276 HIGHLAND AVE - BUILDING INSPECTION (4) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wNtar RIF.Y Ualf[]lLL
M. Aytla 12C a$AtJ[K w.%2LAan.Lo-7.1\01970
TILL:97L143.9595 a FAX:97i740-9946
Workers' Compensation Insurance AlIdavit: Builders/Coatracton/Electriciaru/PMmben
Aonllcant Information (� Please Print Legibly
NamEtfillvnvss!(kasniruituvtlulrvlaAnn:
Address-
Cit /Ststcizi ar�\<�-ti^^ . yv p a��'L
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Areyou an eatpleyer7 C"he appropriate bow 14pe orprojeet(required):
I.t12} 1 am a employet with 1 4. 131 am A general contractor and 1 6. ❑New construction
employ(.•=(full and/or puvt tine). have hired the sub-contractor
2.0 1 am a sok proprictm,or partner. listed on the attached sheet. t 7. bi Remodeling
ship and have no employtxa Theca have V. 0 Demolition
,vorking for me in any capacity. worker' comp. insumnec 9. ❑ Budding addition
(ISO worker'comp. insurance 5. ❑ We am a corporation and its !0. Electrical roquirtxl) officer have exercise!their ❑ repairs or additions
3.0 I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repair or additions
myself. (No worker'comp. c. 152.41(4),and we have no 12.0 Roof repairs
insurance required j t cmployeos.LNO workers'
13.0 Other
com insura p. nix ccquired.]
pity 4pptia'ani the Chucks boa at man also as"the sectim b61mv rhowiae eleir Irlokms'cwnpwldiuw puli.y infiumuiod
I t,rw,lwnms who submit this amdwu indkatina May ale Juice d)wWk and Ih®hie auuide eamraetoe mml.ubmil a raw amda•it indiadina auk.
'f�alal'XLlfa lttY C Wrk Ma boa mtlN anaehed all adJitiooal disci Lhawila MC flame orals aMKelmprtaa Ind Ihmr Wet1'e1a'COlap•pWlry Mferlllmllla,
lam ton employer that lr provlding workers'compearadon hrsmraaee for my etnptoyeer. Below Is the pa/fry and Job site
Insurance Company
Policy 4 or Scir-ins. Lie.
__- Enpirdtton Date: l
J00 Site Address: a-1 6 , ,:f>> Q^ �(, CityrSlawZip:-4'Nvsn t v,P
.%ttach it copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure w swum coverage as required under Section 25A of.IOL c. 152 can lead to the imposition of criminal penalties Ora
ri ne up to 51,500.00 and/or one-year imprisonment,as well as civil pcnalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy urthis statemunt may be forwarded to the Office of
Iit\Yalhal14115 af•t a f0f IOl .Ll• Ct1Y Cta4e YCflticahan.
/do hereby renij sad r par s and penalties ajpeiJmry that the injarmallon provided above is Irmo and correct
2 41 ®�
O/J!aial art amla Do war writo/a fhis area,to At completeid by city or Iowa off eW
City or 'rown: Permit/l leeltse 4
Issuing Autburity (circle onc): —
i. ILtard of ivaith 2. Building Department 3.Cityirowa Clerk 4. Electrical Inspector 5. Plumbing lospector
6. Other
Gmtact Person: _ I'honc p
Information and Instructions '
,%Iaasachuscus General Laws chapter I52 requires all employ workersrs to provide another under any onnmd w' compensation for titeir �
an
pursut to this statute.an ewpfeyee is defined as'...every person in the derriere
e%press or implied,oral or writtim-
er�e�is debited m-on individual.Pam,asmeanee,corporation or other legal entity,or any two or aloes
of the foregoing engaged in a joint eruerprim and including the legal representatives of a deceased employer.or the
uaoeiation of other legal entity,employers employees' However the
receiver err ttttateo of m individual. ag gang aht a and who resides therein.or the occupant of the
owner of a dwellint house baving not mere than three apartments
dwelling house of another who employs persons ro do maintenance,cuoaauca°n or repair work on such dwelling hairs.
or on the grounds a building appurtenant themt*shall net because of such employmcat be decreed to be an employer."
