6 HOLLY ST - BUILDING INSPECTION O
PUBLIC PROPFKT�
LI : l
APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT 1
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS J
IMPOKTANr:Applicants must complete all items on this page
SITE INFORMATI N
Location Name 1 t'�'�`�V,1 Building j
Property Address
Map p
Located in: Conservation Arca Y Historic district Y
Use Groups
(check one)
Residential(3 or more knits) RZ
Type of improvement Residential (hotel/motel RI _
(check one) ` Assembly(churches) Al _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants, recreation) A3_
Alteration Business B_
Repair/Replacement - Educational E_
Ihmolition_ Factory (moderate hazard) FI _
Mme/Relocate Factory(low hazard) F2_
Foundation Only_ High Hazard 11_
Accessory Building Institutional (residential care) 11 _
Other(describe) Institutional(incapacitated) 12_
Institutional(restrained) 13
Mercantile M_
Storage(moderate hazard) - S I _
Storage(low hazard) S2_
OWNERSIIIP INFORMATION(Please type or Print Clearly)
, -
' OWNER Name l-- tJ \,k • �
Address
Telephone .GL-4 $ -
DF-SCRIP 1111Z OF W RK'10 BE PEW OR�IF:I/,
P\Q-bLk Id uLl_ YIJC�.( v �y
ESTI.MA rED CONSTRUCTION COST / � W J-_6®
i
CONTRACTOR INFORMATION
Name FI�ITAIK
Address /5/ �roy� �067 mac/
Telephone _mod V
Construction Supervisor's Lic #
Home Improvement Contractor# /S 7 �S
ARCHITECT/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 = Od
Commercial est. cost x $I1/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signed
Date
or
s
CITY OF SALEM
,r, 1, ; PUBLIC PROPRERTY
��' �=�" DEPARTMENT
- �"�
,1,ntl M'I'an li(.,u 1
1 ^^V W,�SHL\JIU.\S1:l LL l' 0 SALI`M.M.,i1.%'.I It it'I IS U97.Z.
1'c1: 978JsiH5'15 • 1'.ts. 974-74C78+6
Workers' Compensation Insurance Afftdw it: Builders/Contractors/Electricians/Plumbers
A scant Informalion - Please Print I eCihlV
Nainelnuwksyt)r;;amr:uioNindlvu(uull:,Al T/T/
ndilL-"S:/y S4/,t' j-/ ��
cily,stare,7.ip S/ /vtV 03071 Mimer':
:t rc sou t employer:' Check the appropriate box: T)pe of project(required):
1. unl a employer with_r• 4. El am a gcnural contractor and t 6. ❑ New construction
e ngtloyees(full andilor part-time).' have hired the sub-contractors t. 7. [�'I modeling
2.❑ 1 alit a sole proprietor or partner- Thee on the ntract d shave
ship and have no employees These sub-contractors have K. ❑ Demolition
workers' comp. Insurance. 9, Building addition
working for me in any capacity.
lNo workers' comp. insurance 5. ❑ We are it corporation and its lo.❑ Electrical repairs or additions
I required.) officers have exercised their
right of exemption per MGL I I.❑ Plumbing repairs or additions
3.❑ I ant a homeowner doing all work S s O.a and w have no
Myself (No s.,orkers' comp. c. 152, �l 4 12.❑ Ruuf rcpaus
insurance required.) t employees. ]No workers' 13.❑ Other
comp. insurance required.]
•4m.,+pLcanl dlut checks box It nIDYI Abo IIII Um the KUIUII 1w1Yw bhowinit their workcis eumpenu iun pulley inlilrmatium
` I loM.,..wn whu wU nit this affidavit indicauny the)a1c doing all work alv)Ihcn hire Iwlside co,imxaors must auhmil a new aIra.vit inJiuliny such.
-C'mlrwwn Thal check this box Mimi allwhcd.In additional..heel+hawiuy[he name of the sub•conlracturs and their+vurkets'carp.pu6cy Information.
