19 HERSEY ST - BPA-8-767 CONST. STEEL BLDG ei-r�r-oFg�t�c -
� PL'BLIC PROPERTY
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APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION !
DEMOLITION. OR CAANGE OF USE OR OCCUPANCy FOR ANY EXISTING �I
STRUCT[JItE OIt BUILDING i
. 1.0 SITE INFORMATION � " I
Locatton Nams: �L � - � Build(�g: �jX/G
Property Addresr.
��. -�G �� �<Sl�i/<� S,
Properly b bcatsd in a:Coneervatbn Area YM HlaWric OlsMct Y/N
4.0 OWNERSHIP INFORMATION
4.1 Ownar of Land f �
_ Cf �
Name:
Addreas:
Telephone:
3.0 COMPLETE THIS 3ECTION FOR WORK IN FYI�+T�un BUILDINGS ONLY
Addition ExiaGng
Renovation Number of Stories Renovated
Change in Use N�
Demolitlon Exist(ng
Approximate year of � Area per floar (s� Renovated
construdion or renovation
ot exieting building New
Bde[Description of Proposed Work:
[ 0 n 5 f!'�1�-- '��j �l kl /c9 v /
,5-t-ee( c�w��l�,
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What is the curteM use of/the Building4 �� � �
Matetial of B�ilding4 v��� N dwelling. how many units?
Will the 8uilding Confor/m to Law4 y//s
Asbestos? //�i�
Archited's Name o�L�-�_/�/�/�6Gd ,�G
. .�. -- �p
Address and Phons /�/�n���c��.��/•G e 6s����f� ) 7/ t-/1-�6`CL �
� t� � as�c�; b4 �Z�cTde
Mechanic s Nams h a( 4 YZS
Address and Phone�,2--�''� �-�- �1,�•-�P.c�c.��, I.U.
Conayvotion Supervisors License# S 93 l 6 HIC Registratio��i
Estimated Coat of Project S / 7 ,v u v pertnR Fe� Calwlatlon
pertnil Fee i 3° Estlmated Cost X S7Ii1000 ReaWenHal
Estlmated Cost X St t/i1����� _
M Addkbnal 55.00 Is added aa an
AdministraWs char9s.
Make sure that all flelds are properly and legiby writte�to avoid delaya in processing.
The undersigned doea hereby apply fa a Building Pertnit to build to the above stated
speciflcaUons. Signed under penalty of perJury �
Date a3-�-� �`�
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� CTTY OF SALEM
PUBLIC PROPRERTY
�` DEPARTMENT
;.�W1F Rtf.Y lAliCUll
N.�r�r ►2t wws�+.w"rarSnar�t►�.lt�suc.yn.�i•i�01973
TrL 97i7�i%9S •F.�x:97L7�GW�6
Wurkan' Compen�sdo� Iosunncs AfYtd�vlr. Builden/Contracton/Eleecrlcia�u/Plumbers
annlicant inform�+tios Plea Prtet Leei�
V�me�uu.inwQrye�zuiaN�muv�.Anit: k�.,.�#rRn� � ���z6��� .
A�ldreas• �O Clvt(. � 'F
CirylStac�lZip: "�'�'�z�-b F�r�A� �(U�L1_ pp�p: 7� 1 — (03 �— S3
Are yor�a eapMyu?C�eelt tAe approPrisq boc
I.0 1 �un a emybyar wiV 4. Q I am a yauaal coo�netor ond 1 �'M��ProJ����d1•
._ tfry�luycer(full uuUur p:ut-tinst).• hrve hin.-�l the sub-cwunctors 6' ❑ P'ew cauarueti�
? L1Yl yn a aok propricta or�anna. listed ua df�atmehed shcd. f 7. ❑ Remodslia�
ship and have no omployue� T6er wb�onaacWrs h�w tl. ❑Dsmolitioo
worlein; far mc in wy capacity. worke�t'eomp� insuranaa 9.
