278 LAFAYETTE ST - BUILDING INSPECTION CITY OF SALENI
PUBLIC PROPERTY
DERAR17]NIENT
NIA)"OR
9
APPLICATION FOR PLAN EXAMINATION'AND RUI LDING PERMIT
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS
fMP0 . ANT:Applicants must complete all items on this page
SITE INFORAIATION L/
Location Name- .4 Building
Property Address '111S LAF&%-%[fTTe Sr
Map
Located in: Conservation Area Y/N- Historic district Y/N—
Use Groups
(check one)
Residential(3 or more Units) R12
Type of improvement Residential(hotel/motel RI
(check one) Assembly(churches) Al —
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants.recreation) A3_
Alteration Business B
Repair/Replacement Educational E
Demolition— Factory(moderate hazard) Ft
Move/Relocate Factory(low hazard) V2
Foundation Only High HazArd H—
Accessory Building_ Institutional (residential care) 11
Other(describe) institutional (incapacitated) 12
Institutional(restrained) 13
Mercantile M
Storage(moderate hazard) Sl —
Storage(low hazard) S2—
OWNERSHIP INFORMATION(Please type or Print Clearly)
OWNER.
Address 14 VjKla S-T�
Telephone
178-Z61 - (0' 039
I)ESCRIP'FIONOFWOIM'fOBEPERFORMED
IUIV)
ESITNIATIED CONSTRUC110N COST 0 o 0
a 1
CITY OF S.AL&M. iNLkSSACHUSETrs
�,� f�• BUMDLNG DEP\RTMEINT
120
_0 WASHLNGTON STREET, 3"FLOOR
TEL (978) 745-9595
FA..[(978) 740-9W
K►%,tBERL.EY DRISCOLL
TMAYOR THobtAs ST.PtERRa
DIRECTOR OF PtmBLIC PROPERTY/BtTLDLNG CO\LMSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 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 150A.
The debris will be transported by:
�}11r2 b(sPCst�'
1 •q�8 (name 6'3335
The debris will be disposed of in :
(name of facility)
(address of facility)
!L r
signatuA6 of permit applicant
�8
date
dcbriulT.dcw:
CONTRACTOR INFORMATION
Name 15%;L\Ic@-
Address 9 uSP-- WA-4 I' C>LoJtE "or
Telephonel7i.Lm. H191. (,(7.291.38&7
Construction Supervisor's Ic# 74501
Home Improvement Contractor# %Z'M t
ARCHITECT/ENGINEER INFOMMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is trite to the Lest
of nzy knowledge under the penalties of perjury
Signed W-L
Date
CITY OF S.XI.EMs 2UNSSACHLSE-17 17S
a
BUILDING DEPA E.N
RTJT
120 WASHCVGTON STREET, Sao FLOOR
� (979) 745-9595
FA.e(978) 740-9846
Kl,MffiFRi EY DRISCOLL
MAYOR THOMAS ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BL'IIDDIG CO%5f1SSI0NER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BusimssOrganizatioNlndividual):
Address: L4(!C6'C&dCor- w /
City/State/Zip: &W(41,515M M O Phone #: (0(12q(3so CE:I�071aja c v
Are you to employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
,.._/employees(full and/or part-time).* have hired the sub-contractors
2.pd l atn_a sole proprietor or partner- listed on the attached sheet S ?• ❑ Remodeling
_ Ship and have no employees These sub-contractors have 8. RrDeniolition
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 I.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.r❑y Roof repairs
insurance required.]t employees. [No workers' 13 OtherRtrl{.trrF
comp. insurance required.] L�Lv�J
•Any applicant thul chocks box 91 most also fill out the section below showing their workers'compensation policy information.
'1 fnmeownen who submit this affidavit indicating they arc doing all work and than hire outside contractors most submit a new affidavit indicating such
=('onttact)n that cheek this box twea attached an additional gheel showing the none of the sub-contmetota and their workers'comp.pol icy information.
I am an employer that Lt providing workers'compensaton insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ALh r]
Policy N or Self-ins. Lic.q: G F 0114 n(p� Expiration Date: 4=6_46
Job Site Address: Z78 City/State/Zip:5&t-IE"t min
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 S 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 S250.00 a day against the violator. Be adviu:d that a copy of this statement may be forwarded to the Office of
Investigations oldie DIA for insurance coverage verification.
l do hereby,certify under tie sins un penalties of perjury that the infarmadon provided bove true and correct.
•nat ire• V Date:
n #: a 18( L
Official use only. Do not write in this area,to be completed by city or town aJrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing inspector
6.Other
Contact Person: _ Phone p:
FROM : PRINCE INS. RGCY. PHONE NO. : 9782810314 Sep. 25 2008 11:38AM P1
OATEIMMIDDM'YY)
ACORD CERTIFICATE OF LIABILITY INSURANCE® As A MAT1Et of mFOI�9 25 8
THIS pRQDUCER ONLY AND CONFERS NO WGFfT3 UPON THE CF'JC HICATE
Prince Insurance Agency HOLDER THIS CEF(TIFICATE POPS NOT AMB'ID.
