6 HERSEY ST - BUILDING INSPECTION 1\ hhr ('t,nlnl011-Ac llth of \Iu.+.lehu+Cll+
t BOJIJ 01 13uIIJi112 RCgu u IJ(Jtn .Ind St.111J.IrJ, I (
I \II NJ( I1,I' \I II1
l y NhsS .Achu>CIIS State HuilJing ('.)Je. 'S(I ( MR. 7"' cJu1)al i
- Tnrrl'"unllr !)ur Ise
I uilding Pet nl( : r. non To Constr ue(. Repair. Rent))Me ()r h I)cmith, .I
( It' Iu K •„l r•: ,,,,,, .
— rsSL"� n For Ot tiCral I',e )IIIBuildme Pennu um er. D.tte :\ppIICJ _ -�00iSiettaluc - -- ----- ---.--- ------- ..
IiwlJng 'nnunn, n . In,1 (ot.�I HuilJwes Date
SEC"I'ION 1: .SI FE INF(IRS1A HO:N _
1.1.Pro crh Address: -- -- —"--� L? \ssessors \lap Parcel N11lllileh --
- -6._He fz�,e - -- ---
�I .LI Is Ihi., an Jescplul street' se+ -
1 1-3-Zoning Information: --- 1.4 Property Dimensions:
1.5 t.u.lding Setbacks (ft)
Front Yard Side Yards HeatYarJ _--�
Heyuu rJ+—r Pnnlded Requited Pni"ded HrquoeJ I Pn„iJ.J
1.6 Water Supply: (M.G L e. A). §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone" .\turns al ❑ On ,ilc Ju m)osal s.N,ie ❑
Public ❑ Pri)ate❑ Check It yes❑ P I
SECTION ?: PROPERTY OWNERSHIP'
2.1 Ownert of Record:/ r�
N.w;• I Pnnl i 7-
Address lilt Sen ice:
—� 6 a
Sign:tore Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK z(check all that upplvl
N'zv: Construction ❑ Exi Ling Building ❑ Ow nzr-Occupied Rep;u r.,(s; ❑ P.Iterarum(,) ❑ :Wd Inin ❑
Demolition ❑ A.'ce++t try Bldg. ❑ I Number ut Units---^ I Uthzr - ❑ Speclt}._ .
let "esc.:pnon. tt Proposed -
e� rat Sk. r��F + f Wit( t rcr/ —
III
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Eoumated Cosa: -
j Item (Lahor.md Matenalsl Official Use Only
I BuJJurg 5 I. Building Perms I ze: 5 [_ Indicate hiss ice Is Jetei Mined:
�--- ❑ Standard City%fawn Apphrauon Fee
Flectncal ❑"final Project Cost' (Item GI s muitlpher —_ s
i I'lumbing S ! I. Other Fees: S
4 Mechanical iIfV \CI S i
lj Mechanical (Fire
S r,�iai All Fees- S
\u + nes,lni
�L —
' (heck No _ Chesk Amount _l'.nh \ul,wnt
0 total Project (Usl 5 ] a-'o Waid in Full —_— 0 Olast.InJln,• B_ lanse Uue_
SECTION 5: CONSTRUC'HON SERVICES
5.1 licensed Construction Supervisor lC'SL1
Lt
St. IIolJer irsunliJ pup lO ��.IMn)l�u
K R:.I n.IcJ I&2 F.mnl�
� IJi phi�ni i1a \\7k� 8dj —
� �ll R id'uli.J S hJ I '.ni ISuuun \LLi n Lni I' i m
5.2 Registered Ilome Improrement Contractor 1111C) p _
HIC ('ump.i is Nalltc Or fl Rcelsvant Name Rcgsoauun Numher
1JJros r� .y� -- --
S l shone F.yulall,al U:uc
I Signature frlrphunc .
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25061)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure m prov ide
this affidavit will result In the denial of the Issuance of the building permit.
