrNs VC MM FalnRe es CAMCWAAM REFORM we®lFNATIDN 10 r"ParFwey TwTE TNf>®F,TH4 1®/wle Ne 4t RYIIILLNATEAVOR To MAILLff"md FL .Q_ DAYS vvATTYFx ntrRCE TOTRE L9TRNOATC W U OR MWIM TO TI!IAPT.eUY FMAME TD OO e0 WALL nAVC6E IIO.gypATmR 4Mt UA6I MW M►NAItr VPON THE AIaURCR,ITa AOEATg DR Iag�4N► TIVE4. AIIITTOI�IMIIe'EENTeTNa CORD 25S(7197) Ye.�.wNrir w..w.w.wr.snAwAr •w.n+rnrWFn.e...�A NAaFr At"" WAII gym aaF• eACORDODRPORAT1pN 13S8