51-71 LAFAYETTE ST - BUILDING INSPECTION (3) PUBLIC PROPERTY
DEPAR'1'UEINT � 1 L
130WAswbW"Ytfrsr V.�uaasritsOIWM
97e.745-95"•PAC W&740.9"
APEUCATYON FOR THE RKFAr�- RENOVwTrnrr A'ONSTRUCTION
QKWWrION, GE OF USE OR R ANY ��VG
STRUCTURE OR B>Lm.tnrnr�
1.0 SITE INFORMATION
Locadon Name: -n7 -e 3 y d y8
Property Address -. - - ... s e
Property In bated Ina;Coraervv*w Arse YM—Hietnrie Obbla YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Address`
Telephone: YL
3.0 COMPLETE THIS SECTION FOR WORK IN E —Midp BUILDING$ ONLY
Addition Existing
Renovation Number Of Stories Renovated
Change in Use New
Demolition
p�L�lIO Existing
Approximate year of Area per floor NO Renovated
construction or renovation
of existing building New
Bdd Description Of Proposed Work:y /
Mail Permit 73
S
C Use,of the Building?
What is thecurrentItdwelling.how many units?_��
Material of Buitdk+g? p Asbestos?
Will the Building Conform to taw? c1
Architeas Name j
gddre"and Mona p�
Address and Phone
Consyudion Supervisors License
y (',r�(0O887 HIC sdon
Estimated Cod of Project$ O b PernaFee Cala+latkut
GQ Sa o0 Estimated Cost X=7I:1000 Residential
Permit Fee i
Estlr."d Cod x Sw$1000 Comme►cta4-_.__
- An Additional$5.00 is added as an
Administrable charge.
Make sure that all fields are properly and legibly written to avoid delays in processin0.
far a Building P build to a stated
The undersigned do"hherebya apply
apeci}leationa. Signed under penalty of PerjurY
oat 07
06
N
!� V
ilia UUNNL. 19 001/004
BR CERTIFICATE OF LIABILITY INSURANCE DATE WISDOM
MISDO "~'
03/09/2007
PRODUCER (800)333-7234 FAX (508)655-8853 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION
EASTERN INSURANCE GROUP LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
233 WEST CENTRAL STREET HOLDER,THIS CTIFICATE DOES NOT AMEND, EXTEND OR
NA TICK, MA 01760
ALTER THECOVERERAGE AFFORDED BY THE POLICIE BELOW.
INSURERS AFFORDING COVERAGE NAIC 0
INSURED Groom Construction Co.,Inc. INSURERA: Travelers Indelmity Co 256SS
96 Swampscott Road INSURERS; Travelers Prop & Casualty Amer
Salem MA 01970 INsLI iEftc: ComnerCe & Industry
wsuRER D:
INSURER E
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANOIN
ANY REOUIREMENT,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
POLICES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
TYPE OF INSURANCE POLICY NUMBER POLICY eFFECTNE PODGY EXPdIAYION LIMITS
GENERAL WBRJf1 C04630947A 03/10/2007 03/10/20011 EACX OCCURRENCE $ 11000,00
X COMMEROIAI GENERAL LIABILITY DAMAGE TO RENTED $ 30O O
00
CLAIMS MADE O OCCUR MED E%P IMY ene PenmJ $
10 00
A PERSONAL E ADV INJURY S 1 OQO
GENERAL AGGREGATE E 2 OOO OOC
GEN-L AGGREGATE LIMIT APPLE$PER PRODUCTS. IAPIOPAGG E 2 000
001
POLICY X jrcT F-jLoc
AITOMOB�UASIL+ry 81046309481 03/20/2007 03/10/2008 am�DD SINGLE LIMIT $
I 1100010
ALL OWNED AUTOS
SCHEDULED AUTOS BOOILYINJIIRY $
B (Per L .INJ
HIRED AUTOS
6001LY INJURY S
MON•OWNED ALTO$ (Per ettl W*
PROPERTY DAMAGE $
(PertDIS�E
Odenll
GARAGE LIABILITY ONLY•EA ACCIDENT $
ANY AUTO
THAN EA ACC $
ot
ONLY: AGG S
EXCESSNMBRELLA LIABILITY BE4953127 03/10/2007 03/10/ CCURRENCE $ 10,000,000
i
X OCCUR cwMSMAOE GATE E 10 000,
B $
DEDUCTIBLE
E
X RETENTION E 10,
WORKERS COMPENSATION AM WC9688758 03/10/2067 03/10/2CSrATU- m-
ENMyPLOTEFtW LIABILITY EoyFPOEEPMEMBE"EART11(CLUDEo7ECU71vE CHaccIDENr $ 11000,00SPECIAL PROVISpNS belc. E E-EAEMPLOYE E 1000QFASE-POLICY LIMB $ 1,QQQ,Q
OTHER
OESlY11PTXIN OF OPERATIONSI LOCATIONSIYEHICIE$1EXCLUSIONSADDEDBYENOOR�.M_EMIsrr;c LLPROWSIONS
9ANQELLATION
MOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENUEAVOR TO NAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIM UPON TIIE INSURER,IT$AGENTS OR REPRESENTATIVES.