Signed Affidavit Attached'! Yes .......... H-� No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authonte to art on my behalf. In all m.uters
:elalive it, work authorized b this building permit application.> I
Si nature of Owner Dale
SECTION 7b: OWNERI OR AUTHORIZED AGENT DEC'LARA"rION
nn
I. `SC z as Owner or Authorized Agent herahy declare
that the statemems and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf'.—
Pont Name
Signature of Owner or Authoru :lgent Date
ISi coed under the ains and enalues of (u I
NOTES: _
I. An Owner w-ho obtains a building permit to do his/her own work or.an owner who hires an unrcgl,ict ed c,naca, h11
(nut registered to the Home Improvement Contractor (HICI Program). wdl nit have access to the .ohina(lon j
program or guaranty fund under M.G.L. c. 112A. Other important inhvmauon tin the IM Program and
Construction Supervisor Licensing (('SL) can he found in 780('MR Regulations 1 10 R6 and 1 10 R5. rr,pcc(I,cly
When ,uhmannal work Is planned. provide the information below:
Total flours area i Sy. 1:1.1 including garage, finished hasement/alttc>. decks ur por.h,
_ Gross Ilvtn,_ area ISq. Ft.l Habitable morn cuuro
I Nu)nber,d 1i1rp1aLCS Numher of hcdro,,m,
Numbcl of h.uhi,Ioms Numher of
fvpeotaooling ,},tern_—_— —_--__ - I[n.h„rd __..—_-___-_. . Opcn
1 3 .dotal Pr,yect Square 1'0111.1ge" rn.lr he ,uh,niuled tnr fond Pnqect C-1..
{'' = CITY OF SALEM
< ,. .P PUBLIC PROPRERTY
DEPARTMENT
I \\ r,[HN `\1lt 1.1 r • SAI I \ , %1A.,\t I . . .I'I
I I. 9-8--4;.1;4; ♦ 1'\Y. 'i,4-'4_'�5fi,
Construction Debris Disposal Affidavit
(reiluiied h)r all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 Cb1R section 111.5
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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
1 11, S 150A.
The debris will be transported by:
�;DP �f�,/-,�4 a"/ ) r-�5
....ter Iran • of hauler)
I he debris will be disposed ot'in
(name of facility/
❑ddress of tacllity)
.lguatutn of per lit applicant
7�/ —✓J.
,late
CITY OF SALEM
PUBLIC PROPRERTY
,' MPJr/ DEPARTMENT
MA IR I_'. \f�\,i \i: \I, \I.\',.\' !it 'i 1
hPI: '�'S-'�i-•li•li � l'vX' 9'S-'i;-'lgih
Workers' Compensation Insurance Affida%it: Builders/Contractors/Electricians/Plumbers
mlicant Information Please Print Legibly
`:Illle Innsute.o t 4g.11111aIn a Indl\iJuel l: -Pn Jl7 S ✓ .tit �n C.
Address:
('ity. StaterZip: SAjPn n_/9 ac i 70 Phone
Are you an employer? Check the appropriate box: 'Type of project(required):
I.QI am a employer with /_� 4. ❑ 1 am a general contractor and 1 6 ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors � ❑ Remodeling
'.❑ I :un a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
Working for me in any capacity. workers' comp. insurance. y. ❑ Building addition
insurance 5. ❑ We are a corporation and its
[No workers' cum p required.] officers have exercised their 10.❑ Electrical repairs or additions
3. I am a homeowner doing all work g P
right of exemption per MGL 11.0 Plumbing repairs or additions
❑
myself. (No workers' comp. c. 152, §1(4), and we have no 12.E Roof repairs
insurance required.] 1 employees. [No workers' 13.0 Other
comp. insurance required.]
•Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
n I Iumeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
['untraoors that check this hox must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/unit an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
huurance Company Name:.
Policy At or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy(if the workers' compensation policy declaration page (showing the policy number and expiration date).
Ftihue to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the torn of a STOP WORK ORDER and a fine
of op to S250.00 a day against the violator. Be advised that a copy of this statement may be turwarded to the Office of
Irnc>ti_;uions of the DIA for insurance coverage verification.
/do hereby ret-14.I'under the pains urrd penulticn'gfperjary that the injitrruation provided above is true and correct
D:uc:
tlf ficiul use only. Do not write in this area, to be connpleted by city or too•n ofjiciaL
Cit% or I i m n: - .__ _ PermitiLicense #—--
Issuing Awhorily (circle one):
1. Board of Health 2. Building Department 3. Cit%I fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ___-_---- ---
Contact Person:--.—__-- --.--__------- Phone #:_---- —.
Information and Instructions
r.
%IaNs acIIuse us ( eneral Laws chapter I Iequues all cnmployers to prom ide workers' compensation for dtcir emmployees.
I'ursu.uu to this ,t:uute, .an entplunee is defined ,as em ery person in the service of another under any contract of hire,
e\press or implied. oral or written.'.
