60 JEFFERSON AVE - BUILDING INSPECTION (2) —.— EI��F��"r�L - -
,,
"' ` PUBLIC PROPERTY
`` DEPi1RT'I4fENT
�i�me.w sr owuou
�SAYOR 1�WwuNcmN J"txEE��yut�r,�l.�cucH�st�'is 01970
/ 9��a�, . 141978-7iS959S 1 F.at:97&7i0-9846 �
L�JC/
APPLICATION FOR THE REPAIR RENOVATION. CONSTRUCTION.
DEMOLITION OR CAANGE OF USE OR OCCUPANCY. FOR ANY EXISTIl�IG
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Locadon Name: (�b ;��Ft2s�:.� �t Building:
Property Address: � S���s,;.,,, /�v i
Property is located in a; Conservatlon Area Y/N � Historic Dfatrict Y/N N
2.0 OWNERSHIP INFORMATION
2.1 Owoer oi Land 0.TQ �GM\V`�f� '�a��1r �f�'�t'
Name: ��bFn.� `�v..��nr.+.� "'t:„s��
Address: (�3i��T�'��re-ss�,�-+ �"�
Sa \��.—, !w>
Telephone: �j�8 ���1 �^ S�S v
3.0 COMPLETE THIS SECTION FOR WORK IN EXlS:i1NG BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
DemoliGon Existing
Approximate year of Area per floor (s� Renovated •
construction or renovation
of existing building New
Bcief Description of Proposed Work:
__ - - --- _ -- ——
- — - _. ----
wR�-l� `'�NC . �s`���;d- �L'�.•a�.� .�L .�A��w�
MailPermitto: C-""`z- '� °
i ` ^'- --
I What is the curtent use of the 8uilding? �'�ti`�`�"' ���� �E"r'� ��N t'/U,b � � -
Material of Building7 S�'Ef t t°''�. If dwelling, how many units? �
Witl the Building Conform to Law? �'�ti5 Asbestos7 �
ArchitecYs Name Gf� �¢��"`�`�i
Address and Phone l �
Mechanic's Name �� 2 0�~°`' Q`'�- �-"'�
Address and Phone �3� Ia- ���`''`�`� �'E S�+ 1�.«, C"?S-7yY- Sasa
Construction Supervisors License# c� o4oyG� HIC Registratfon#
Estimated Cost of Project$ � �5, "o" pertnit Fee Calculatlon
Permft Fee S�� Estimated Cost X$7/51000 Residential
EsUmated Cost X$11/31000 Commercial
M Addkional$S.c�O is added as an
AdminiatraUve charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permk t uild to the abbve stated
specificallons. Signed under penaity of perjury /�
Date i� I ly o�
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CITY OF SALEM
� �� PUBLIC PROPRERTY
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DEPARTMENT
KMBERLEY DNSCOLL
�lAYOR 120 WASF�.IGTONSTREET�SALEl1.A�ASSACItUgTT501970
'1k1:978-74S959S �F,�x:978-7r49816
Worken' Compenaatlon Insuraace AfRdavtt: Bullders/Contractort/Etectticianyp�amben
Auodcant IntormaHoe Ptease Print Le ibhr
Name (BusinesvOrpn'va6odfndividiul): �G I^12 O�Y w at_t_ �N�
Addtess: �� ��aL ���tsZcw ��
City/State/Zip: ����-^^ i �� pl�J� Phone#: ��S 7��{ JOS�
Are yon an empbyeri Cbeek the apprey rlate boz: Type ot peoJeet(requlredj;
1.� I am a employer with `C^'�2 4. Q 1 am s genaal contractor and I 6, �ew coeahuction
employas(!Lll and/or pact-dme).• have hired the sub-contraccon
2.� i�.�ie P����m�r u��a on�aa�a�. _ �. ❑�a�ung
ship and have no employea 1'heae sub�con4acMrs have 8. ❑Demoliti�
worlcing for me ia any capaciry. workecs'comp. imuran�e, g, ���g��
[No wodceca' comp. ��0••s��- S. � Wa are a cocporad�and iq
*�4�d1 otHcas have mcereised their 10.�Electrical repain or additi�s
' 3.� I am a homeownet doing all work �B�of az�+npdon per M(3L I 1.�Plumbing repairs�addition�
myxlf.[No worlcus' comp. a 152, $1(4).aad we have no
1°eucance n9�dl t emP1aYeea.[No worken' 12.Q Roof npai�s
�•�n4��� 13.�Other
��r wvu��M ehedra box Nl e�uY dw rtu we�ee�«dao bday.eow�iy�6dr wodca�'eoorym�t(On vo�r��nn�tloe.