❑ BuiWins+ddi�im
(no wat�s'eanp. inw�anc� S. � W�aro a co�poratian and its 10. Etxtrip!r
nquired] otTteen hsve emrciMcd e6eir ❑ �p�in or addirions
3.� I am a haneownQ Joina all woric ri�6t of anemption pa MGL 11.0 Plumbin�rcpairs or aJJitioru
inyxlf.([�o wohen'comp. c. 132.41(4).aad we havc no 12.� R�wftrpain
inaunnce requined.J � .mpbyaes.(T�o workers' 13.Q Othm
comp iKwran�z rcquirrJ.)
�n�p.ppliead uw elaMts boa/I nm aW lill ur Or aeaim IaWw Awia��Aw vurla�'arnpsWiu�Vu1i�y iolw�ius
Ilwna�.rrn i+�o auWr11W ellldpu iWisa�uh Mry a��Wiq JI wwk w0 W�Nu aNfd�CaMroebn mrN•uAnL��r.r aRLbvi1 in�Nain�•w�.
�fumrxt�n�hM c�cek bp b�ieuq anae141 ue aJdiUand+h��Ja�ri�y We nae�of 0r alsontrs�on aM iMi►�rurk�n'ta�0�P�KY��6m�atMr
/u.w um m�ploytr that!r provldln,q wontirt'eompentadoa bu�ranee jor iny�em��p��/u�{y�r�eys . /ow/r rhe puNay und fab aile
1/�Y/'qtlfM/f�. ��IF 0��
In.urancr Company Vams: n• 1 l f�-#t�A.�A_Tj�'„yt T'i.a�',ca OacL� � I
Policy.Y ut Snlf•iru. Lic. A: W G r/ Gn'7 2 6-Qio--� --- E+�pin�ion Date:
�
l�b �itc AdJrcaa: 1� �6�.err Y .�' � City���awZip: �T�.4G�M . U�,�Y
A�tacA�coyy of Ih�wortan'compens�Hoa polley declaralloe pax�(s6owln4►ha pollty number�nd e:plr�Nun date}
I��i luro w xcwe co�e�Qe ss«quireJ under S�ttiun?SA ul'�IGL c. t 52 au Iead ro the imposition of etiminal penaltia ota
fin. up to 51.500.00�nJ/w ona-year impriw�nmcnt,�w�ell as civil pcnnitiu�ia ihe form of a STUP WORK ORDER arn!a fint
.�(up�e i250.00 a Jry a�uioal d�e vfala[nr. Ik idvi.+cd thut a wpy uf this etahuunt rwy be IurwarJeJ to �he Ullice�f
In�„u�;.u�nuc�f ihc DIA °Of i�ttu��rtce Q1YGt]�'C YCfIF11:,111U11.
/Ja htrv6y r.Mi�y unJd thr puia�uud yenu/, Ilrr ujper/ury rhw dw i���orenlloe provided ubow ia ari aiiJ corrcct
ii�t:r.�ti�r_ � .
- I)�fe• Z�S �/�-�ti Zoa'�
C�,cy_a� ZSl- �..3[ - Q,s'3 !0 4t7 -Z°c�• s zz t
U/J&�id rr�un/�t /b wa wr/it/w iAb ares,m d�ruwp/dd Ay dIr oi ro�rw a/jli•/rL
Ciry ot ('nwn: _ PermitlL(eense Y
bauinK .�u�huri�y (cird� onc): — -- - -
1. IS���rJ uf Ilealth 2. ISuildin� Dcparemcnt J. CilylfoNo Clerk 1. Electrical Inspertor 5. Plum6in� lnspector
G. O�hrr
C��uta�t Pcrsoic _ 1'honc p:
Informat�on and Instructions
�fnsa:+.hu;etu Gc�xral Laws�hapter 132 cequim�II employ���s�etv�ich anoi�un,.fa any�coawet of hin.
