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3 HILLSIDE AVE - BUILDING INSPECTION (2) y PUBLIC PROPERTY DEPARTmwr wrae 139 ern 8enaea• s�r.a�oa;s.,,xoos�o i �:rr��+s+ta�tree rreaa+ue - A_*PLtCATI IN FOR TM RptAm R N"ATIOAL_ c 9NCT1Qi1["17nN DIMOL1T &Olt CHANGE OF USE OR OCCUPANCY, FOR AD?Y ZXjSTING STRUCTURE OR RIMJ G 1.0 SRE INFORMATION LocaftA NWM 3 NiL�.StJ� Aviv , A"a l l b beabd ins;Cww vadon Mee YM tJb Wditb n- - -ot YM 2.0 OWNERSHIP INFORMATION 11 Owner of Land _ Marne: C A - d• LUI l o TOULE Address: &000MPLETE THIS SECTION FOR WORK IN LDINGS ONLY Additlon Ustln g Renovation Number of Storbs Renovated Change In Use N Demolitlon Existing Approximate yew of conns&udton or renovation Area per floor (sQ Renovated of existing building I I I Now Brie!Deecripdon of Propoled Work: --- - ---Mail Permit to: What is Vw cuff"use at the 8ui&VI Madanhl of DuiidMq?�jT�— w dwe*o&hoW ten►UIAsz we Ow s�kIkw contOM le Las/r y�s Asb.atoa9 ArcN1•as Name _ Adams and IMOM 1 A10 �~ a �ly�t6 Address and Phone 4, 0--V u p,L t ILIA i 1LI�l�C 14� r15� gap-_1 con rvction llupeml�+LkenN d ..HIC RapMiralbn EatrnMad Cost of FFci!-Kt Pannll FM Calpilbn -� Eatlntelad Cost X=71$1000 Resider" pump Fee i — An Additional Sd.0r3 is.odeo as an Aenw dtupa. Maw sun" all flelda are properly and wbb`"ten to avoid delays in proceselmo The unduslonod dose hereby apply far a 9uudhq Pwrnm to build to ma above stated spegllptlonc SWwd under penally of pw)MY Date oi �I oil . In Ground Pools PRIVATE POOLS - CONDITIONS PRIVATE POOL - DEFINITION Any pool intended to be used primarily by occupants of a one or two family j Any such pool more than 24 inches deep or having a surface area + permit dwelling. gre foot diameter beforer than installation, enlargemen square feet t or alteration. requires a building 2. PERMITS plan Applications for a permit shallen(scale not less than Plot 201 ) , bearing the stamp of a registered surveyorer of relation of structures fully dimensioned, showing pool location on prop on the property, location of all fences and gate, and abutters names. Applications for a pool shall also be accompanied by 2 sets Of plans s and statop specifications, acceptable to the Inspector of Buildings, bearing of a qualified professional engineer. 3. POOL LION No side of any pool shall be closer than 6 feet to side or rear property lines, . no closer to front yard lines than the zoning setback requirements, 10 feet to any building-bofromVthea f Board of Appeal.requirements shall be permitted only Y Special Permit 4. SAFETY REOUIpEMENTS Pools will be surrounded by a fence at least 4 feet high and mitted. Pools further than h l feet from the sideslof the ool.icable codes. BONE 3efoot wide gateail fnces will notbwithrclosing and locking comply with all app device will be permitted. 5. CERTIFICATE OF COMPLIANCE Compliance n must be issued- Before a wiring permit can be obtaineda Certificatenew o fiedplotplanshowingt at Said certificate will be issued only erly sited has been filed with the Inspector of Buildings, or a the pool is pro P request l. for an on-site inspection has been lacementeofbreinfor eementobutf paiordto s. The plot plan shall be filed following p pouring of concrete. (Applicant) L'0!_ Qv 1� �_�l Address) �1 � avw CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT atsta.'ater uatst:axi Mvrcta In VAsw.,c:'feNsawr o SA tsar,hLcya.atrtsot9TJ fht 9711•745.9595 a Fax:970.740.9a46 Workers' Competuatioo Insurance Ailidavit: Builders!Contractors/Eleetridons/Plumbers Anallcant Information Please Prier Legibly Nametua�nesuorsanin� ��tioanmu(v��fualt: ,�I'U7� Address: "C�11��� V�9�ir r la-W �' �, I LA'icwIrnWs� MU`i)- City/Stamizip: R1\ Photo H: ,%!apu as employer?Cheek the appropriate box* T ypeLZ ct(required): 1.