/unr an rurp(uy¢r thin is pruridinr nvurkcrs'c•urnpen.rnlinn insurrurre fur my entplayres. Below is the policy and Job site
injarututioa
IA- ee>ry F/{QL ovl co
Insuranclr Company Name: -
Policy y or Self-ins. Lic. *: / ufaL y�� --- Expiration Dam:
b ltrc __..
/L Clty%State/Zip:
Job Sim :\ddreis: (f/ �!e /L --
Attach a copy of the workers' cumpenxation policy declaration page (showing the policy number and expiration date).
Imuilure 10 Secure coverage as required wider Secliun 25A ul'.%IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imps isamncnt,us %cell as civil penalties in the form of a STOP WORK ORDER and a fine
Of up ut j250.00 it.lay ❑gainit llm violator. Ile advised that a copy of this stulcmeni may be forwarded to the Office of
Inc�ali,aunls ul ;lac DIA or wtstitarce coss;lgc sccitic,tt:on.
/do herrby certify und,riliepulliv.'utd ndlies u perjury that the information provided ubuce is true anddccorrect.
DatS—
�y/� U
�i :rn ore: �y Q ��11 n_—
V d
official use only. Dd nal L•rite in this urea, lu be•ruarplelyd by city ur to tvn nJJiciu/.
City or Town: _-_ Permit/License N._
Issuing.\uthurily (circle one):
I. hoard -if Health 1. Buildin, Deltaruncot 3-Cit-%:fotsu Clerk J. L•'lectrical Inspector S. Plumbing Inspector
6. Other
('o utacl l'cnono -_ _ Phone th
Information and Instructions
.'ctassacllasetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplorre is defined as"._every person in the service of another under any contract of hire,
cypress or implied, oral or written."
An employer Is defined as"an individual, partnership, associatiou, corporation or other legal entity, or any two or more
„r the lOr"0111g enguged in a Joint cmerpnse, and including the legal representatives of a deceased employer, or the
receiver or trustee of .ul individual,paltner5111p,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."
MGL 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, MGL chapter 152, a25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomiance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill 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 confimlation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he ruunled to the city or town that the application for the permit or license is being requested, not the Department of
I 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'rown Officials
Picric he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
-111easc be sure to fill in the pennitilicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permitilicen se 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 f'or future permits or licenses. A new affidavit must be filled 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. it dog license or permit to bun leaves etc.)said person is NOT required to complete this affidavit.
I he ()I lice oI Investlgalluns N%ould line to thank )'ou in advance for your cooperation and should y'011 have any questions,
please du nut hesitate to give us a call.
Thu: Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
!trtC.cd 5-_'b-I15
www.mass.gov/dia
FROM :N.H.Sunrooms FAX NO. :6038906333 Sep. 11 2008 09:49AM P2
Sep 11 2H88 18:17:17 -> 6030986333 The Hartford Fax Page 804
ACORD OBB voara CERTIFICATE OF LIABILITY INSURANCE `"'�
09-11-2008
~MR - THIS CERTIFICATE IB ISSUED AS A MATTER OF INFORMATION
PAYCHEX AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
210705 P: O — F: O — ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
308 FARMINGTON AVE
FARMINGTON CT 06032 INSURERS AFFORDING COVERAGE
MSurt!G INSURERAITWin City Fire Ins Co
NSURPA AI
N H GUNROOMS & CONSERVATORIES INC INSURBI C;
14 STONE POST RD. NSURM00:
ER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHBTANDIN(3
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSUFANCE APPOROEO 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.