1'ursuacu ro�his�:uw�.an�w/t��is defined a`...evaY P�
eaprcis uI impli�.�xa�ot wrictt0."
asweiuia�,oo�Paiaoa ar od�m k���Y.ai auy iwo a mar
An�rOfsl`d��p0d�s"u ia�dwl.P�t6ip. lo tr,ot che
oP�he fuceeoin��"1t�li�'a a�Ot10t�ueryrw'a+d�oe1wW��e le�al cepresenndva o!a deceaaad noP Y
uweiation or othar te�al eudtY.�a+PbYu+t��oY� �revet�bt
e
recaaver ot ttuwes�f ye iu�dividua�.D��P. md who resida theiei4�tht oocupw of dr
ownac of a�rdtin{haus m�^°s°O�mae th�e�ee apum�t
,�wepi�Couss ot aoodrr��P�OYs P�nau ro Jo maiatenance.cunaauccaa at repair work oo such JweUia�Aoua
merea shaU aw beeauM of ine►�plo�yom�be deemed to br rn employa.•
ur on rhe�nds or buildina appurtmaa� , _
132. ¢2SC(b)sW sro[es�hut"wery stW or loeal tlee�sbt 4��ry+�witiYoY tM luua�e►
�tGL chaP� h tb eemmO�wfa11\�K�.
nuwd ef�Ikew or p�rdt a opent��Mst�w o�ta w�struet baiW6aP
�pptles�t MM W Mt ycod�e�d aecephbN w1d�w ot co�ptla�o�wtt�t4 Wurs�et eovenp requtr�d."
aJditwmlly.MGL chapier 133. $2SC('f)uaoes'Neidier tAe conunaa�eallh mt mY o!ib politied�L��hall
f�� �d �('puWic wort uncl aeccpnble cvidence oPaampliance wi�6 the inwranes
ennr i�uo any conaaet P� - au�otity.'
requiromenls o[t6is chaPur haw beeu P►esanrcd ro the eonaae�nt
Appffe�sM
Pleaie fill out the workan' compensadon aPBdavit oompletab.DY ch�km`du boxa ehu apply m your sstustioo aa4 it
aub.conaacwi(s)aama(s��a)�P�O�nwnber(s)aloa;wit6 rheir cartiAcatds)ot
nace�sary�wPP�Y ip L ot Limited Liabiliq P��nerthip�ILLPj wiW no emploYaas other than tht
i��. Limital LiabilitY Compao (1- p��,c�����. [f au LLC or LLP doaa have
memben or puctae:s.am nd required m carry
employea.a po�uY�+ro4uired. Be advwed dut�bis atiidavit m�y ba submicred w the Depr�Emen[of faMia�rial
Accident+for conflfmation oP insursnce�°�'`'�siQ' �O���1O�1�asd date t6e vffldavlt lbs utYdavit ilauld
be retumed w[he city w oown that the application for the pennit ac license is bein� requeste4 sW eba Depacanent o[
tnJusaial AN:i�lenu. Should you have any queatioo�reQardinQ the law or if you rra required w obrain a,worlcen'
cumpentuioa poliey.PkaW call the Dapa�ent u ehe auwber listod below. SeIP-insured compauia s6ould anter theu
,nlf-insuraaa licenas number on the liae.
CIry or Tow�a OHklab �
Ptcau hc wrc thu cha affiduvit is complete and printed leQibly. The Depsetment hs�providsd u xpaaa•rt the botWm.
uC che aifii!•rvic for you to FIl out in the eveat dfe OtTiee af lnveati�aaona haa w conwct you rcQnrdin��he iPPlicant
�•�,:� pe sure ro ti11 in du p:R+�utisense numbtt which will bt u�ed a�a rcYerence nwiiber. In�ufdidun,an applicant
itwt mu►t submit muttiple petmiulicenae applications in aay�iven year,need only submit one affiduvit inditacin�curteat
policy informa[ion l if necessary)and under"Job Site Addrcs�"�he appucant 9hould write"uU la:ationr in_.(�iry ur
cuwn►."A wpY of tla uP(idavit dut ha�bem officially stamprJ or muked by�he ciry or town may be prov iJcd w clu
spplie•rnt u pmoP rhac a vuliJ afPulavic is on file for futurc permiu or licensea. A new atTidavit mwit be tllled ou�ue6
y�ar. W1�ue a hame uwner or cidmn is obuinin`a licenye or pmnit not rclated eo aay business or commercial ventura
�a
i i.e. a Su�{licerw or ramit w burn Invw ete.)u�d penua ir YOT requ'ued to wmplete this�t doviG
I'hc �)fii:c or Inve.rig�eiuna wvuW Ii:ce w �hank you in :,dv:uu� for yuut coopereciun and should yuu hrve:u�y questions,
p:caae du not hctieate to give us a call.
