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1 HOLYOKE SQ - BUILDING INSPECTION (5) , .� , . . ; ��e�IlfS��£fiLf�-iN0 Af�PAOVE{) 8Y ��E .lI�S,P.�CJ.4fJ .Ff�R Zp A PEF3MIT �,�WG GRANTED CITY OF SALEM No.�/� ,:o i�. (1� ;�e"`� .'�. �`\ Date Z� � � /^ a!y7�'y 3 • .a`�i Sif �,� .. \��f�, � �'h'4rnNso°� ' Is Property Located in Location of ' the Histor.c District? Yes No_ Building fl�, ��!O Is Property Loceted in �/.(,pY� I�, the Conservatlon Area? Yes_No_ BUILDING PERMIT APPUCATION FOR: Permit to: (Circle whichever apply) Roof, oof, Install Siding, Construct Deck, Shed, Pool, Repa dR�epla_ Other: PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELA1fS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby appties for a permit to build according to the following specffications: - Owner's Name I"��`�� �� -�SUV�nr�a.1 ��v�^� I —T— Add�ess & Phone l �°l`/� S4uan4 ( l`�� �?�y 61�3 Architect's Name 1r� � ��'�'' Address & Phone �7 b n 1 IG2�+ M lcJ�1D7�� (O�b13Y���S S 9 I obv5 �! Mechanics Name -� Address & Phone ( ) What is the purpose of building7 .�GLC.VJ�Yr-� Material of bWlding? 5��i1-� II a dwelling, for how many families? Will building cpnfortn to law? � Asbestos? Nv � Estlmated cost�13�� c�ty Ucense x N C` state uc�nse n v53 �9 3 � ��� D Home Improvement /f i� �J" ""L—M' Lic. i I�S375 �—� �' M Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO SE DOPIE b\fa: ;1�/1 i � 17�1 I�I MAIL PERMIT TO: oG ZY' �4�i^�Yr►��^`1 �ir�.� � l D Ld�o��� S�e �} S�ln +"'� �'rq 01�'� No. APPLICATION FOR p PERMIT TO / /"1 e � u✓�F�a y �r� !moo� �� . �r�G LOCATION PERMIT GRANTED AP F�OV�D �n INSPECTOR OFf BUILDINGS The Cotnm.3nrtrealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia ---Workers' Compensation=Insurance-A€fidavit:-Builders/Cont--actors/Electricians/P-lumbers==- ADAHeant Information Please Print Legibly Name (13usiness/Otganization/1ndividual): �cygo k Q ) mb l-C^1 OZ V5 Address: 10 6Z1�U'Aic A )c J ZAe � ` City/State/Zip: SGUVv%, vyso Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 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. # 7.- f�5)Reniodeling 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.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑ Plumbingsepairs 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.] 3Any applicant that checks box#1 must also 511 out the section below showing their workers',compensetion policy information: - t Homeowaen;who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating.such. tConbwtors that check this box must attached sn additional sheet showing the name of the sub-contractors end 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. Ik Insurance Company Name: A ) G' Policy#or Self-ins.. Lic. #: �.�— D L ZRl S Expiration Date: 1 0 Job Site Address: ! k-017 a1 Sd=L— City/State/Zip:Jc--6�-,at. [)-- 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 pennalties of perjury that the information provided above is true and correct Si lure: �t . t%�i t Dater l Ll 7_9q bil Phone# rWl�� 7Yr� � offWa/use only. Do not write in this area,to be completed by city or town offuiaL 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 M 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." — --An-employerds=defined-as_=`��ndrvidual p rartne[s1up, association,-cgrporanon or other le-gal entity or any two or more _ – _ of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased emq�loyei>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." 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, §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 suretosign and date the affidavit. The affidavit should be returned to the city or town that the application forr 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 y Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the"event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit'license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license 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 filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (ie, a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would bike 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 and 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 ' � �4R '�M,y41�lpP�yltl�FSR'}':;✓t��f.4'1u �i Ucense: GpNBTtUdTIONSUPERVISOR 053693 Tr.no: 1 8 VERLY 1uU1 098 T� VIA- . 