JMII1pP _
M -. TVMOFIAVLNMAVE P'GLATrftvAw PO roucYexagA LPWrB ---
°rAIYRAL LLAMLTY EACH OCCURRENCE 9
COMMMCIAI.OFNERAL LIABILITY FIRE DAMAGE(Anyone 0
CLAIMS MADE ❑OCCUR MED EXP(Any ano ,r,w 0
_ PERSONAL&AOV INJURY 0
,__ALAGGRRGATE e
GEWLAOORETIATE OMIT APPLIES PERT pRODUCTB-COMPIOP AGO 0
17 POLICY LOC
ABTOLIDBRff" MN - COMBINED SINGLE LIMIT
ANY AUTO (fiL mcawRns)
ALL OWNED AUTOS —�
BODILY INJURY e
SCHEDULED AUTOS IPv penon)
HIRSO AUTOS
BODILY INJURY 0
NOry•GWNED ALTOS (Per ectlOeml
PROPERTY DAMAGE 0
P.RooidenJ
GIRAGRLYBRT✓ ALT.ONLY- ACCIDENT e
ANY AUTO OTHER THAN EA ACC B
AUTO ONLY AUG 0
ff ° LMP&TY ;EL.
HOCCUARENCE Y
OCCUR CLAIMS MADE REGATE 0
0
DEOUCTIELE 0
RRGNTION • ,— 0
WORKL9l3 CMalbvAATBW AAb WC tRySTATU-U.TS OTW
A `""'GVERB•LAL®LTY 76 WEG RL0405 03/20/08 03/20/09 ACH ACCIDENT e100 000
ISEASE-SA EMPLOY;R I *10-0A 000
&I..GIAEARO-POUCYUMIT e500 000
BTNEN
gEBCR/YlRTNGF°RIYAIRWN°°ATlOA9I11�NBlF$fARIJRRN0B AL1R6B BY 8YD°XBEMBVI'Ai/FpALTON6tloxe '
Those usual to the Insured' s Operations .
CERTIFICATE HOLDER AaLRnwvmL Lmw;AraLLRFRLeneR: _ CANCELLATION
SHQUW ANY OF THE ADOVE DLSCDIDED POUCIDS ESE CANCELLED REFORE THE
EXPIRATION DATE THEREOP,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE 110 PAYE FOR NON-PAYMENT)TO THE CERTIFICATE
Bertha Cappuccie HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO
OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
6 HOLLY ST REPRESENTATIVES.
SALEM,MA, 01970 ArLTMo BR�EBrrorArn�
ACORD 25-S (7/971 ®ACORD CORPORATION 1988
FROM :N. H. Sunroom5 FAX NO. :6038906333 Sep. 11 2008 09:48RM P1
09/11/2008 10:43 FAX 603 898 8269 FOY INSURANCE SALEM lihool/001
SSSLQBla�, CERTIFICATE OF LIABILITY INSURANCE 091 1/2 a'
PRDOUCBR.. 603 898-6320 FAX (603)898-8269 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Foy xnsur8nCO Group - Salem ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
130 Main St - Suite 103 ER THE C VERAGE AFFORDEDY THE POLICIES BELOW,
Salem, NH 03079
Terri Truhn INSURERS AFFORDING COVERAGE NAIC IV
INDUReC NH SUNRORST—M—NNURNATOKIES INC INSURER& Maine Mutual-MMG Insurance Co. 15997
23 DELAWARE OR t 15 INSURER B: Jr
SALEM, NH 03079-4061 WauceERc�
INSURER 0:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE 1.13TED BELOW 14AVE 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 e1FFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
TYPROPINSURANCII Poudv NUMBER PoLiev EppPLTIYE PENEW
um"
OEMERY-wBBPTY SC100222ZI 02/11/2008 0211112UQ9 EAC0O0CURRENC4 s 1 ON
X COMMERCIAL OSMORA44MBILITV DAMAGE TO RENTS-71 5 SO DD