MGL chapter I52. 625g6)also st
ates that"n'esY state or I"licensing agency skat withhoM tba isun ee an or
operate a business or to construct buildings In the commonweahk for any
renewal of a license or Puma to
applicant wbe bar slat produced seeeptable evMaate of compliance with the Insurance coverage required."
Additionally.MGL chapter 152,$25C(7)states"Neither the commonwealth nor any of in political wbdivisioos shell
for the performance of public work until acceptable evidence of compliance with the insurance
enter into any of
chapter
Perf - authority.'
requirements of this chapter have been presented to the contracting
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub eontractor(s)name(+).address(es)and Phone number(a)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 t licenseigmas is being d date he norequested, not the aft1da nensho f d
be returned to the city or town that the application for the permit
or lodustriul Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
lease Call the Department at the number listed below. Self-insured companies should enter their
compensation Policy.p a line.
self-insurance license number on the
City or Town officials
Please w 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 die applicant
I'luase be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
thrt must submit multiple Pe applications in any given year,need only submit one affidavit indicating current
policy must
subtstinn multiple
(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 maybe provided to she
applicant as proof that a valid affidavit is on file for future permits or licenses. A now affidavit must be filled out cub
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
I'hc Ot ti;u of Investigations would like to thank you in advance for your cooperation and should you have any questions,
plcabe du not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Depattment of Industrial Accidents
Oaksi of bvestiptlees
600 Washin0tan Stied
Boston,MA 02111
Tel. #617-7274900 ext 406 of 1-977-MASSAFE
Fax 0 617-727-7749
2cvi.cd 5-26-05 www.mass.gov/din
05/31/07 15:32 FAX 16 002/002
AEORD CERTIFICATE OF LIABILITY INSURANCE „Zgio z cos 3�0�
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION -
Eastern States Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
50 Prospect Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Waltham MA 02453 -
Phone: 781-642-9000 Fax:781-647-3670 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSLIRERFc First Mercury Ins. Co.
INSURER B: Ae 1. Antaenauonal exuw 43974
Vision Builders Company Trust INSURER Hanover Insurance Co. 22292
Anthony Gagliardi
615 Concord St@702 wSVRER D:
Framingham MA 1
INSURER B '
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 AFFORMI)BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLXAES.AGGREGATE LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NS TYPE OF INSURANCE POLICY NUMBER InA MMFDD DATE M LIMITS
GENERAL LIABILITY EACH OCCURRENCE S ,51,000,000
A X COMMERCIAL GENERAL LIABILITY TEA 05/27/07 O5/27/08 PREMISES . 3$50,000
CLAIMS MADE 7 OCCUR MM EXP(A y one penwn) s $5,0 0 0
PERSONAL SADvINJURY S $1,000,000
GENERALAGGREGATE S $$2 O00 ODO
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPAOP AGG $ $2,000,000
POLCY LOc EMP Ben. $1,000 000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
C ANY AUTO TED 05/27/07 05/27/08 (Et am `) $ 1,000,000
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Peroemon) s
X HIRED AUTOS LLOOILYINJURY
X NON-OWNED AUTOS - (Peraodden0 B
PROPERTY DAMAGE S
(Pe,a[ridenQ
GARAGE L.IABILIry AUTO ONLY•EAACCIDENT S
ANY AUTO OTHERTHAN EA ACC S
AUTO ONLY: AGG S
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CWMS MADE AGGREGATE S
S
DEDUCTIBLE S
RETENTION S 5
WORKERS COMPENSATION AND TORY LIMBS ER
EMPLOYERS'LIABILITY
B WC 684-13-68 05/27/07 05/27/08 E.L.EACH ACCIDENT $SODOOD
ANY PRIVNIEM ORIPXCLUDE/FJD:CIRNE .
