400 HIGHLAND AVE - BUILDING INSPECTION (11) EIT�OF�Elt
PUBLIC PROPERTY
i DEPARTMENT
MW b •wvuN�nN 17ra<T Snta�M,�naa;sers01970
TM-M-7459S9S•FAM M740-94K
A4PLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION,
DEMOLiTiO_N. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING `
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 1(2 A h 1u)cl Ave— Building: I, 21 S, G t;, 61 '7
la (70 <v)h lAn d Ave
Properly is located in a;Conservation Arse Y/N Historic Distird Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: F'as{ Can St Pronee715-
Address: � nU A' .
Telephone: q 7-'— 7
3.000MPLETE THIS SECTION FOR WORK IN EYISXIXG BUILDINGS ONLY
Addition Existing
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
add Description of Proposed Work:
jTK;,p 06 i,nsTo11 New �hP
Mail Permit to:
C oNoo�
What is the current use of the Building? N
Material of Building? 00&7-�, if dwelling.how many units? —
ye s d
Witl ltle Building Conform to l0 Law? Asbestos?
Architect's Name
Address and Phone I
Mechanlds Name
Address and Phone ZSY375'
Conalruction Supervisors License 0 Registration
Estimated Cost of Project S 9 y Pertnit Fee Calartatlon
Permit Fee= Estimated Cost X$71$1000 Residential
Estimated CostX St1/i1000 Commercial---- —An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields we property and legibly written to avoid delays in processing.
The undersigned does hereby a far a Building Permit to build to is above stated
specifications. Signed under ally of Perju -
Date---f-----
Al
N
s
I � v
ACORD CERTIFICATE OF LIABILITY INSURANCE ' °ATE(MM1 y)
T*" os/za12oo720o7
KNPROGUCER ERAN TION TLIN U (kll)BSGRO THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATON
KNIGHT INTEFNATIONAL INSURANCE GROUP ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
500 VICTORY'h?OAD HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
MARINA BAY ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
QUINCY MA 02171
1 INSURERS AFFORDING COVERAGE i NAIC a
i
I
INSURED INSURER A; FIRST MERCURY INSURANCE COMPANY
ALPINE PROPERTY SERVICES CO.,INC. wSURER B: HANOVER INSURANCE COMPANY
11 WILSON STREET
SALEM MA 01970 jINSURERC: ATLANTIC CHARTER INSURANCE COMPANY
!INSURERD: I
i INSURERE: -
COVERAGES
THE POLICIES OF INSUMNCE USWO BELOW HAVE BEEN ISSUED TO THE INSURED NM9ED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INeR;AOo•C; TYPE OF INSURANCE POLICYNUMBER POLICYEFFEttNE AotKY EAPIRATIOx DM17tT$ _.....
ITR IM.3iD DATE4111MDOIMGATE ro
!GENERAL LIABILITY 'FMMA001186 06/14107 06/14/08 w EACH OCCURRENCF Is 1,000,000
X COMMERCIAL GENEM O L"IUIY' N ETOFBPTED _
'CLAIMS MADEi'— ' P MMLS W wzrtnu) IS _.�.000
I X OCCUR ;NED.EXP(Any oAe ptroerp . . $ .—
A X: e!ani.el Adaa�oAAI InsvAb ircaxAO ____
PERSONAL k AOv INJURY !S 1,000,000
X;We1wH a SuOroBation ircluacd _....__
' GENERAL AGGREGATE is 2,000,000
CENL AGGREGATE LIMIT O APPLIES PER: : iPRODUCTSCOMP/OP AGG. �S 2,000,000
I POLICY I X! JEC LOC!
AuroMoelLE Luewn _ I AFN857158"0 01/09/07 09109/08 COMBINED SINGLE LIMA
ANY AUTO ! I I i(EeatGOeM) .$ 1,000,000
ALL OWNED AUTOS ! 180011Y INJURY ---_ _----_-
' SCHEDULEDAUTOS i(P'r P6TEDx) $
B ' X HIREOAUTOS
X NON-OWNEDAUTOS i I BODILY INJURY S
:PROPERTYDAMAGE
' (Pa ecddlsn) {5
i GARAGE UABI IIY
ANY AUTO AUTOONIV_EAACCIDENT -
! OTHERTHAN EA ACC j$
:AUTOONLY: AGO is
EXCESS T UMBRELLA LIABILITY' CUMA000117 06/14/07 06/14/09 I EACH OCCURRENCE is ___ 5,0001000
CLAIMS OCCUR _J CMS MADE ' I AGGREGATE iE 5,000.000
A ..._..... ..
DEDUCTIBLE—X RETENTION S { ! 1$
10,000
i 'ff
WORKERS COMPENSATION AND WCV00754200 EMPLOYERS'UABDJTY 09f05/07 ! 01l05108 ! X roREv uNlra !oTxeR .
I
C E.L.EACH ACCIDENT ,$ $00,000
I DFFICEWNEMBE0."Mum? '--'-
!� E.L.DISEASE-EA EMPLOYEE $ 500,000 Dyea,a.e m..Aa.. .BPErAI PIWYIBIDNS mlu. f i i �E.L.DISEASE-POLICY LIMIT ff 50Q,ppp
i OTHER:
DESCRIPTION OF OPERATIONSILOCATIONSfVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ASOvE DESCRIBEo POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL CNOEAVOR TO MNL 10 DAYS
wartTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO JnE LEFT.BUT FAILURE
TO OO SottALL IMPOSE.NO OBLIGATION OR LIABILITY OF IONO UPON THE INSURER,
ITS AGENT F
OR REPRESENTATIVES.