Thc D.partmrnY�aJdreu. ca�ePlwn�a^J fax numErr:
The Commonvrcalth of Massachusetts ,
pepanmeot of Industrial Accidentt
pma st[�w:dpden
600 Washio�oon Strcet
gosooe, MA OQ 1 l 1
Tel. p 617-727-d900 ext 406 oc I-877-I�MSSAFE
Fau A 617-727-7749
z,�„�� ;_a�-us www.mase.�ov/dia
, . CITY OF SALEM
PUBLIC PROPRERTY
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at��•s txr.�a�::�+fatsT�iu'.�4�IAVl1�'sw.��1s"�-
t111:rOrl+�l1!�R�te 9�J�6tW
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� con:crucdos Debrta uispo.al ,smdavtt
(�aluiroJ Ibr all darotitioa md�+anovatia�Mra1c)
In aowniatks w itA t!a slx�aditioa ot tM Statt Huildia�Cad�,7�0 C'l�l�sactics t l 1.!
pebci�,�nd t�proviuoeu of 1�tQ e 44 9 Sk
8uildtn�M+�it� _ . ia faw�ad�rid�th�000dlNae fiot�he debris rea+itins�os
ihis wak rhail b�di�posod of in a peop+rly Uctnred waa�dtsposol fSeiUty u deMed by vl(�.e
ttt.l110A.
The debris wiU b� cransporsed bS"•
1�6�51.��c ���s�t
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fhe:k-brii will bir di�y�osed uYin :
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; Atlantic Charter Insurance Company VDAC
'. NCCI Co. No.:29211 Policy Number: WCV00726901
1. INSURED: Prior Policy Number: WCV00726900
RA Erbetta Associates LLC
Producer.
PO Box 44 Willard D. Martin Insurance
Marblehead, MA 01945 Federal ID Number:510568770 Agency, Inc.
Risk ID Number: 189 Pleasant Street
Marblehead, MA 01945
Business Type: Limited Liability SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS
I�� Other Named Insured:
Other Work Places: See WCE107
i
... _ ----------------- � �-- ----
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� 2. POLICY PERIOD: The Policy Period Is From: 6/24/2007 To 6/24/2008 12:01 A.M. Standard Time
---- ---------.------_._. .- ---------
at The Insured Mailing Address
3. COVERAGES:
A. Workers Compensation Insurance: Part One of the policy applies to tfie Workers Compensation Law of the sfates liste
here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our
liability under Part Two are: godily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insured: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
All states except Monopolistic State Fund States
D. This policy indudes these endorsements and schedules: ,
See WCE105
4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates & '
Rating Plans. All information required below is subject to verification and change by audit
Code P�emium Basis Total Rate Per Estimated
Classifications No Estimated Annual $?00 of Annual
Remuneration Remuneration Premium i
See WC 00 00 01
Minimum Premium: Deposit Premium:
$197 $821
Interim Adjustment: Annually ',
Servicing Office: Total Estimated Premium $gpp '�
25 New Chardon Street Surcharge(s) 21
Boston, MA 02114-4721
Total Premium and Surcharge(s) $g2�
�ssue Date o6/26/2007 Countersigned By: Date��� 2 �i 2007
�opynght 1987 Nationai Council on Compensation Insurance � . - Fo�m:100m
.
�
� Fax/MAIL
Atlantic Charter Insurance Company
P.O. Box 3127
Boston, MA 02241-3127
Attn: Candace
Re: Policy# WCV00726900
June 21, 2007
Deaz Candace;
Please be advised that I, Robert A. Erbetta, wish to be included on the renewal policy for
the period 6/24/07 through 6/24/08.
Thank you.
Yours mily,
R.A. Erbetta
Cc Willard Martin Insurance
� �
MANAGEMENTDESIGNASSOCIATES, INC. PO.Box4QMaiblehead,MA01945 • TeC(787J631-9536Fax:(1B1)631-9451 •rae�betta@comcas[net
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