CLAIMS MADE CJ OCCUR MED EW(Any ona person) 5.0001
A PERSONAL&AOV INJURY r2,000,0"
GENERAL AGGREGATE CENL AGGREGATE LIMIT APFT.IEB PER! PROCUIrTV•COMP/OP AGG17 POLICYJECOTLOC
AITfOMOBILE UAKILfiY KA109aaa21 02/11/2D06 D2 11 2009 coMB1�JeD SINGLE LIMIT ANY AUTO (Ea am osnt)ALL OWNEO AUTOS SOOILY INJURY
X SCHEDULED AUTOS (peefwaen)
A X HRED AUTOS BODILY INJURY s
X NOWOWNED ALROS (Par goodmd)
PROPERTY DAMAG0 °
(Par aaeldont)
OARAOBLNMUTY AUTO ONLY-EAACCIDENT B
ANY ALTO OTHER THAN EAACC
P S
AUTO ONLY: AGO S
FSCESSII1rBREW LIASILIr EACH OCCURRENCE $
OCCUR Q CLAIiNSMAUE AQORWOATq e
5
DEDucrlele °
RETENTION S i
TA - OT
WORID'.NS QOMFL9IBATDM ANO Tws
TU
IMPL7 MO,I.WILIpTpYTN9 E.L.EACH ACCIDEF/f S
OPPICReR/M[Me[R CxCLU6ED?�IRIVE E.L OISEABG•EAeMPLOYE
Ifym,deea B 9A
lG under .L 019SE-POLICY LIMN S
SPECIAL PRONSIONS be1N
OTHER
I B ICRO,FM OF OPERATIONS)LOCATION&I%rpm C FS I MaCUISIDN9 ADDED BY ENDORSEMENT I SPECIAL PRDv=NS
CFKUEIC�41E HOLDER CANCELLATIQIM
ONG"ANY OF THE ASOME oeSCR. IDED POWd98 05 QANC OMS0 DLTORS THE
WCIAATIDN UATE THEREtlp,THIN IS9OINQ INSURER WILL ENDEAVOR TO MAIL
'P
0 BAYSWM"MNOTWETOTHECERTWICATEHOLDERNAIMPTOTMRLM",
Bertha Cappuccio BUT FAILURE TO MAIL SUCH NOTICE SHALL MOSS NO OBIJOATION OR LIAmLRY
6 Rally Street OFANYXIM UPONTMEMURER.ITsaO°NT8 OR RgR9PNE9ENTATW"W
Salem, MA 01970
ACORD 25(2001108) GACORD CORPORATION 1988
T1.
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
3%
Registrafion-� 157854
ExPiratjon 1'I/8/2009 Tr# 261368
i7
PrlY te Corporation
N.H. SUNROOMS I& N�C+ONSERUATORIES, INC.
FRANK RULLO -
14 STONE POST RDA .
SALEM, NH 03079 �'—'��
Administrator
Y /Tj
t �f , � � ✓/tE ��xr�e¢Cl�e o�,_�Grna�ac/ �t- ;].,card of Buildin "� Is
]ConstrUct(ort gRegulations and S[addartls
�Supervisor.Cicpnse �
Llcglf CS
4 I
-57
� I
t' plrapo 1 �009 Tr# 12411
R str C _
ik � _I! I
1 FRANK RULLO ice- f`L•7
j 14 STONEPOST RDc
SALEM, NH 03079
i
Commissto� ne—�t"'�- �� I
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
i
.. .•I „ ,r 1 I ': U „ire,.., •:1: iir ♦ \vial, \I �„�i . .. i . , :l'� -
Construction Debris Disposal Affidavit
(r�yuired for all dcnwlition and renovation work)
In accordance \6th the sixth edition of the State Building Code, 750 CNIR section 1 1 1.5
Debris, and the provisions of AGL c 40, S 54;
Building Permit rt is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I It, S 150A.
The
/debris will be transported by:
(name of hauler)
I lie debris
/jwill be dispp�Josed otin
(nainr ul tanluy)
may/ I;nlJres. ,it1]cilrtvl
aenalwr of p�nuit .gtphcant