488 HIGHLAND AVE - BUILDING INSPECTION .,. . �
� CITY OF SALEM
�/'� . � : PUBLIC PROPERT'Y
y� DEPARTMENT
IKIMdERLEY UAISfO1,L
MAYOR
1ZO WASHINGTON S7'ItiGT�SALHM,MASSACHUSP.TTS O1B7O
� "Cec:978-745-9595�Fnx:978-740-9846
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT:A licaots must com lete all items on this a e
SITE INFORMATION
Location Name� � Building /l�Q —�1��N%�_ .
Property Address
�r[S t�i }-4-i C�1�L PC�� A1!��7'vlF
� Located in: Conservation Area YM Historic district �
APPLICATION DATE � �O I � �
Use Groups — �x��sr�.,4 �CFa-=c.�''r;` �Uv"�'v` .
(check one)
Group Homes R3 R4_
Residential(3 or more Units) R2
Type of improvement Residential(hotel/motel), Rl
(check one) Assembly(Theaters) - Al
New Building_ Assembly(restaurants&clubs) A2r_A2nc_
Addition Assembly�(churches) A1 _ �
Alteration Business B
Repair/Replacement� r'�''`F-�'"jD' t\�Pd��ir Educational E
Demolition Factory(moderate hazard) Fl
Move/Relocate Factory(low hazazd) F2 � - � - � �
Foundation Only High Hazard H �
Accessory Building -Institutional(residential care) Il '
- institutional(incapacitated) 12 ,
Institutional(restrained) I3 �
Mercantile M � �
Storage Sl Modera[eHazard� �'
Storage S2_Low Hazard � � ��� :
I � � N r
b L: -y M_
OWNERSHIP INFORMATION(Please type or Print Clearly) , � o 't7 � �,
bA � o0
OWNER Name VE¢.�zcU U� cc��.��5 �%- •Sor.-� �ACo-tLuc�„�oD�/ � � �„ �
Address +rk;c� �pa�� � �'urti � luac��,�ayiv,ta �u� piSB i i � �� � �
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Telephone 6 {g - , 3Li o o �
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Signature :�n � � �� o � �
DESCRIPTION OF WORK TO BE PERFORMED �.���: a 'G
I?i—�, Aa� S,�t1H� EitiSl/�lc PRA�6-L /�L'1�h:N�l-�� UI�-L' i � � ,
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ESTIMATED CONSTROCTION COST I OL7C� � ,
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� CITY OF SALEM
� ��r PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRItiCOLL
MAYOR
120 WASHING'1'ON S7RGI^_T�SAI.EM,MASSACI NSETI'S 01970
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CONTRACTOR INFORMATION /� .
N&iRe .��5��= �-s4.Di�+N �- �F i�RcA 41L��AV.Y.)'C R'1 L�NS..
Address �ir 3 Co�nr ��1�L�dnovm+ � I�na O�,6a
Telephone (iz�.)ss€Fj -£uZ`�
Construction Supervisor's Lic # O� 'h"1
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name F FtMni� i1.�,o�A-N d4E.�2 .�4� '�Ec"n7.wV�
Address 5�9 i�e�+-r b�va. .�u�SS-`� � Willt�FELT ;WJ� a i ��v
Telephone 1�-fii� Z5r o��Y�
Mass. Registration # y���'�
PERMIT FEE CALCULATION
' Estimated Cost x $11/$1,000 + $5.00=�- 1�'_Q6
COMMENTS
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the penaltie of perju
Signed � — V�-'ty..c-� LU� — r ner) (agent)
�
APPROVED BY: �
DATE APPROVED: �� ����1
_ _ _ .