Hamownms who mbmit N6�AIdMt mNatiot t6y�n domi all wak�od�hrt�awid�emtr�ctan mu�t mhmit�osw�vit m�q ar6,
=Coeuuran diu chaek tht�bme mim mached�o�eoml�hen e6ovm�tlr n�of�M a�b.contraaan�od tl�lr wodras'eomp.V�Y�. '
/ani an en�ployn that!a provfding warkers'conipaarodon in.twrones jo►my employees Below fs the policy andJob s!q
injormatioa
Insurance Company Narne:/9/nF/t/cod.✓ o�r� ..rsr//Zipr/CF CO ,
Policy q or Self-ins.Lic.p: CC/C ��`.�0�..?� Expirstion Date: � / a7
-_ Job Site Addrw: CirylState/Zip:
- Attach�copy of t6e worken'compematlos policy daluadoe pa;t(show(ng t6e pollcv nnmOer aad e:ptrstb�date}
Failure w sceure coverage as required under Secpon 25A of MGL c. 152 can lead w rhe imposiaon of crimina(peey(tiee oPa
fine up co S 1,500.00 and/or one-Year imPrisonment,as well ae civil penaltiee in the form of a STOP WORK ORDER and a fwe
of up to 5250.00 a dsy against the violator. Be advised that a copy of tdis statement may yQ foM,arde���O}��of
Investigariom of t6e DIA for insurance cuveraga�erificatioa
!do htieby cert�fy ander t!u poin,t and perta/det ojper/rtry tba!du in/ornwafon provWed obovt/s/aw anAcarrset
Sienasurc:
Da[�
Phone#:
O,Q7ciaf ws only�. Do not writs Iw th6 areq m b�cornp/deJ by clty o�www o,07eloL
Ciry or Towo• Permit/L(ceme N
Isauin;Aut6ority(circle one):
1. Board of Healtq 2.BulldinQ Department 3.City/I'own C1erk 4. Etatrical In�pector S.PlumbinQ Iwpector
6.Other
Contact Persoo: Pdooe p:
Information and Instructions
Massachusetn Generat Laws c6apta 152 requires all employers u in che smice of another under any c naact�of hice.
p�uant m d�is scatuu,an eerOloyst ia defined as"...evaY P��
����imptied,oral or writcen.
o •is defined ati"aa individus�.PaRaash�P+assoeisaoo.cocPor+aon or other legal endty.oc anY two�mo�e
An awpJ Ye amd i�l the kgal repraentaava of a decessed employer.or the
of rhe focegoing mga�ed iu a joiut ent�a. �D��otha►e�a1�i�Y.�P�Y�i�P�oyea. However the
reeeivec or austee of an individua4 P��p•��OII aad who reaidat thexm.a tlte o�of the
owna of a dwellin�houae 1�svin�mo�mae than ehrca apaKments wod�on such dw�llini hou�e
i�ouse of another who emPbYs P��m w do msintensaee,eunsteu�aon or repair to be an empinYer."
or on the�ds or building a��°,°��w shall not because of such emPloYm�be deamed
MGL chapta 152.$23C(6)aLw sntes that"every state or toeal Ikeesis{rQ�seY shag wlt6hold the Isenanee or
reuswd ot a Iteame or permU to opuata a buaineu or to connruet bulWinp i�tbs commo�weakY tor aay
rodneed uee tabls evidenee ot eomptla�ee wiH the issurance covera;�reqafred."
appueant who has not p P of its litical subdiviaions shrll
AddiaonallY.MGL ehaP�152,$23C('n staas"Neithu the commonwealth nor any Po
' c�aact for ehe performanoe of public wo►ic until ueeptable evidr,nce of compliance with tha inauia�e
• enur inw aay ted w the con4actiaB sutho¢ity."
nquiremena of this chsptac hsve been pcesen -
APP��°n
affidsvit compleuly,bY aheclaa6 the bozes tbat apply wyour situation snd.i4
Pleasa fill out the wocken' compenastioa es sod phone numbec(s)alon8 with their certificace(s)04
aecessarY.�PP1Y��onascmds)name(s).addrese( ) with no employees other than the
in.y�rance. Limited Liability Companies(L7-G�or Limited Liability Pazmershipe(LLP)
are not sequired to cazry wocicen'compmssdon+s••,,a��'•,. If an LLC or LI.P daes have
memben oi Pa��. � Be advised that this affidavit may be submitted to che DepaRmen�of tndusa'ia!