[g I am a employer with 4. Q 1 am a ycnt ran contractor and Inatrucuoe cmpluyces(full and/or part-tine).• have hired the sub-contractors2.❑ 1 am a sole proprietor or partner- listed on die attached sheet t ling ship and have no employees Thee have tionworking for me in any capacity. workers'comp. it sumnee. kldWoo(no workers'comp. insurance 5. ❑ We arc a corporation and itsrequired) officers have exercixod their . ectrcal repairs or additions 3.© I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workcrs'comp. c. 152.044).and we have no 12.0 Ruof repairs insurance required.)t cmployetm LI\o workers' comp. ins mace inquired] 13.0 Otber -An4 VplicaM n,,g tAurka boa/t ram also all uu iho aeeliuo IKbw Ahorina rtgir Wonias'eumygWww policy iafi s ion llatmmtwrore WIWI aubmtn doa atadwil ind"i"S AVY ale&Ale A work and not kin eW7be conuacnre no— submii a new arn&vY i diawina v h. :C. rxwn Ikel clack cue bra[mute aruehd an additimel ahon.hewing the neoe of ale and their worken'camp policy internualm I urn tin employer that is provlWAs workers'compe'"itien brruronee for my emp/oyeot Bdow/s the policy and/ob site i i/orur"doAt, y� I U Insurance Company.Name: Policy Al or Sclf-ins. Lie. 0:W CA-0 i3`P�� �` ExP,rauon Date: `` NN! CityrStaterZlp: S�L.�71'��____t`►�NSS AItach a copy of the workers'compensation policy declaration page(sbowing the policy number and expiratlua date). Failure to wcurc coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a rive up ar S1.500.00 and/or one-year imprisuntncnt, it w•c11 as civil pcnaltictl in the form of STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Ile advised that a copy of this stawarunt may be I'urwarded 10 the 011ice of In\balhallUlla oI the DIA for Inliurance covcrugu vcrlf c itWn. /Ja hereby reni�y under the pains and penu/tks ulperjury that the itifwareNoe provided a ve fp„mi and correcit D. F udit Ito not write/n Mix area,to be completedby dry or town O/Jklld :rity(circle one):ealth 2. Building Department 3. Cilylfowa Clerk 4. Electrical Inspector 5. Plumbing Inspector C.allact Person: Phone p• Information and Instructions on or their cin loyces. Islassachusetts General Laws chapter 152 requites all employeprovidein the erworke e another under y contact of hire. pursuant to this statute,an rxsybyte is defined as"...every person express or implied,oral er written." sna&corporation or other legal entity,or any two or mare An eespkyer is defined as"an individual,partnership.astoeir f a deceased employer,or the of the foregoing engaged in a joint cnierpriaa and including the legal representatives oemployees. However the .aaoeiation or other legal entity.employing receiver a tewelfi of m individttal,P and who resident tbetein.or the occupant of titer owner of a dwelling ttaixse having na more ten three maintenapartaance. _ house dwelling house of another who employs Perms to do maintenance, fconstruction such to mpl or rent be decimed to be dwelling employer." or on the grounds or building appurtenant thereto shall not because of siseh employment !