0AP 0.112 S d6L) IA Masonry cgIy - 'IG-1d,2 Family 1lomes FOWe to possess o orient edition of the ." I Massachusetts State Building Code Is cause for rewcmtion of this Iken t r I t DIG SAFE CALL CENTER: (888)344-7233 l Board of Buid�,' ig Regulations and Standards I NOME IMPROVEMENT CONTRACTOR License or r Re Ist egistrat"I valid for individul use only 0 ration 145375 before the expiration date. 13/2 Board ofBuildin Iftoundreturn to: / 007 g Regulations and Standards ` - ` OneAshlm I ROGER q.TREM�r t5 hyais COMOration Boston,me. 2108 PlaCe Rin 1301 �4EYCpNT�t� i 10 COLONIAL R SU Tfn-4: SALEM,MA 01970 Admin( = unu without atgnature [PRODUCER CORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ 2Y06 11/16/2006(781) 246-3421 THIS CERTIFICATE IS ISSUED AS A MATTEROF INFORMATION . Jenkins Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR alem Street - ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. . Box 69 field MA 01940-0069 INSURERS AFFORDINGCOVERAGE PA INSURED INSURERA:SAFETY INS(JRANCE ROGER A TREMBL Y CONTRACTORS, INC. INSURER B:OHIO CASTIALTY INSURER C:AIG ' 10 COLONIAL ROAD STE. #4 INSURER D: SALEM MA 01970- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE 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 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. INSR ADWL POUCY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPEOFINSURANCE POUCY NUMBER DATE(MM/DDfYY) DATE MM/DD/YY LIMITS B GENERAL LIABILITY BXW52519822 04/15/2006 04/15/2007 EACH OCCURRENCE E 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES TORENTEDS 50,000 CLAIMS MADE a OCCUR / / / / MED EXP A one amen E 5,000 X BFPD,XCD,CONTRACTOAL PERSONAL&ADV INJURY E 1,000,000 X CONTR.PROTECTIVE / / / / GENERAL AGGREGATE E 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E 2,000,000 POLICY X JECT LOC A I AUTOMOBILE LIABILITY 1500143 04/19/2006 04/19/2007 COMBINED SINGLE LIMIT ANYAUTO (Ea ecddenl) E 1,000,000 X ALL OWNED AUTOS / / / / BODILY INJURY X SCHEDULED AUTOS (Per pemon) E X HIRED AUTOS - - - - '/ - / / ' / BODILY INJURY E X NON-OWNEDAUTOS (Per eoddenU PROPERTY DAMAGE. . .. $ (Per"dent) 'I GARAGE LIABILITY _ AUTO OTHERNLY-EA ACCIDENT �ACC E.. ANY AUTO /,. / / / AUTO ONLY: .AGG $ 2ESSMMERELLALIABILITY / / / /' EACH OCCURRENCE E OCCUR CLAIMS MADE - - AGGREGATE E E DEDUCTIBLE / / / / E RETENTION E- E CWORKERS COMPENSATION AND WC 8948958 07/01/2006 07/01/2007 X' TWORVLAMITS TRH EMPLOYERS'LIABILITY 100 OOO ANY PR OPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT E , OFFICERIMEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE 500,000 If yes,describe under 100,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT E OTHER DESCRIPTION OF OPERATIONS/LOCATIONS HICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS - CONTRACTING OPERATIONS CERTIFICATE HOLDER - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED' BEFORE THE .. EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE:CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE YO D0503HALC'IMPOSE'NO.OBUGATON OR LIABILITY OF ANY KIND UPON THE ' INSURER ITS JLOENT SORREPRESENTATIVES. ACORD 25(2001108) ' ! C ACORD CORPORATION 1988 INS025(0103).05 ELECTRONIC LASER FO S,INC.-(600)327-0545 : Page 1 of 2 'PUBLIb PROPERTY DEPARTMENT .120 WASHINGTON STREET, 3RD FLOOR SALEM,MA O 1970 TEL (978)745-9595 EXT. 380 FAX (976) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40,SK I acknowledge that as a condition of Building Permit# , all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility,as defined by MGL c III, S150A. The debris will be disposed of at: Location of Facility Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant Firm Name, if any Address, City&State The above statute requires that debris from the demolition, renovation,rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S150A, and the building permits or licenses are to indicate the location of the facility.