AUTHO 1 REPRESE
Attention:
ACORD 25(2001/08) Cen!ficate t: 6918
0 ACORD CORPORATION 1988
OLYMPIC
Painting,Roofing&Siding office 978-535-0943
515 Lowell Street—Peabody MA 01960 facsimile 978-535-2008
Cyndy Ansehno
East Coast Properties
400 Highland Avenue
Salem,MA 01970
978-741-2003
978-745-9684fax
Property Location
Highland Condos
BLDG 21
I-7 Lyons Lane May 15,2007
Dear Cyndy,
Pursuant our conversation I have prepared the following estimate for the roof replacement of the above
units. Below is a detailed description of the work that will be performed.
I would like to point out the importance of stripping the roof verses shingling over the existing roof:
a. Stripping will allow us to install ice and water shield directly to the roof decking
b. We would install all new drip edge throughout the roof
C. There will not be any additional weight load by having two layers
d. With today's shingle quality you should get 25 years of shingle life or more
e. My company will be able to warranty the roof for a period of three years
Installation Procedure
1. Strip existing roof
2. Strip all transition walls and install ice&water with step flashing
3. Install ice&water shield on the perimeter
4. Install an 8 inch drip edge
5. Install 15 pound felt paper
6. Install a new ridge vent system
Additional Specifications
1. Condo Association to choose color of shingle
2. Cost for any decking replacement will be$5.00 per foot for the
3. Olympic shall be responsible for the removal of all debris and dumpster expenses
4. All Shingles will be GAF 3-TAB,you may choose to upgrade to an architectural for an additional
$20.00 per square. Each unit is approximately 10 square.
Cost for Labor&Material: $9,450.00 per unit
Warranty: Olympic Painting & Roofing guarantees all work performed for a period of one year. If any
problems occur, a will er the cost of all labor and material to carrte problem to meet the
custom s so i cti C %
George Vasiliades,President Cjqy 6hselmo
Olympic Painting&Roofing P erty Manager
l
CITY OF SALEM
I PUBLIC PROPRERTY
DEPARTMENT
11C WA91lN'1:'CONSCREET •SALP\1. SfMiAC;n iL l•15;;9��
Tru:979-743-9595 #r.%X:978-74G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Ch1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ ._ __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by vIGL c
111. S I50A.
The debris will be transported by:
Cl ades VCar;\2_T�fuL{-"n Y
(name of hauler)
The debris will be disposed of in
A ll l'ej .....lXlG s Fe
(name of facility)
_ 00 . 5_r Pevlpdy
iadurcin of 1JC:Ll;/)
-� CITY OF SALEM
r _ Od1 PUBLIC PROPRERTY
DEPARTMENT
;JxtaiiRTFY DRIS XA-L
M vat 12CWASHI.NGf0,NSTREET0 SALr:W,MASSACIn:s:'l IS 0197�v
'ftj:978-745-9595 9 FAX:978-740-9346
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.applicant Information q� y Please Print Legibly
Name (Business/Organi7atiorVIndividuul): V�YM /�I L P� t o I ITt4
Address: .515 L ot.,Pll S'f
City/State/Zip:ge� 144 , Z D1g6y ['hone 11: 9'7,Y-
Arcrvv art an employer? Check the appropriate box: 'Type of project(required):
1.Ly 1 am a employer wish G/7 4. ❑ 1 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 sub-contractors have S. ❑ 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.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.yRoof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑ Other
-Ally applicant that checks box al must also fill our the xectiou buluw showing their workus'cumpunsation policy inhumation.
' i Wmeuwrters who submit this affidavit indicating they are doing all work and then him outside comrxrors must sutmtir a new affidavit indicating such,
jC,mtmu rs that chuck this box must at1whed an additiunul sheet showing the name of the sub-contracrors and their workers'comp.policy information.
I ern tin employer that tv providing workers'compensation insurance for may employees. Below is the policy and job site
information. /
Insurance Company Name: h n h t_i'det'll,jigriez.,/ l�su+ � n e n 911✓
Policy #or Self-ins. Lic.it: W C_V p 0154 qQQ. ._....____ Expiration Date:
Job Site Address: 400 hnSh le"I L+t 5 f City/StateiZip: sr—le, Y1e1s 01Ct-70
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 ul'MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 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. Ilc advised that a copy of this slatement may be forwarded to the Office of
In%\' 11gatlVns oI the DIA for Instuance coverage verification.
I da hereby certify under the wins mtd penaties of perjury that the information provided above is true
/u/r°d correct.
SI L':1W _ DatCr — I _ V 7
Phone:�:
Official rise only. Do not write in this area,to be completed by city or town ofjiciuL
City or Town:
Issuing Authority (circle one):
1. Board of health 2. Building Department 3.Cityffowu 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."
.fin 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."
h1GL 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, [vIGL 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 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)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 ut the,bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitllicense 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 tilled 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 licence or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I'hc 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 Lind fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office 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