52 JEFFERSON AVE - BUILDING INSPECTION ,CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:<L\Ihl'.RIIiY UNIS(:ULL
MAY(*-
120 WASHINGTON,STREET#SAt EM.MAssAU H.NW rn 0197,^, -
. TEL-979-745.9595 ♦FAX: 978.740.984E
Workers' Compensation Ins6rance'Aff3dav1t Builders/Contractors/Electricians/Plumbers
:1 ) licant Information "' " ' " -
n
_. .. _...._..__.._.... Please Print Le ibiv
Natrle(dusi;N:ss/Or anizatioNln'dividuul //'y'
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Address:_ a cTf f �tCe✓j 6V f C�
Cuy/Slate Zlp:�� /17/� 6/ / /U Phone-&- 'ram/ 7�_ _. 7Z1�/
Are you an employer?Check the uppropriute_box "
[:�e
project(required):1.�1 am a employer with,_ 4. d l am ti gencral'coutractor and I
employees(full and/or-part-time).• have hired the sub-contractorsew construction
2. 1 am a sole proprietor or partner- listed on the attached sheet. t Remodeling
ship and have no employees These sub-contractors have molitionworking fur me in any capacity. wor,14- m"comp. insurance.'lNo workers'cutup. insurance 5..❑ We are a corporation apd its ilding additionrequired.) ot�cers hive exercised their ectrical repairs or additions3.❑ I am a homeowner doing all work right ofexenptionpgrIviGL mbing repairs or addition+myself. (No\workers' comp, c, 152,§1(4),and wehavenoinsurance required.) t emploees [l\' orkrs "' ' of repairser
A 11Y opplicunt chat chucks box r)I most also lilt out the section Iwluw showing thuiaworkers'compunwtion policy inlitr.". .
I lumwwrcn who submit this amdavir indicating they are doing all work and then Aim outside cwtoxton must sut rail a new afrdavit indicting such.
=C.'omrxwm shot chuck this box moil anxhcvl tin additional shxt showing the nano of the subreontraaors and Their workers'comp.policy information.
1 am un employer that&providing workers'compensation irrsurrnrce for my employees. Below is the pu/icy wrd job.vile
laformatiorr,
Insurance Company?lane: e�e/5
Policy 4 or Self-ins. Lie. #: k- 72'D
Expiration Date: /3--6
Job Site Address: Z ✓E'T p,i,�QyJ � . .:• pp //ll
City/State/Lip 9
Attach a copy of the workers'compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Scction 25A-uf:vIGL C. 152,can lead to the imposition of criminal penalties of a
tiny LIP to S1.500.00 and/or one-year imprisoomcm,us well as civil Penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. 13e adviwd that a copy of this slatemcnt may be forwarded to the Office of
In\�sngauuns ul'rhe DIA for insurance covcragu vcriticatioh: - -
/rla here by c nrfy ur cr thee puma cud pen /nc�eryury that the rnforinullon provided above is true and correct.
_ �CiLCC%e
Sieaunird: ... —d,7 Dtst'e
Ph,�me 9T' 7 /
F(hu
only. Do not Ivrite in this area,to be cuulpleled by'eity orlown aJ)ic•iaL -
i . iA 'n,
n: Permit/1.1cense#
Issuing ) .. --....._- -..._.___
y(circle one):
health 2. Building Department 7 Cilj-/fotvn Clerk 4. Electrical Inspector 5. plumbing Inspector
son: _ _ _. Phone#:
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CITY OF SALEM
i PUBLIC PROPRERTY
.,ot DEPARTMENT
\l.�llK I_'C W.\91IXC:JNSiREET $Alr:61, MMSACM iLl CS:197.
TEE 979-745.4595 # F.%x:978J4G7846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accords nec with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ _ __ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 1.50A.
The debris will be transported by:
(name of hauler)
fhe debris will be disposed of in
(came Uf facility)-
. - . _— +ad�tres+ of tScil+lyl
a1_ ..IUlt 7I 7iflllil ap C1+][
TRAVELERS WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6KUB-7207A59-8-07 )
RENEWAL OF (6KUB-7207A59-8-06)
INSURER: THE TRAVELERS INDEMNITY COMPANY
NCCI CO CODE: 11347
1.
INSURED: PRODUCER:
CONTILLI . PAULA DBA ROSEMARY WALKER INS
SMALL FRY NURSERY SCHOOL 74 ELM ST
52 JEFFERSON AVE DANVERS MA 01923
SALEM MA 01970
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the scheduie(s) attached.
2. The policy period is from 05-1 3-07 to 05-13-08 12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limns of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
o�
a�
^� D. This policy Includes these endorsements and schedules:
o SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
e
- 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
<� Plans. All required information is subject to verification and change by audit to be made ANNUALLY .
DATE OF ISSUE: 04-03-07 DS ST ASSIGN: MA
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: ROSEMARY WALKER INS 73KCD
OOOB11
EITy-0'7-
PUBLIC PROPERTY
DEPARTME►�1T
KImbERL_EV DRISCOLL
APPLICATION FORT) REPAIR RENOYATION. CONSTRUCTION.
DE,riOLTTION. OR CAANG)E OF USE OR OCCUPANCY. FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Loatlon Name: U Se S a
---
01976
Propsrty is bated in s;Consovadon Ares YM_ Al Hisbrb Dkgrld YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: pa (//0
Address: 7 /re"? ,u o a '
evel-/ M4 6/ }/J'
Tom: 9 7 g Z
3.0 COMPLETE THIS SECTION FOR WORK IN E�IISI1Nd BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of GAS Area per floor (sf) Renovated
construction or renovation n 1993
of existing building New
Sdet Description of Proposed Work: Ice
D/! /o D/G/7 9�-
a ) ,�ve fUi^2_
--- — Mail Permit to: t2, � c
What is the current use of the Building?
Sc1.F,r,1.. •
Material at Building?
u9 9 It dwelling.how many units? l
WIN the Building conform to Law? Asbestos? OEL -
Architeas Name
Address and Phone N
Mechanids Name
Address and Phone
� liense sy C Z:U3 , L HIC Registration 0 P \3R a,5
Construction supervisors c
Estimated Cost of Project i Par"FN Calculstlon
Permit Fee i UO Estimated Cost X$71s1000 Residential
Estimated Cost X$11/:1000 Commercial-
An Additional SS.00 is added as an
Administrative charge.
Make sure that all Melds 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
specftatlons. Signed under penalty of perjury
Date 'l ^ Z,0-1
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