`iGL chapter t 52,4 (b)also states that, lev my state to iced licensing sganay slang withhold tits issiteace or Operate evidence business or to construct buildings i•the commonwealth fir any renewal of s unease or pertt��to Op arate e of compliance with the insurance coverage required.' applicant wbe bus ant prod .kikWiaxinlly,MGL chapter 152. ;25C(7)states""eider tie commonwealth nor any of its political subdivisions steal work until acceptable n. for the performance of public evidence of compliance with the insurance enter into any con resented to the contracting authority." requirements of this chapter have been p Appikanta please fill out the workers' compensation affidavit completely.by checking the boxes that apply to your situation an4 if necessary.supply entracwr(s)nan*s).address(a)and phone number(s)along with their certificates)of Companies(LLC)or Limited Liability Partnerships(LLP)with no employe Other than the insurance Limited Liability Com members or partners,are re new red to carry workers'compensation insurance. if an LLC or LLP does have d. employees,a policy is required. Be advised that this affidavit may be submitted to the Department of industrial . Ababa sure to sign and date the affidavit. The affidavit should Accidents for confirmation Of insurance Coverage. license be returned to the city or town that the application for the permit or being requested, not the Department of you am requirea workers' Industrial Accidents. Should you have any questionsregarding the number listed low o below. Self-insured aompanies obtain should enter their compensation policy,please call the Department the self.insurance license number on the appropriate line. City or Town Off clsb Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottorn. out in the event the Office of Investigations has to contact you regarding the applicant. of the affidavit for you to fill Please be sure to till in the purmit/license number which will be used as a reference number. In addition,an applicant drat must submit multiple petmitilicense 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 Ili*affidavit that has been officially scarped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fixture permits or licenses. A now affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or peanut not related to any business or commercial venture a dog license or permit to burn leaves etc.)said person is YOT required to complete this affidavit. Chc Ot its of Investigations would like to thank you in advance for your cooperation and should you hive any questions, plcube du not hesitate to give us a call. The Department's address,telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Oak*of Inwsttptiona 600 Washington Sumer Bost^MA 02111 Tel. p 617-7274900 ext 406 or 1-977-MASSAFE Fax 0 617-727-7749 Zcvibcd 5-26-05 www.mass.gov/dia 03/13/2008 TBU 10:05 FAX 978 538 5385 Peabody OB GYN LLC R 002/002 978 538 5385 N / F Princeton Crossing Limited Port. N / F O'Shea N / F e, Lutrzykowski i•i q-56. Shed 1k $' 48.99' CB(fnd) Base of Wall LOTS I & 2A o 9,2'd- N / F 12,350 S:F. N Retaining Kirk Wall 8.4't Deck to Q PROPOSED No 3 s, 1/2 S OOpp to o Wood Dwelling N / F IV F Retaining Lutrzykowski / Harney ^6g Pore o 75.00' LCD(fnd) N / L L S I D E AVENUE PLOT PLAN OF LAND BVta.3i37� SALEM, MA. Zoning District: R PREPARCD FOR. Deed Reference: L.C.Cert. 58657 CHARLES KONTOULOUS Assessor's Map 15. Lot 404 >1118LLS1�E AVENUE Proposed Lot Coverage 247 SCALM f�-30' dDAT9. MARCH 7. 9006 i POO—OOQ 03/13/2008 TBU 10, 05 FAX 978 038 9385 Peabody OB GYN LLC �OQ2/002 978 538 5385 N / F Princeton Crossing Limited Port. N / IF O'Shea N / F 0 � Lutrzykowski a•i 48.9�' � Shed CB(fnd) Base of Wall LOTS 1 & 2A o 9.2't N / F 12,350 S.F. N Retaining Kirk Wall 8.4'f Deck PROPOSED Tc' CD POOL POOL ND S No.3 1/2 Stor o 6 Wood Dwelling N / F F IV Retaining Lutrzykowski / Horny Porchg ^6� o , e 75.00' LCD(fnd) I L L S l 0 E AVENUE DAMID T ip "PA1. b 3/7/0� PLOT PLAN OF LAND SALEM, MA Zoning District: R PREPAPJg FOR: Deed Reference: L.C.Cert. 58657 CHARLES KONTOULOUS Assessor's Map 15, Lot 404. 