1 KERNWOOD ST - BUILDING INSPECTION (9) -PL*NS1*WST-6EfILfi i APPROVED By T*IE
WSPfXTDB PfWR TPA_PERMIT BEWG GRANTED
CITY OF SALEM
No. 5 Date
Is Property Located in Location of 1 kernWood St.
the Historic District? Yes No✓ Building
Salem, MA
Is Property Located in
the Conservation Area? Yes No ✓
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other. LZe1?0+14- 1 Qa I-s ;r\ M,2),'J
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's NameCrl °
Address & Phone
Architect's Name
Address & Phone 1
Mechanics Name 4
Address & Phone I
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cod a, ' 7)"-- CIN License o N A state License# Ls D 7 6 8,6
M=e ImproveW.at G�
t
� ,\ Signature of Applicant
,� SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Fepair egistin$ tvien's sho�Jer room 4 Steen Yoorn mreo'
from re�16'cin2 exisf nQ tiles end
suppoYt; ng Wo,ll boards, Once Wails oYe opened CAP, Othe-e
Works moy be required to put back k)oII toptheY ivi soundCond;Gov,
MAIL PERMIT TO: N) H CONS7Ruc-rionS CORP,
31t; MAIN . STREL-T� READOJ6i ) MA018b7
pA.r
APPLICATION FOR
PERMIT TO
TION�,4
PERMIT GRANTED
APPROVFD ,
LA
ECTOR OF(BUILDINGS
� f
Tire Commonwealth of Massachusetts
7 Department of industrial Accidents
olmcsa�mfesupanasa
600 Washington Street, lt°Floor
Boston,Mass. 01111
ALU /Workers'Com enation Insurance Affidavit: Buildin lumbin lectrical Contractors
4
name: �6„� i h M i 5'1;YY
address: 315 Hoon Street
cry Reo.d'o, star : HA vno1867
phone# (78 1) q4'4-61Foo
wok 'r o i address), 1 kerncaood Street, 5odem , MA ojg7o
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction ErRemodel
❑ i am a sole proprietor and have no one working in any capacity. ❑Building Addition
------ ----❑✓'Lam an employer proytdmg workers compensation for my employees working on this)ob
selap me:
city:
1 }n
L(T Il I f
7
/7 t a_� onlfi�,a
insurance co. L
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
company name: - -
address: . ..
a
surnett 6
n
company pame: •",�. ° +�`ti, v .a{.^ 1 +�
address: +v,d u P t ani
r t
-
-.
1111013,1191 WA •iol;f��arsli�ai "o, P, Pry R. f , ,tl ,.rs ' npli�/F ass +� sa P e,.;�„�'� u ..;,�9.<a;-.
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of Me up to St,5oo.00 aodtor
one years'imprisonment as well as civil dpenalties In the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
COPY of thio statement may be forty rd / the Office of Investigation of the DIA for covenage verification.
I da hereby cerci un the pains a d penalties of perju at the information provided above is true and correct.
Signature , I Date
Print name _ f301in iMistry —Phone# OeI) 5/+-f'— b4Os
Official use only do not write in this area to be completed by city or town official
city or town: permit/license#
❑Building Department
C]check if immediate response Is required ❑Licensing Board
❑Selectmen's Oalce
contact person: phone p: ❑ncalth Department
aenuJ S” asol []Other
f �
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
q every employees.to ees. As noted from the"law",an employee is defined aspe
rson 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 section 25 also states that every state or local licensing agency shalYwlthhold 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,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.ftfill.n the-workers ccompensation affidavit completely,-by checking the box that applies-to your situation_ Please
supply company name,address and phone'numbefs along with;a certificate of insurance as all affidavits maybe,
L-
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' compensationpolicy, please call the Department at the number listed below.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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 d 18118098111811111
600 Washington Street,7'"Floor
Boston, Ma. 02111
fax#: (617)727-7749
phone#: (617)727-4900 ext. 406
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
1 Jp 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, S34,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, S 150A.