OFFlCER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $SOOOOO
V%de eunder
CIAL PROVISIONS Dhow - - EL DISEASE-POLICY LIMIT 55DDDDD
SPE
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
EVIDENC SHOULD ANY OF TH E ABOVE DESCRIBED POLICIES BE GANCELLED EEFORE THE EXPIRAITON
DATE THEREOF,THE ISSLANG INSURER WILL ENDEAVOR TO MAIL _DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Evidence of Insurance IMPOSE NO OBLIGATION OR LIABILITY W ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES
AUTHORIZED REPRESENT
TAATIVE
J
ACORD 25(2001108)- ®ACORD CORPORATION 1988
CrrY of SALEm
PUBLIC PROPRERTY
DEPARTMENT
t'l7.\eN::Jra1sR•1�to->•.1L�\YN�M•t61sii9
Construcdon Debris Disposst Affidavit
(requiml for an danoiition aid naeovativn work)
In=Wdsnce with the sixdt cStias d hs State Building Coda 730 06111t sactim 111.!
Deb<*sad the provisions o(MWL a 44$ St
Building;Permit 0 _ _ issued is with dte eoadttios that the debris reatdng f M
this wort shall be disposed of in a prvpady licensed wrier disposal, &dlity as dented by M. GL e
111.1115G&
The debris will be transported by:
laomr o(turt+d
rho dlcbds will be disposed of in :
YhO 1rj-A4C
(a.rnr uY fa.,tuy)
t'..:i.iy�
city l 7fiE7ss �
'f Fire 3epatt ten
A ry
C � Cf
+ 48 Gafa et e Street T -` -_ j
Salmi; Ylasacfvrsetfi01970- i 24 Fort Av:
Robert 7� Turner ire✓ention
Ck e 4eL 47B-744 W5 Bureau
978-7441-05V Fox 97�-7454646 r , 4 ":97& 745-7777
FIRE`DEPARTMENT"'CERTIFICATE OF APPROVAL FOR A BUILDING PERMIT
IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE
AND THE SALEM FIRE CODE, APPLICATION IS' HEREBY MADE FOR TEE APPROVAL OF PLANS
AND THE ISSUANCE OF:A CERTIFICATE OF APPROVAL FOR A. BUILDING PERMIT BY THE
SALEM FIRE DEPARTMENT; - ( Ref `Section'113 -3 of the Mass. Bldg. Code)
JOB LOCATION: 4 -)-(to H 1 y4knd iWy
OWNERIOCCUPANTi ATIYtSS �. r S
ELECTRICAL CONTRACTOR:
v
FIRE SUPPRESSION CONTRACTOR:
sirmi RE or
`- -APPLICANT: 'C ?' ^J PaOxE
> y ,
ADDRESS OF 4 ` crry`OT
, APPLICANT l0�'S ao4 j�K'V T_5 y ' /tl/U��'�yl�"'�-tTOM:
•= APPBOVAL'DATE:_
Certificate Ofapproval is herebq'grsnFed, an approved`plins or submittal of
Project details by the SALW4 FIRE,DEPARTM3ft_. All plans are approved solely
for identification of-tppa and16cstion of`fire protection devices and equipment
- All plans''are subject:to .appravar of any other authority having jurisdiction.
Upon ab pletioo; the applicant> 1t installer(s)'`shall request an inspection and/or
-test of,`the`tire. protection' devices and equipment.` (ADDITMONAL REQUIREMENTS.
SEE RVERSE SIDE
ftW CONS
TRIICT2ON: f
PROPERTY-LOCATION HAS NO COMPLIANCE'WIT3 THE PROVISIONS OF
CHAPTER 148, .SECTION 26 C(E, M.G.L., RELATIVE TO THE INSTALA-
TION OF APPROVED FIRE ALARM DEVICES. THE OWNER OF THIS PRO-
PERTY IS PEQU= TO OBTAIN COMPLIANCE AS A CONDITION OF ,
OBTAINING-A BUILDING;TERMIT.
`PROPER—Is LOCATION IS IN COAIFLIACNE TYtt THE PROVISION OF CHATTER148, SECTION 26 C/E; M.G.L. .
