400 HIGHLAND AVE - BPA-07-299 UROLOGY ASSOC, SUITE 7 r
-
' PUBLIC PROPERTY
DEPARTMENT c�
I:I�MERLEY DRISI:OLL
MAYOR 120 WASHIN=N S`r4 ♦,UEK WAhSACHLM-M 0197e
TEL.978-745-959S* FAx:978-lie-9946
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
IsO SITE INFORMATION
Location Name: —r2A,,-vL r�.0 r Building:
Property Address:
�C� f�/6HLrtn/O �t ✓ e 5ulrE 7
property is iicmed in a;Conservation Area Y/N Historic District YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land 72ociGG r7-
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation X Number of Stories Renovated
Change in Use New
Demolition Existing X0005p'
Approximate year of Area per floor (sn Renovated
construction or renovation /9qE
of existing building New
86Pf Description of Proposed Work: ;
ndJi9[ r� ExSnN6 c.�o/LLS /l VOn- -
R4-t104r/N6 wVL-L
— ----- Mail Permitto: G�0/gIS
What is the current use of the Building?
2 yE 5
Material of Building? 2,1'��� 4-VJO°10 If dwelling, how many units?
Will the Building Conform to Law? U"-�s Asbestos?
Architect's Name N�'��tycic�V 2C- 4/Lo%V i rc G r s
Address and Phone Gy GOB Yi s> ✓AMd>oN�A- ( )
Mechanic's Name
Address and Phone
Construction Supervisors License# 03:2 0 32, HIC Registration#
Estimated Cost of Project$ '>odo O Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 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
specifications. Signed under penalty of perjury
Date c/ Z 7-0(�
04
3t 0 1 N V O
4 u L G,
CITY OF SAL.EM
PUBLIC PROPERTY
DEPARTMENT
KIIWFJL6Y D�lSCOLL LSEM 01970
�1nYos 1�Wws,os+Gn>N 5n�r C
� AI Fy %{A1�H
I.M.978-74S-9S9S•IFA)c 973-740-984
Construction Debris Disposal Affidavit
(required for all deinoution and renovation work)
to accordance with the sixth edition of the State Building Code.780 CMR section 111.5
Debris,and the Provisions of MGL c 40.S is issued with the condition that the debris resulting from
this work shall be dispos
ed of in a properly licensed waste disposal facility as defined by MGL c
111,S 150A.
The debris will be transported by:
�G C ov GV4,� Z-
The debris will be disposed of in :
(name of P cility)
(address of fociliry) /
s� K of emtit ap e
Z7 D h
date
CITY OF SALEM
' PUBLIC PROPRERTY
DEPARTMENT
KIMBERL EY DRISCOL L
MAYOR 120 WASHINGTON STREET♦SALEM,MASSACHUSETTS 01970
TEL.978-745-9595 ♦FAX:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/OrganizatiordTndividual): A501:20(y'L aU
Address: %,V I3 d T S S
City/State/Zip: = /, ' 110'IV Phone # :
Are you an employer?Check the propriate bo Type of project(required):
1.❑ employer
I am a em to er with 4. I am a general contractor and I
+ have hired the sub-contractors 6. ❑Ne construction
ey+Ployees(full and/or part-dine). 7, emodelin
2.0'I am a sole proprietor or partner- listed on the attached sheet. t g
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]P q ]
*Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy infonnatiom
t Homeowners who submit this affidavit indicating they are doing all work and dim hire outside conuacton must submit a new affidavit indicating such.
'Contncton that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. /
Insurance Company Name: GtJ��7�,—A / It"'OlCUIel
Policy#or Self-ins. Lic.#: Expiration Date:
— lob Site Address: City/State/Zip:
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 of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$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 up to$250.00 a day against the violator. Be advised 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 under the pains and penalties of perjury that the information provided above is true
//and correct
Signature: Date: —O l7
Phone#:
Official use only. Do not write in this area, to be completed by city or town ofciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
PANY RENEWAL CERTIFICATE
,/�ESTERN WORLD Renewing Policy Number NPP971442-1
NSURANCE COMPANY, INC.
I KEENE, NEW HAMPSHIRE
RENEWAL DECLARATIONS
Named Insured and Mailing Address (No., Street, City, State, Zip Code)
JAY LEVY & NEIL LEVY
dba BEDROCK BUILDING CONSULTANTS
P.O. BOX 3001
BEVERLY, MA 01915
z.
Policy Period: (Mo. Day Yr.)
From 04/13L to 04/13/07 12:01 A.M. standard time at your mailing address shown above.
IN RETURN FOR THE
ENT OF THE
STATED ABOVE. SUBJECTITO ALL THE TERMS AND CONDITIONS OF TH THE ABOVE E EXPIRING POLICY,LICY IS EXCEPT AS ST STATED BELOW.
THE FOLLOWING CHANGES ARE APPLICABLE TO THIS RENEWAL: ' 1.
(If no entry, then only the rates or premium basis changed - a
9 a shown below.) '
Attached Endorsement #1 denotes changes to and does not replace the original Forms and Endorsements List
Forma Added: CG2149; CG2167; CG2186; WW247 -
Forms Updated: WW104C; WW204A
Forme Deleted: WW392
LIABILITY RENEWAL CHANGES
Rate Advance Premium
Classification Code No. Premium Basis Pr/Co All Other Pr/Co All Other
EXECUTIVE SUPERVISOR 91580 28,600.(P) INCL 85.00 INCLUDED 51000.MP
CARPENTRY 91340 IF ANY(P) 13.22 27.32 INCLUDED - INCLUDED
SUBCONTRACTED WORK-RESIDENTIAL 91583 150,000.IC) INCL 7.60 INCLUDED INCLUDED
OFFICE 61226 30O(A) INCL 408.10 INCLUDED INCLUDED
Commercial Liability Advance Premium $0.00 $5,000.00
PROPERTY TERMS AND CONDITIONS
NOT APPLICABLE Property.Premium 80.00
Commercial Liability -Total Premium from above $5,000.00
Commercial Property -Total Premium from above $0.00
Terrorism Risk Insurance Act Premium $0.00
Other Charges $0.00
Total Advance Premium $5,000.00
State Taxes (4%) $200.00
Grand Total $5,200.00
i.
Countersigned: 217A ` ,y
DLW:CMS By
' APRIL 18, 2006 Authorized Representat!Va
QUINCY, MA 02169-7477
THESE DECLARATIONS AND THE COMMON POLICY DECLARATIONS, IF APPLICABLE,TOGETHER WITH THE COMMON POLICY CONDITIONS,
COVERAGE FORM(S)AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY.
HTB-WW243 (Ed. 07/03)