� CITY OF SALEM
� �a� PUBLIC PROPERTY
DEPARTMENT
KIMBERLEYDRISCOLL . �
�AY�R 1?O WASHINGI'ON STRF..ET�SdI.FM,MASSACHUSETTS 01970
"1'sc:978-745-9595�Fnx:978-740-984G
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/r.t � T/te Conmeonwealrh ajMassacGuseas
L�4 Uepnrtment oJlndaslrin/Accide�rts
Ojfice of/nvestigatrons
600 Washington Slreet
� Boston,MA 02171
www.mnss.gav/Aia
Workers' Compensation lnsurance Affidavit Builders/Contractors/Electricians/Plumbers
A licant InformaYion Please Print Le ibl
Name(Busincss/Organizatinn/Indi�idual): �-�e; nrP�. �ni,�.n..an; e+;..�g LLC_
Address:_ol'1,5 Q� �`owr"T' ��ee'Y"
City/State/7ip: �IU m�-r.. rnA oa3t�o Phone#: ��• �Y��7 -�03"7
Are you an empinycr?Chetl<the appropriate box: Type of projecl(reyuired):
1.� I am a employer with �0 4. � I am a general contractor and I 6. ❑ New construciion
employees(full and/or part-�ime).' have hired the sub-con[ractors
2.Q I am a sole proprietor or par(ner- listed on the attached sheet.; �� ❑ Remodeling
ship and have no employees These sub-coniracrors have 8. ❑ Demolition
working for me in any capaciry. workers'comp.insurance. � 9. ❑ Duilding addition
, [No workers'<omp.insunnce 5. � We are a corporation and iLs '
required.] officers have exercised iheir �i �0.❑ Elecirical repairs ur addi�ions
3.❑ 1 am z homeowner doing all work right of exemption per MGL ��.❑ P�umbing repairs or additions
� myself.�1Jo workers'comp. c. 152,§l(4),and we have no �2,� Roof repairs
insurance required.j� employees[No workers'
comp.insurance required.] 13����her_
'Am�applicam tha�check'box HI must aiso fJl ow�be sectiov below sbowive Ueir workers'compensa�ionl�polity info�mation.
��Homeowners who submi�tLis atLEavit inAica�ing they ve doing all work and Nen his ontside convecmrs mua submii a`rew andavii indicating such.
�Conrta<mrs thm check this box mus�anacM1ed an addiiional s�ce�sbm•�ing the name oflhe sub-conrtacwrs nnd their workers'mmp.pulicy iN'onna�ion.
1 am an employer 16a�is providing worRers'compensntioii insurnnce jor mp employees. Below is Ihe pn/icy ond job site
informntion. '
InSurance ComPany NamC:�}�lc�.}j C �bbf_'f,�r J-��i�llin['P ��n M D!.'yp�._
Policy t or Self-ins.Lic.N:�G���G']�/d��;} _ Expiralion Dale:�. I'��2.0(C
Job$ite Address: �G� i�hQm�..t,� /�.t2 Ciry/State/Zip: � Y�U� G\"(�Z�
AUach a copy of the workers�cmnpensation policy declaration page(showiog the policy number und expiration Aate).
Pailure to secure coverage as required under Section 25A of MGL c. 152 can lead[o ihe imposition of criminal penalties of a
fine up to$1,500.00 and/or une-year imprisonment,�s well as civil penalties in the form of a STOP WORK ORDER and a fine
o(up to$250.00 a day againsi ihe violatoc Be advised ihat a copy of this statement may be forwarded to the Office of
Imes�igations of�he DIA for insurance coverage verification.
/do hereby cerli !he ains anApenalties of perjury thot[he information provided above is bue ar+d rorrect
Sienaiure: � �� Date: 4/��0�
Phone N:
Officia/use axlv. Do nn1 write in!h"v�nrea,Io 6e cnmpleted by ciry or town ajfu•inL
City or Town: Permit/License#
Issuing Au�hority(circle one):
I.6oard of Heallh 2.13uilding Departmen[ 3.City/Town Clerk J.Elecirical Inspector 5.Plumbing Inspector
4.Other
Contact Person: Phone#:
�, ��
�-�o���s sc�Nu�:sr�c�iorf��fl,�,�i���,�i.�R���d�e'fi�i�`r,riNs"Ua�Nc�:�qWcv .