ERPiRATION DATE-: - - -
SI f,'A7C'? Or Fi?. Oxr t; AL
r OE: UNDER 7,500^ SQ. 6F?. - $30.00 u ;- 81 37 $
J SQ. FT, OR L GIP.- 8
CHECK#a
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMNERLEY DRISCOLL
MAYOR
120 WASHINC'CON 5'txEE"r 0 $ALEAt,MA.SSACHti$E71S 01970
TEL:978-745-9595 ♦ FAx:978-740-9846
2007
Sa �� Fire Department
TVt A
DearGhW LT.6le fF/A/
Please find the attached set of plans for the proposed construction for
/!/ ESJ (9/L1N?— located at 276 H/6 NCR d� _,
as shown on Assessors Map #_..__,block lot#
I am forwarding these plans to you for your review per the current regulations of 780 CMR
(Massachusetts State Building Code) Chapter 1 - section 110.8 and Chapter 9 - section 903.1. Please
review these plans for compliance with Chapter 9 and/or Chapters 4 & 34 as applicable. Please forward
notice of your approval, disapproval, or request for an extension of time for review, to this office within ten
(10) days. As provided in Article 1 section 110.8, if your approval, disapproval, or request for an
extension of time is not received by this department within ten(10) working days,the plans will be deemed
to be in compliance with the applicable sections of Chapters 9, 4, 34 and, therefore, approved by you.
For the purposes of your review, it has been determined that the proposed use group(s) is/are
Q SS and the proposed construction type is 33
A 780 CMR fire protection narrative is attacl not;attached
A 780 CMR Chapter 34 evaluation is attac not attached
Thank you for your prompt attention to this matter.
Sincerely, /
Building Inspector
Cn-f OFgXLE1�
Y ' PUBLIC PROPERTY
DEPARTm&NT
tyros 13p wesn►w�+w�•surw wsuoasas ois7o '
h:m�+s-ss,s•res m�agets
A_pPLICATION FOR TM R>!pA_M R>irNOVATION CQM j3] ii['T1 Q
D&NAM M OR CAANGZ 0>r U3Z Olt OCCUTANCY FOR ,ANY fMffIN
STRUCrURZ OR BIMJMG
1.0 SITS INFORMATION
Location Nemee p ' C5 Glare 1'VR0L�S eultdr,a
--- Piopetty Add` 1:--------\-- — -- ----- -
a,L
Properly le kxabd Ins:Correm*w Am YM L) Hktotb DkMd Y/N rJ
F2LIOwnwafta"
ERSHIP INFORMATION
L��rSs i4
�A
Tel.pl,on.: Vqn I>
3A COUPLETS THIS SECTION FOR WORK IN M( @M= 9UILDINGS ONLY
Addition Existing
Renovation (/ Number of Storks Renovated
Change In Use New
FA.
Existing
OJD
year of Area per"am NO Renovated
or renovation
ilding New
on of Proposed Work:
p.hS y �'+,,,a^\fN ".,.�
--- -- ---Mail Permit to: - - -
What is tM cwraet use at 00 Budd ft?
Matarbl a Buidkq? Y'^'�""' If&A*0416 hoer many units? -
Asbodn? "jO
AnNIOds Nan'*AddrMs sttd P1►otw a.\ S3 5"1
Medtsnies Name
\�' c,�<2 � , �'iA.r:rS�•�, ,..� l ,reel � 03 63
Clause CS os`2 3"1 HOC Rapbtrdfott•
EstYnatad co.R�a�P�.�oj.�a�t s — PM+"c•bwsuon
Permit Fee f -=d Estlmafsd Cod X=7/s1000 ReaMentid
-- --- — - Edrr+dsd Cod X:11/:1000 Conwnada�-------
M Adds =nd U.00 to added sa an
Adminboadim dwpa.
Make aum that aU flelds are properly and too*w►htan to avoid do"In P nO
TM undersigned does hereby apply far a BuUdit Pon* the above stated
spwjkadwa. Signed under pwlaft Of PWAO ,-
Date
o)
o
A4ftj