The debris will be disposed of at: I Kern good s tree t, Sv l ew , HA
21, Location of Facility
.. 4", k .'- 46 --6 S�
Signature of Permit Applic t Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
�altn MiS�Y`�
Name of Permit Applicant
1J M Coos-rizucT(oN CORP,
Firm Name, if any
315 Hon StYeet , IZeo d ng > MA o 18 67
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, S 150A, and the building permits or licenses are to
indicate the location of the facility.
:k'
DATE: 02/27/05 TIME: 11:22 OZ/ZZ/ZOOS
AC W, CERTIFICATE OF LIABILITY INSURANCE
PRODUCER (617)472-3000 FA% (617)472-7248 ONILYAND CONFERS INoRIGHTS UPONTHE CEIION
CERTIFICU ED CERTIFICATE
Burgin, Platner, Hurley Insurance Agency, Inc. HOLDER.THIS CERTIFICATEDOESNOT AMEND,EXTEND OR
14 Franklin St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NAICH
Quincy, MA 02169
INSURERS AFFORDING COVERAGE
Janet Sweeney INSURERA: Liberty Mutual Insurance
INSURED N. M. Construction Corp. INSURER B'.
31S Main St INSURER C'
Reading, MA 01867 INSURERD
INSURER E'.
NEI—Al o COVE G SNSURED NAMED
THEANY REQUIREMENT,TERM OR CONDITION ION OF ANY CONTRACT OR OTHER(DOCUMENT WITHAREOSPECTO TO WHIOHITHIS CEIRTIFICATE MAY 8E0I SUED OR
POLICIES OF INSURANCE XCLUSIONS AND CONDITIONS OF SUCH
MAY PE STAIGG HE INS RANCE AFFORDED BY THE SHOWN MAY HAVE POLICIBEEN ES DESCDUCEDRIBED
Y PAID CLAIM IS,SUBJECT TO ALL THE TERMS,E
LITSPOLICY EFFECTIVE POLICY LICE EXPIRATION LIMITS
INSR 00 TYPE OF INSURANCE POLICYNUMBER M ID EACH OCCURRENCE $
NS GENERAL LIABILITY DAMAGETORENTED $
COMMERCIAL GENERAL LIABILITY MED EXP(Arty one person) $
CLAIMS MADE ❑OCCUR PERSONAL B ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS COMP/OP AGS 8
GEN'L AGGREGATE LIMIT APPLIES PER.
POLICY JEC LOC
COMBINED SINGLE LIMIT $
AUTOMOBILE LIABILITY (Ea accident)
ANY AUTO $
BODILY INJURY
ALL OWNED AUTOS (Per person)
SCHEDULED AUTOS BODILY INJURY $
HIRED AUTOS (Per accident)
N09OWNED AUTOS $
PROPERTY DAMAGE
(Per accident)
AUTO ONLY-EA ACCIDENT $
GARAGE LIABILITYEAACC $
OTHER THAN
ANY AUTO AUTO ONLY. AGG $
EACHOCCURRENCE $
E%CESSIUMBRELLA LIABILITY AGGREGATE $
OCCUR ❑CLAIMS MADE $
DEDUCTIBLE $
AT
RETENTION $ ORY LINT S OER
WORKERS COMPENSATION AND WC5315322943014 06/23/2004 06/23/2005 %LEACH ACCIDENT $ 11000,000
EMP LOYERTLIABILITY EL.DISEASE-EA EMPLOYEE $ 1,000,000
A OFFCERYMEM ER EXCLUDED?CAVE
EL DISEASEPOLICY LIMIT 8 1.000.000
IIis.describe under
SPECIAL PROVISIONS below
OTHER
DEESSCRIPTID OUCTYS ES IE%CLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
KERNWOOCRCLUB
C C LL 10
CE CTE OLDE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
X10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEPT,
TOWN OF SALEM BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
TOWN AHLL OF ANY HIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
5 BEACH ROAD AUTHORIZED REPRESENTATIVE
6.
SALEM, MA 01952 f7
Michael Prender ast DFM CORD CORPORATION 1988
ACORD 25(2001108)
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