� ,S> .�.,, .<� .�.�. 1.`�. ,?""yiY;;,��7,fD�il2flpll`PeyC.:_�"+' �` �'.ad� ° ;WC.UODD'01 ��
Atlantic Charter Insurance Company VDAC ��
� I NCG Co.No.:29211 Poticy Numbe[ WCV00766202
1. INSURED: Piior Policy Numbe[ WCV00]66207
Heidrea Communications,LLC
Protlucer
275 8 Court Street The Driscoll Agency i
Plymou�h.MA 02360 Federal ID Number:71�Ot9655 PO Boz 9120 I
I ftisk ID NumDer. Norwell,MA 02061
Business Type: Limitea Liabiliry I
SIC:9999 NONGLASSIFIABLE ESTAB�ISHMENTS
Ot�er Named Insuretl: Ot�er Work Places: See WCH07 �
�______ _"' —_'_-- —___"'_—_—___ _"__--_"_ '__'__ �
2. POLICY PERIOD: The Policy Penoa Is From:3l152009 To 3/1520�0 12:0'I A.M.Stantlard Time
a�The InSuretl Mailing Atla�ess�
'_"—_'___"—"_ _ _—.__""—__ ..__._-____—___"_—__"'_
3. COVERAGES:
�—_—.___—. _ ,
IA. Workers Compensation Insurance: Part One of ihe policy applies ro t�e Workers Compensation Law of cne states fisre�
here: MA
B. Employers Liabiliry Insurance:Part Two of Ihe policy appiies to work in each slale listetl in ilem 3A.The limi�s of our
IiabiliN under Patl Two are'. BoOiiy Injury by Accitlent $ 1,000.000 each acciDent
Boeily injury by Disease S ipD0,000 policy limit
Betliy Injury by�isease 8 1 000,000 eac�employee ! .
C. Other States Insuretl:Part T�ree af the policy applies to the sWtes,if any.listetl here: �I ,
- COVERAGE REPLACED BV ENDORSEMENT WC 20 03 O6A
I
All sUtes except Manapolistic Sbte Fund States j
D- This polity incWEes these enCorsements an0 schetlules:
See VJCE105
� � The remium Iw Mis olic will be daieiminetl b ow Manual o!Rules,Classifications,ftates B
4. COVERAGES: a p r r i
Rafing Plans.A!1 inlormation requiiea below is suDjecf fo venlrwfion antl Mange by au0if.
Cotle P�emium Basis Tofal Rate Per Estimafetl I�
Classi�caGons ESGmatetl Annual E100 of Annual �
� I Remune2tion Remune2tion Premium I
—_--__". —__.._. ..._.o. .__ __—_ ."__._._._—_'_ _._ ._.._"_'_—
I I
See VYL 00 00 01 I
I
I r � -...•• t���N1i[IRr:. ..
IMinimum Premium' Deposi�Premium:
i � I I$575 $6,66C MAR I ,i �Q�� — --'-'--
�utly Tcth
i I In�etimAdjus�ment: Annually
IServicingOH�ce: TotalEstimaledPremium $1�,9t�
I Surc�arge(s) 708
, ; I I 25 NEw Cha�tlon SUeet I �
' �. Boston.MA 02119-472t �
'. � � Total Premium ane Sumharge(s) S�Z,g�g
�_.____ —_"'__'_____"_ .__ ___. —__"—"______—__"_'-_-__—"_'_" _
�� ' I Issue Date 03I052D09 Countersigned By:_ ____ _______ _,______ Date
CopygM1�i88]NatlonalCoun[ilonLompensa�onln5u2nC¢ � PoIm:�COi
-- -
, �r
',r4
ACORD CERTIFICATE OF LIABILITY INSURANCE 4iz2i2o 9'
PRODUCER (781) 681-6656 FAX: (781) 681-6686 THIS CERTIFICATE IS �SSUED AS A MATTER OF INFORMATION
g Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
The Driscoll A ency, HOLDER. THIS CERTIFICATE DOES NOT AMEND, EX7END OR
93 Longwater Circle ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. -
P.O. sox 9120 .