AV1110RRFD REPRESENTATIVE /1�,*
Rosema Fu1h PNA fVj/
ACORD 25(2001/08) SACORD CORPORATION 1968
The Con,ntonwealth OJ Massachusetts
Department of'/ndustrial Accidents
Office of hivestigations
600 Washington Street
Boston, MA 02111
+a wwly.m ass.gO vIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
:Applicant Information Please Print Legibly
Nanle (Business/Organization/Individual): Groom Construction Co. , Inc.
Address: 96 Swampscott Road
City/State/Zip: Salem MA 01970 Phone #: 781 -592-3135
Feployees
mployer? Check the appropriate box:
Type of project(required):
ployer with 4. ❑ I am a general contractor anJ[9
es (full and/or part-time).* have hired the sub-contracto6. ❑ New construction
le proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
have no employees These sub-contractors have8. ❑ Demolition
for me in any capacity. workers' comp. insurance.
No workers' comp. insurance 5. . ❑ Building addition
[ p. ❑ We are a corporation and its
required.] officers have exercised their 10-❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LE:] Plumbing repairs of additions
myself [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑ Other____
•Any applicant that checks bex#1 must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing nil work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infornialion.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: American rn na ; o; n-1 Cronn _
Policy#or Self-ins. Lic. #: WC96RR75R Expiration Date:
0 3.--1-0=08
Job Site Address: City/State/Zip:
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 verif' ation.
I do hereby certij i er the pains c penalties ofpeijui that the information provided ove is t tie rind correct.
Si nat
Date: " t
Phonc H: 7 c;
Official 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#:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\4uK IX W.\i1"'7.ON5,9EET 41\l:V.AWW::it a115.:a�C
TF..t:97L745.95a5 972-74G9944
Construction Debris Disposal At7idavit
(required for all demolition atxl renovation work)
in accordance with the sixth edition of the State Building Code, 730 CN1R section l 11.3
Debris,and the provisions of MGL c 40, S 54;
Building Permit 0 _ _ 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
I It.3 150A.
The debris will be transported by:
Groom co(\a
(name of hauler)
I'lie debris will be disposedof in
No
-- (natile ol'Iacillty) J
+J.:r�;. ui Cx:Ltyl
d
f v 1
What is the curcent use,of the Building? '
Material of Building?
ifdw m
elling,how any units?__— ---
Asbe
"li the Building Conform to Law?__I- =l J? —
Archited's Name pv v19 � �
Ad&"*and Phone
Med+anic's Nam ( /
_I �j Ci r�ivy�pLL
; fC
Addrou and Photw Ill (�4°0 fo�'�$7 HIC Registratkxr f1
�y�n Supervisors License
Estimated Cost o��1 CCP,,��rojje�e t.S O �O Permit Fee Cak ulatlon
Pertnd Fee S IA a =0 Estimated Cost X$?IS1000 Residential
- _ _ Estimated Cost X S11/$'000 Cornme ---
An Additional $5.00 is added as an
Administrative dtarg&
Make sure that all fields are properly and legibly written to avoid delays in Processing.
The undersigned does hereby apply
for a Building P build to a stated
specifications. Signed under penalty of PedurY ��
Dat
•�t
I
3
a
I.., •� � a � (7 y 3
---- - -
;PLJLi.IC PROPERTY
DEPARTI EINT
uw�nsr o■�.�
%IAva
130 WAOUN NN-S�•SntI&K UAZACHUM-M 01970
TU-9.W74S.9S93•FAX 97L740.9"
APPLICATION FOR THE REPAIR, RENOVATI N CONSTRUCTION
DEMOLMON, OR CHANGE O! USF OR OCti^ittp FOR ANY EJOS.a
STRUCTUI>� OR BUII nnv�
TING
--�_
1.0 SITE INFORMATION � _
Location Name —f tlBung; 3 BS—
Property�°Wdreac- - -- - S Properly Is located In a;Conservation Ares Y/N oittriet YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone: YC
[Approximate
.0 COMPLETE THIS SECTION FOR WORK IN E7tinTimLi BUILDINGS ONLY
ddition Existing
enovation Number of Stories Renovated
hange in Use New
emolition
aLll b� Existing
year of Area per floor (sf) Renovated
construction or renovation
of existing building New
add Description of Proposed Work:
R
Mail Permit to: V i I
Dva 000 aaDs LAS ILHN INS COMML. 12001/004
'
ACO ATE(MMND/YYYY)V ,RD CERTIFICATE OF LIA�ILI'rY INSI�RANCE DATE
PRODucER (800)333-7234 FAX (508)6SS-88S3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
EASTERN INSURANCE GROUP LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
233 WEST CENTRAL STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
NATICK, MA 01760
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGEMAme
INSURED
Groom Construction wOURERA: Travelers Indemnity Co uct on Co.,Inc. y96 Swampscott Road NsvRERD: Travelers Prop & Casua
Salem MA 01970 INSURERC Commerce & Industry
INSURER D:
INSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN
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.