An eurp6arer is defined as "an ill dI%iiludL.p:utnenhip, association, corporation or other legal entity. or any nvo or more
,.'the foregoing cng:aged in a joint aucrprise. and nieluding time legal representatis es of a deceased employer. or the
rccciN er or trustee of;um individual. pviner.hip, .association or other legal entity, employing employees. I lowever the
o%s ner of:a dmvclling house ha%ing not more than three ;apartments and-who resides therein, or the occupant of the
dmm ailing house of,another who e tip Iocs persons to do maintenance, construction or repair mvork on such dwelling house
or on the erounds or building appurtcna-tat thereto shall not because of such employment be deemed to he an employer."
\I(R_ chapter 152, §25(.(0) also states that -cvery 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, SILL chapter 152, §25C(70 states"Neither the conununwcalth nor any of its political subdivisions shall
enter into.any contract fur the performance of public work until acceptable evidence of compliance with the insurance
rcquirenments 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) mmnie(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 till in the permitllicense number which will be used as a reference number. In addition,an applicant
that most submit multiple pemmi0icense 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 burn leaves etc.) said person is NOT required to complete this atfidavit.
The Orrice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please (it) nothesitate to give us a call.
the Drp;artntent's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
OfRce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Rc�iscd 5-10-0 Fax # 617-727-7749
www.mass.gov/dia
From:Ondy Carey At.The Protector Group FwJD:508-852-8600 To:George VanHillo Date:122008 04:31 HM r'age:[Or 4
ASPEROO-01 CACI
ACORD,. CERTIFICATE OF LIABILITY INSURANCE °A 102008
' PRODUCER (508)852-8500 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Protector Group Ins.Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
100 Front Street,Suite 800 - ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Worcester,MA 01608-1435
INSURERS AFFORDING COVERAGE NAIL#
INSURED Aspen Roofing Services,Inc. INSURER A Acadia Insurance4 Florence Street Unit#3 INsmR B: AIG American International Group
Salem,MA 01970- INSURER C
INSURER D'
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 CLAIMSINS .
POLICYEFFECTME PC'LICYEXPIRATION LIMITS
LTR D TYPE OF S POLICY NOMBER 1,000,00
GENERAL LIABILITY .. EACH OCCWRENCE $
A X COIMERCwLGENERx LABILITY CPA520233366 12/3112007 1213112008 MEMI�S Ea opturen.e $ 250,000
CLAIMS MADE a OCCUR MED EXP(Arty one perIMI $
PERSONAL d FDV INJURY $ 1,000,00
GENERAL-AGGREGATE $ 2,000,00
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMProP AGG $ 2,000,00
POLICYFXl
PRO- LOC
AUTOMOBILE LABRITy COMBINED SINGLE LIMIT $ 11000,00
A ANYAJro MAA520236243 11213112007 1213112008 (Eaacdd.rt)
ALL OWNED OS BODILY INJURY $
X SCHEDULEDAUTOS (Per person)
X HIREDAUOS BODILY INJURY $
X NONOV,MED MIr05 (PeraccitleM)
PROPERTY DAMAGE $
(Per acciEerd)
GARAGE LIABMY AJTOONLY-EAACCIDEM $
MY AUTO OTHER THAN EAACC $
AUTO ONLY. MG $
EPCESSUMBRELLA LIABILITY EACH OCCURRENCE $ 2,000,00
A -XI OCCUR �C,MSM,OE CUA520236246 1213112007 12131/2008 AGGREGATE $ 2,000,00
$
DEDUCTIBLE $
RETENTION $ WC i
TH-
WORKERS COMPENSATION AND
X TORY L MIT OER
8 EMPLOYERS LMBILm WC6716013 12I31I2007 1281/2008 E.L.EACH AcaDENr $ 7,000,00
ANY PROPRIETORrPARTNER/FXECIITIVE 1,000,OD
OFFICERMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $
If Yes. a Ioea E.L.DISEASE-POLICY LIMIT $ 1,000,00
SPECIAL PROVISIONS oeb
OMER
-7 -
OFSCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES I EXC'.W SADDED BY ENOORSET.IENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES RE CANCELLED BEFORE THE EXPIRATION
DATETHEREOF,THE ISSUNG INSURER WILL ENDEAVOR TO MAL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE UZI,BVr 1AI1l1RE TO DO SO SHALL
- IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE INSURER nS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001108) 0 ACORD CORPORATION 1988