employees.a Po1icY� 4��
Accidena for confirmadon°f wsu�a°�e coverage. Nw be�nra�o ai�n and date the at5davl4 'fha a�idtnt�°�
be rehuaed w tlu city or wwn tlut the application for the pecmit or licenee ia beiaQ requested,nat ttie Depactment of
Industrisl Ac�idents. Shauld Yon 6ave my 4ues�°°r nB��i the Lw or if you are required to obtain a workers'
compensatiou policY.Ple�eaii the Depsiemeot at tha number listed below. SeIY-insuted com�n�b ehoula entar t�r
self-insivance 1ice�°�°�O6 the a ►iae.
City or Tov►�OfIIelaV
Ptease be sure t�s��°��vit is complete aad printed legibty. The Deparanent has provided a space at the bo�wm
of the affidavit for you m fill out in ttu event tlu Office of Invesdgations has w contact you regarding the aPPlicant
Ptesse be wre w fill in the pesmidlicense number which will be used as a mference numbec. In additio0.�aPP�ant
�hat mwt submit multipk pesmidlicenx applicatiooe in aay given year.need onty submit one afFidsvit indicating cunent
policy informatiun(if neeesearY)and unda"Job Site Addrea�"the applicant should writa"atl locations in_—��11Y or
town)."A copy of the afTidavic_that has been ofRcislly stamped or marlced by the ciry or wwn may be pmvided ry the
applicanc as proof that a valid�afTidavi[is on file for future pecmib or licensee. A new at;,drvit mwt be filled�ut each
year.Whero a homa owner a citizen is cbtainiag a Gcense or permit not mlated W any busiaeas or commercial venwae
(i.e. a dog license or pecmit w burn leavea eteJ said person ia D7JT required to comptete this affidavit
The Office of Investigations would like to thsnk you in advance for your coopecatioe and should you have aay quesdons.
please do not hesitate w give us a caq.
The Depacanent's address.teleQhone and fa�e numba:
T�LO COIDmOnWG�tll Of Mi4S8ChuSCdS
�EpB[1mCOt Of jIIdOS�[l�ACCIdEIILt
O�CO 0�IIIYlSfI�i�I00�
60o w�8o�s�c
soston,MA o21 t 1
Tel. #617-727-4900 ext 406 or 1-877-MASSAFB
Fax#617-727-7749
tta�ss�d s-26-os wvwv,anass,gov/dis
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CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION �
CERTIFICATE OF OCCUPANCY
LOCATION• �� ����'�`'�"'�J� DATE �a � � � �6 6
APPLICANT: �-'"�2 ��y'�'�
FRAN�ICKULIK� �'��`�`r✓/C°''��� DATE:L `_" ��b
(93 Washington Street)
�
CITY CLERK
CHERYL LAPOINTE����DATE: 2 ZU (�,�
(93 Washington Street) ��
PUBLICE SERVICES
BRUCE THIBODEAU DATE:
(I20 Washington Sheet)4'�F7oor
WATER
DOTTIE THIBODEAU DATE:
(t20 Washington Street)41°F1oor
CROSS CONNECT SUPERVISOR
BRIAN THIBODEAU DATE:
(5 Jefferson Avenue)
'P�—������` �� ��d�i/t
��� DATE:
(i 20 Washington Street)3`d F7oor ,
CONSERVATION COMMISSION '_ /� /�
CAvw� l�x.�., N/�4 DATE:_[��
�120 Washington Street)3'"FI r
ELECTRICAL
JOHN GIARDI DATE: �� z/f�
(48 Lafayene Strce
FIRE PREV T
ERIN GRI �e d � DATE: .�7 (�
(29 Fort Avenue)
HEALTH j!
JOANNE SCOTT � DATE: � �� �J
(120 Washington Sv )4ih Floor
BUILDING
THOMAS ST. PIERRE DATE:
(l20 Washington Sveet)3`d F7oor
� �� a�i �b � go
� , .
CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION �
CERTIFICATE OF OCCUPANCY
LOCATION• 60 J e���'�5��' !"��� DATE ��/ � � �06
APPLICANT: �`� p�y`"'a LL
aSSESSORS �,� ��—�� .