3 HILLSIDE AVENUE Proposed Lot Coverage _ 24% + 'i POS-008 °% �amm mw eal o� a�acl aaelle Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Registration: 113772 Board of Building Regulations and Standards One Ashburton Place Ron 1301 Expiration: 7/15/2009 Tt# 129984 Boston,Ma.02108 Type: Private Corporation ANDREWS GUNITE'CO INC. RODNEY ANDREWS - 6 REPUBLIC RD `` : Not va without signature N BILLERICA,MA 01862, Administrator * - ✓/e -elo—LW." ✓�.aaaa��ueeLt . Board of Bmlding'Regulati sand Standards'- 1^r.^r �' !t Construction Supeivisor L cense. - S License CS 27999 ' �v #„k, •- Expuetiori 3'114/2010 Tr# 1�7567 i AA ROD%? }- 1647 LOWELL 'p CONCORD,MA 01742 Commissioner 1 � Fax:508393 983 afar 5 200A 10:b0a,m P901,/002 � COJi� CERTIFICATE OF LI,R►BRUTV INSUt�l�ALIC M,:�'�15 03 05 08 _ ODUCER 5 0 8 3 9 3 6 9 8 3 THIS CERTIFICATE IS ISSUED A5 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE I mittredge Insurance Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 55B Otis St. , P.O. BOX 1129 - ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW_ Nortbboro MA 01532 Pbona! 508-393-7744 Fax;508-393-6983. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A' Acadia Invi remce Cc m any 31325 INSURER 6: Firemanrs Ina. Co. 21784 Andrews Gunite Co. , Inc. ' IN�urcr.C. 6 Re ub11C Road INSURER D: North Billerica MA 01862 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOWREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE IISURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIDNS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY NAVE SEEN REDUCED BY PAID CLAIMS. POLICY NUMBER X I LIMITS LTR NSR TYPE OF INSURANCE' DATE NIWDD DATE IMNUD f GENERAL LIABILITY EACH OCCURRENCE 51,000,000 A X COMMERCIAL GENERAL LIABILITY CPA0136208-12 03/01/08 03/O1/09 PRElnlses E occumnr< $ 250,000 CLAIMS MADE O OCCUR MED EXP(Any one P9reon) E $,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,0 0 0,0 00 POLICY $ ZUT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 ANY AUTO (Ea eccltlenQ ALL OWNED AUTOS BODILY INJURY B X scn6DULEDAUTOS MAA0136210-12 03/01/08 ' 03/01/09 (Pcr Person) $ -X -HIRED AUTOS BODILY INJURY $ X NON-OWNEDAUTOu" (Pcr acridenl) PRO P ERTVDAMAC-E $ (Pe'.W enQ GARAOE LIABILITY AUTO ONLY-EA ACCIDENT 3 ANYAUTO OTHER THAN EAACC $ AUTO DIJLV: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A- X OCCUR CLAIMS MADE CU $A0136211-12 03/01/08 03/01/09 AGGREGATE 100 D 0 0 0 DEDUCTIBLE $ X RETENTION $10000 S WORKERS COMPENSATION AND X TORY LIM77f A EMPLOYERS'LIABIIJTV WCA0136213-12 03/01/08 03/01/09 E.L.GCHAC000000 ANY PROPRIETORIPARTNEWEXECUTME OFFICER/MEMBER EXCLUDEDy E.L.DISEASE000000 ngs.dcscdbe Under E.L.DISEASE.POLICY LIMIT000000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED ST ENDORSEMENT I SPECIAL PROVISIONS Iasued as evidence of insurance CERTIFICATE HOLDER CANCELLATION ANDR$wG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEU BEFORB THE EXPIRATION DATE THEREOF,THE ISSUING INSURERWILLENDEAVORTO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO So SHALL IMPOSP NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Andrews Gunite Co. Inc. 6 Republic Road REPR NTATMES. N.Billerica MA 01862 AUTN DREPREBD,N TIVE ACORD 25(200110B) 0 ACORD CORPORATION 1988