IN$R D TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POUCYEXPIRATION
LIMITS
GENERAL UAll', C0463D947A 03/ID/2007 03/10/2008 EACH OCCURRENCE $ 1.000,000
X COMMERCwLGENERALLIABILIYY DAMAGE TOFRENTED 300,000
s
CLAIMS MADE OCCUR MED EXP(AnY one persm) $ 10,000
A
PERSONALSADVIN.URY $ 1,000.0001
GENERAL AGGREGATE $ Z.00O
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS_(,pMP/OP AOCi 8 2 DDD DD
PO11CY K PRO-JECT L00
AUTOMOBILE LUIBILJTy 81046309481 03/l0/2007 03/10/2009 COMBINED SINGLE LIMIT
X ANY AUTO (��Gtlen1) S
ALL OWNED AUTOS 1,000,00
SCHEDULED AUTOS 130DILY INJURY
B (Pa Pa.w+) $
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY $
(Par eaJdenl)
PROPERTY DAMAGE $
I Peraeadeni)
GARAGE UABILITY AUTO ONLY.EA AOCIOENT B
ANY AUTO
OTHERTHAN EA ACC $
AUTO ONLY: AGG $
EXCESSRIMERELLALIABILITY BE4953127 03/10/2007 03/10/2009 EACH OCCURRENCE s 10 000
B
X OCCUR D CLAIMS MADE AGGREGATE Is 10 DDD,00
s
DEDUCTIBLE
X RETENTION $ IO, Is
DO - $
WakKERS COMPENSATION AND WC9688758 03/10/2007 03/10/2008 X WC SYATU- TH-
EMPLOYERS'LIABILITY
C ANY PRNMEIABE�ARTNERIF ECUTIVE EL F.ACHAODIDENT $ 11000,00
OFFIF avA.ambeunder &L.01$EASK-CAEMPLOYE $ 1,DOo,00
S�ECIAL PROVISIONS b6 E.L.DISEASE-POLICY LIMIT $ 1,00D,0D
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDERAN L I N
SHOULD ANY OF THE ABOVE DESCRIBED POLICE&BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER HALL ENDEAVOR TO MAIL
30 OAYSWRITTENNOnCETO1 ECERTIFICATEHOLOERNAMEOTOTHELEFT,
BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
AV IMUKI EO REPRESENTATIVE
Rosema Fulh PMA �"'a"a`
ACORD 25(2001/08) OACORD CORPORATION 1988
The Contrnomvealth of'Massachusetts
Departntent,of Industrial Accidents
oViCe of'%nvestigations
600 Washington Street
Boston, MA 02111
wxrrv.ntass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contract:ors/Electricians/Pltunbers
Applicant Inforniatiolt Please Print Legibly
Milne (Business/Orga❑izalion/hidi%iduaq: Groom Construction Co. , Inc.
Address: 96 Swampscott Road
City/State/Zip: Salem MA 01970 781 -592-31 35
Phone #:
FrAe you an employer? Check the appropriate box: Type of project (required):
❑ I am a employer with 4. ❑ I am a general contractor and I
employees full and/or Part-time).* >,,, 6. ❑ New construction
( part-time . have hired the suh-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling
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
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions
myself. [No workers' comp. e. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑ Other__
*Any applicant that checks bcx#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.
;Contractors that check this box must attached an additional sheet showing the name of the suh-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: American Interuat; n`_ i r
n _
Policy#or Self-ins. Lie. #:_ WC9 f,R R 7 58 Expiration Date:
n�
.fob Site Address: City/State/Zip:
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 verifi, ation.
I do hereby cerd a er the pains penalties ofperjur that the irtfornuttioa provided ove is t tie and correct.
Si nat �
Date:
Phouc 6<i 3 3
Official use only. Do not write in this area, to be completed ky 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 #:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\L77x M 12C W.791IN1 :J V S:RELT•5.\LI M.fit.\u.\137t eL l f Y 7:9IC
Ta:978-745.9595 •F.%'t:978.74C.9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of v1GL 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 v1GL c
111. S 1.50A.
The debris will be transported by:
- - G roe
inn _
(namo of hauler)
The Llcbrislwill be disposed of in
Name of faC111ty)
. _— �adLfexa .:f faiil.l;q .
♦i LL[Iu'd :Cfill:(..1;�7.IUAt _ ____
_—_ ,.ale _