FRANK KULIK��'� '� "// � DATE: OZ�
(93 Washington Street) ��`�e�' p�'��
CI1'Y CLERK ,��,�p O
CHERYL LAPOINTE �.lh�//l� DATE:�� �
(93 Washington Street) �—
PUBLICE SERVICES
BRUCE THIBODEAU DATE:
(l20 Washington Street)4'"F1oor
WATER
DOTTIE THIBODEAU DATE:
(I20 Washington Street)4'"Floor
CROSS CONNECT SUPERVISOR
BRIAN THIBODEAU DATE:
(5 Jefferson Avenue)
PLAMVING�A. �M o-�a�1 kr /�
�vT DATE: �d�� a
(120 Washington Street) 3A Floor
CONSERVATION COMMISSION
��teca DATE: IL ll O
(120 Washington Sveet)3"Ftdor �
ELECTRICAL �
JOHN GIARDi DATE:�1'/�O�o
(48 Lafayette Strcey
FIRE PREVENTIO
ERIN GRIFFIN P� .�� _� DATE: /,•7 y�
(29 Fort Avenue)
HEALTH /
JOANNESCOTT �� DATE:�a D(a
(120WashingtonSv 4t°Ftoor
BUILDING
THOMAS ST.PIERRE DATE:
(I20 Washington SVeet) 3`d Floor
� , . �
CITY OF SdLF1bi
' PUBLIC PROPER'IY
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Construcd�►t Debrfs Dfspotat AfAdsvit
(requiee�mr�eemdidas aoe ceav�ior e�
tQ�witb th� ��3N �Cod�,7S0 C��xda�l ll.!
��'��� i�i�u�aib�oo�a�dut t�deMr ewlt�es�aa�
Bu�7d6y MeM N
cM�wadt�11 b�di�oad ot h�p�o�Z1►Ne�o��r�dtapasd 6dltt�►a�d�nd bq�[�$.s
i��,si�►.
�n+.ae�ts w�u b.�oKea hr•
, 1..�`c.. l��S � ��`e- '�,�y a S�c S�-v•c�s
la�d�rNr� '
7'}w dcbds wiq b�di�potd o[in:
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larae.r of heuiM '
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AMERICAN HOME ASSURANCE COMPANY 69194-0000 WC 895-09-38
1378 i � " --------------------------------------------
o13-8z-olo6-00
.••.• . . . - . NEW YORK
. � ...• . . .
E.M.R. DRYWALL, INC.
63 1/2 JEFFERSON AVENUE �� Member Companies of
SALEM, MA 01970-0000 American International Group
EXECUTIVE OFFICES:
70 PINE STREET. NEW YORK, N.Y. 70270
SEE NAME AND ADDRESS SCHEDULE - WC990610
I.D# MA UI#:
WORKERS COMPENSATION AND EMPLOYERS
LIABILITY POLICY INFORMATION PAGE
INSUREU IS PREVIOUS POLICY NUMBEF
CORPORATION RENEWAL 006928418
OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC 0610
ITEM Y POLICV PEPIOD t2:01 AM.standard time at the insuretl's
mailing address FROM 0������6 TO ���0����
ITEM3 p, yyorkers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed �
here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A.
Tha limits of our liability under Part Two are:
Bodily Injury by Accident $ 500,000 each accident
. Bodily Injury by Uisease $ 500.000 policy limit
Bodily Injury by Disease $ 500.000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
AK AL AR AZ CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ
NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
ITEM 4 The premium for this policy will be determined bV our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Estimatatl Total Rate Per Estimated
Classilications Remuneration Premium
Goda Number $t00 OF Re-
- � Annual �3 Vear muneration �q��ual �3 Vear
SEE EXTENSION OF INFORMATION PAGE - WCp754 �}'- � ' ` '
i TAXES/ASSESSMENTS/SURCHARGES 54,393
EXPENSE CONSTANT(E%CEPT WMERE APPLICABLE BY STATE) $28�{ MA
MINIMUMPPEMIUM SSOO MA TOTALESTIMATEDPPEMIUM S $ �Ej�
Ii intlicatatl below, interim atllustmenis of premium shall be mada:
� Semi-Annually � Quarterly � Monthly DEPOSITPREMIUM
ENDORSEMENTS�FOFMNUMBER) SEE ATTACHED FORM SCHEDULE - WC990612
�
. . �Lt•�'�� G�` �, .��. .bf>;:
�' F/-.�:'_s'
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12/29/05 PARSIPPANY $2
Issue Daie Issuing Office Auihorized Fepresentative WC 00 00 01
3996]
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