Norwell MA 02061 INSURERS AFFORDING COVERAGE NAIC#
INSURED WSURERA:LO[1CSNfli]C P.IR0i1CflI1
Heidrea Communications, LLC iNsuReRe�The Employers' Fire Ins
�, 275 B Court Street iNsuzeRCTravelers Casualty 6
INSURER D:
Plymouth MA 02360 INSURERE:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDING ANY
, REQUIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT VNTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN,
THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED NEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OP SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAV HAVE BEEN RE�l10ED BY PAID CLAIMS.
, INSR ADD'L- rypE OF INSUftl1NCE POLICV NUMBER OATEYMMIpD/TY�YVE POA�TE MMIDD Y�Y�� LIMITS
GENERAL LIABILITY EACH OCCURRENCE E 1�OOO�OOO
X COMMERCIALGENERA�LIABILITY PftEMGET�Eeo¢urrDence 5 . 2SO,O00
F1 CL4IMSMADE � OCCUR LHA106691 3/19/2009 3�14�2010 MEDE%PAn one erson S 5.�0�
GERSONAL 8 A�V INJURV 5 1�OOO�OOO
GENERALAGGREGATE 5 2�OOO�OOO
GEMLAGGREGATELIMITAPPLIESPER: PRO�UCTS-COMP/OPAG 5 P�OOO�OOO
POLICV X JEC�T LOC
AUTOMOBILE LIABI4TY COMBWED SINGLE LIMIT
ANVAUTO (EaacciEent) 5 1�0�0�00�
B nuOwNEDnUTos 390000233 3/lA/2009 3/14/2010 BODiLviNdUav
i (Perperson) 5
X SCHEDULEDAUTOS
� X HIREDAUTOS BODILYINJURY $
(Perecatlenp
, X NONAWNEDAUTOS
, PROPERTYOAMAGE $
(P¢!dtCitl20�)
GARAGELIABILITY AUTOONLV-EAACCIDENT $
ANV AlITO OTHER THAN EA ACC 5
AUTOONLV'. qGG S
EXCESSIUMBRELLA LIABILITV N 5 S,000�000
X OCCUR � CLAIMS MADE AGGREGATE 8 $�000�000
5
A oeoucTie�e LHA098077 3/19/2009 3/14/2010 $
X ftETENTION S 0 S.
WORKERSCOMPENSATONAND TO BE ISSVED DIRECTLY 'hLSTATU- OTH-
EMPIOYERS'LIABILITY
ANY PROPRIETOR/PARTNERiE%ECUTNE BY ATI.IftiTIC CBARTER E.L EACHACCIDENT 8
OFFICER/MEMBEREXCLUDED?
I Ifyes,0escnbeuntler E.L.DISEASE-EAEMPLOVE E
SPECIALPROVISIONSGeIrnv E.L.DISEASE-POLICVLIMIT 5
� oTxER I,gpSED/RENTED 6603087e853 3/19/2009 3/19/2010 Sioo,000 � �� IT
EQUIPMENT
DESCRIPTION OF OPERIITIONSILOCATIONSNEHICLESIE%CLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION �
- SHOULD ANV OF THE ABOVE DESCRIBED POLIQES BE CANCELLEO BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
� 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
FAILURE TO DO 50 SHALL IMPOSE NO O6LIGFTION OR LIFBILITV OF ANY KIND UGON THE
� . INSURER,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE -- -. �
Sally Driscoll/JMT --������-`-<' ���'��*���'F-�'- �
ACORD 25(2001/08) � � OO ACORD CORPORATION 1988
i.�cne�.............. �.__._.�
,� ,
J
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an
endorsement. A statement on this certifcate does not confer rights to the certifcate holder in lieu of such
endorsement(s). -
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing
� insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively
amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25(2001108) ,
I NS0251oio8).oea Page z or z
✓��mm ,,/'
rt.�""�. .�� BOARD OF�BUI/p�(JG R�UL�pTlO g
...Q t License: CONSTRUCTION SUPERVISOR
,��� Number. CS 0947W
� �� Birthdate: 10/15/0177
.�
�Ezpires: 70/15/2009 Tr.no: 94707
Restricted��00
� JESSE G BRONlN, .
275B COURT ST - . � G_�
PLYMOUTH, MA�D236Q�
" Commissioner
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