35 JUNIPER AVE - BUILDING INSPECTION i
EI`I`�-OF-�XLEl —
Y+, PUBLIC PROPERTY
DEPARTMENT
KIMBER1.EY DRISCOLL
MAYOR 12O WASHINGTON$IRFE-r♦J AL.EK JiAisncHt:sL-rIs 01970
TEL.978-745-9595♦FAx 97&74o.9S46
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
3 5" �3 Lw 12-
Property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land a
Name: DqW(rz-L J a)Dr,--(JU&L
Address: I LI 5T
_iSr�1, rl s5
Telephone: q ')X -9 ate—t(I y'7
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition ✓ Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: p pp
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What is the current use of the Building? //��� _
Material of Building? /.JQOD If dwelling, how manyVnits4
Will the Building Conform to Law?n Asbestos?
Architect's Name fj al
Address and Phone ldo SOU 4102�13�12� �Ji�l ( )l�✓ Ir��� T 9�Fr-y ��
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ v v v Permit Fee Calculation
Permit Fee$ -5"/0 .6u Estimated Cost X$71$1000 Residential
`D Estimated Cost X$111$1000 Commercial
ez An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit build to the above stated
g penalty of a 'ury
specifications. Signed under p nY P 7
Date
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Brief Description of Proposed Work
1. Replacement of sill and pouring of footings (foundation)
to support structure
2. Removal of horse hair plaster in garage and first floor;
expose and examine framing
3. Removal of carpet and other interior cabinets, floorings,
and fixtures
4. Removal of garage door to be replaced by a window
5. Construct foyer in basement with full bath
6. Install new door leading to back of property
7. Remove siding and windows and replace
8. Insulate structure
9. Update electrical wiring
10. Update plumbing, heating, and central AC
11. Remove interior walls to create open space between
kitchen and living room
12. New plaster walls and ceilings
13. New kitchen
14. New floors
Daniel Spencer
September 2006
CITY OF SALEM
+ PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET♦SALEM,MASSACHUSETTS 01970
TEL.978-745-9595 •FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): -4&Ncq,4- As-sou I 41V_S
Address: I y FV5 f tt i2 S 1
City/State/Zip: (3� M65 O 11 f S Phone #: 9W yak '`11 147
Are y9u an employer?Check the appropriate boxes: Type of project(required):
1. I am a employer with ? 4. lc' 1 am a general contractor and I 6. ❑ ew 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. t 7• ffRemodeling
ship and have no employees These sub-contractors have 8. [ Demolition
working for me in any capacity. workers' comp, insurance. 9, ❑ Bpilding addition
[No workers' comp. insurance 5. [-1 We are a corporation and its 10. El trical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11. PI bing repairs or additions
myself. [No workers' comp, c. 152, §1(4), and we have no
12. Roof a airs oyL
insurance required]t employees. [No workers' � z BA `9POttetr,.Q
comp. insurance required.] 13.SOther o O ct r a
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContracton that check this box must attached an additional sheet showing the name of the sub-contractors and 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.
Insurance Company Name: rlbtM FIM L
Policy#or Self-ins.Lic.#:Jar 0-P- coF4) >L Expiration Date: 61 l 0
r
Job Site Address:3s TUVI /IZfi City/State/Zip:S,4i F&M 0114S nl e17U
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 o DIA for insurance coverage verification.
I do hereby ce f under p ins a penalties ofperjury that the information provided ov is true and correct
Si nature Date: j �6
Phone#: L 2 cdoe?7fl'kl f/SO
Ojjicial use only. Do not write in this area,to be completed by city or town official.
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#•
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 employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,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 coveragesubdivisions required."shall
Additionally,MGL chapter 152,§25C states"Neither the commonwealth nor any of its political(7)
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 sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for 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
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
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like 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 ,
Offlce of Investigations a ;4
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
ACORD,N CERTIFICATE OF LIABILITY INSURANCE °09/1212 06
PRODUCER (978)887-8304 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
UGONE-JOHNSON INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
10 SOUTH MAIN ST., HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
SUITE 208
TOPSFIELD, MA 01983 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: FARM FAMILY CASUALTY INSURANCE
DANIEL SPENCER INSURER B:
DBA SPENCER ASSOCIATES
INSURER C:
14 FOSTER STREET
BEVERLY, MA 01915-2016 INSURERD:
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 DD'L LTRPOLICY NUMBER POLICY EFFECTIVIMMIDDMIE POLICY EXPIRATION LIMITS
NSR E OF INSURANCE DATE DATE(MMIDDMI
GENERALLIABILITY EACHOCCURRENCE $ 1,000,000
P' COMMERCIAL GENERAL LIABILITY 2005X0498 05/12/06 05/12/07 PREMISES Edoccurence S 100,000
CLAIMS MADE FRIOCCUR MED EXP(Any one person) S 5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS,COMP/OP AGG $ 1,000,000
POLICY PROS LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
A ANYAUTO 2005C4085 05/12/06 05/12/07 (Eaacctrlen0 $
ALL O W NED AUTOS BODILY INJURY
X SCHEDULEDAUTOS (Per person) $ 100,000
HIRED AUTOS BODILY INJURY
NOWOWNEDAUTOS (PeraociCent) $ 300„000
PROPERTY DAMAGE $ 100,000
(PeracciEent)
GARAGE LIABILITY AUTO ONLY,EA ACCIDENT $
ANYAUTO OTHERTHAN EAACC $
AUTOONLY: AGO $
EXCESSIUMBRELLA LIABILITY EACHOCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WCSTATU, OTW
WORKERS COMPENSATION AND TORV LIMITS ER
A EMPLOYERS'LIABILITY NEW 2005W 09/12/06 04/21/07 E.L.EACH ACCIDENT $ 500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED? E.L.DISEASE,EA EMPLOYEE $ 500,000
Des,describe under
SPECIAL PROVISIONS below EL DISEASE,POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
LIABILITY POLICY INCLUDES LANDSCAPE GARDENING AND MASONRY.
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 TO DO SO SHALL
FOR INSURANCE VERIFICATION PURPOSES ONLY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001/08) ORD CORPORATION 1988
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CI
TY OF
SALEM
I PUBLIC PROPERTY
DEPARTMENT
rm-WERL"oiusc"L 1�W. r�cT y..�T S L cv NLAbSACHLSEns 01970
MAYOR
'[m.97&74S-9S9S*FAX.975-740.994
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
La accordance
with the sixth edition of the State Building Code$780 CMR section 111.5
54,
Debris,and the provisions of MGL c 40,iss issued with the condition that the debris resulting fmm
Building Permit if licensed waste disposal facility as defined by MGL c
this work shall be disposed of is a properly
L 11,S 150A.
The deb1�r�is will be transpoRed W
1~ toame of bawler)
The debris will be disposed of in :
( of facility)a
(address oP facility)
isi, aawm of iit applicaat
1 Ud
date