15 Washington Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Gloucester, MA 01930 _ NAIC#
INSURB7.SAFFORDING COVtFA.GB_.—_
INSURERA. PheYL1R Mutual Fi:ce, Ins Co —
INSURED --- "—
Bruce Novak
9 INSVRERB'..— ..—_�.-----
Lighthouse Way INSURERC: --
ucGloucester, MA 01930-4277 INSURER D'.
INSURERE:
COVERAGES ow HAVE BEEN ISSUED TO THE
ATED, NOTWITHSTANDING
THE POLICIES OF INSURANCE
LISTED
ON OF ANY CONTRACT OR OTHER DOCUMENT WITTHOR SPEC TTO WHICH THIS CERTIFICATE CAE MAY BE ISSUED SUCH
ANY REQUIREMENT, e
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,
Y EPFEOTI POLICY E%NRA-n.. LIMITS
RAD J� POLICY NUMBER EACH OCC ORf1ENC E S 1 000.000 ,
GENERAL LIASILTY ADAGE O TIEDS 1 000.00"
COMMERCIAL GENERAL LABILITY CP130714863 9/28/07 9/28/08
CIAIMS MADE a OCCUR PERSONAL&ADVNJLRY $ 50 COO'
GENEPALAGCRSS&E $ 2 000 000
PROD UCTS-CONP,DPAM S 2 000 000
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY PRO LOG
ccM®NEDSN iEUMB
ODt'ONO&LE LIABILITY (Fs Botltlern)
ANY AUTO
B]Dpffw) RY $
ALL OWNED AUTOS (PopeISM) _
SCHEOULEOAUTOS
Bp ORYNJURY g
WIRED AUTOS (RR axi®R)
NON.OWNEDAUTOS
(Pv clot
CE S
AUTDONLY•EAACCOMT $
GARAGE LIABILITY J— FA ACC 9
OTHERTHAN
ANY AUTO AUTOON.Y: AGG S
HLCHOCCURWNCE $
EXCESSNMBRELLA LIABILITY MGRMATE $
OCCUR CIAIMSMADE $
DEDUCTIBLE $
RETENTION S WC STATU- OTH.
_ TO E
WORKERSCOMPENSAMONXID E.L EAC H AC aOENT S
EMPLOYERS'LABILITY
ANYpROPRS[TORIPARTNEWEXECUTME EL UMAX-EA EMPLOY EE $
OFFICERIMEMBER EXCLUDED?
RYBB Mlle und.Y F L DIMAff.pOUCY LMIT 6
SPECIAL PROVISI NSINIM
OTHER
DESOMPTIONOF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PRM ISNINS
Policy will automatioly renew On 9/28/08 to 9/28/09
Carpentry
CERTIFICATE HOLDER CANCELLATION
SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E)MAATKN
Salem Building Dept. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAD„_ DAYS WRITTEN
Attn: Thomas St. Pierre NOTICE TO THE CERTIFICATE HOLDER NAMED TD THE LEFT,BUT FAILURE TO DO SO SHAL
120 Washington Street IMPOSE NO OBUGAMON OR LIABILITY OF ANY KIND UPON'THE INSURER,ITS AGENTS'OF
Salem, Ma 01070 REPRESENTAYNES.
AU O R ESEXTA \ .
®ACORDCORPORATION1988
ACORD 25(2801108) '
,
A-
I n
OMPER DRIVER'S LICENSE NUMBER———C_- DRIVER'S LICENSE
7` r ,3231I J? •�» n mreorelaTe158 CLASS REST HEIGHT SET qiy
S, OF BIRTH CLASS REST HEIGHT SEX _ ,
t,56 o cal M 02-07-1956 ° stt M IUI t
EXPIRES EXPIRES
02.07-2009
BRUCEA NOVAK
9 LIGHTHOUSE WAY t '+ BRUCE A
9LIGHTHOUSE WAY
GLOUCESTER,MA -'' ;y, `" GLOUCESTER,MA arras
0 7 330-4131 019301Y-�L 'n�tl_ Y ✓r
L ,
Im Al. 1,ArmacIuaetd�
' E Boa nl of Ruildmg Regulations and Standards ,' z''e �` ° Board of Building Regulations and Standards {
ai Construction Supervisor License ' t Construction Supervisor License
asi License: CS 74501 - 4 a ��- License: CS 74501 € 7
k Birthdate: 2/7/1956 - Y H-xy°q,�a Birthflats2/709Expiration: 2/7/2009 Tr# 905 Ex B"Ort! 2l7/20 tti Trtc.905
Restriction: 00 Restriction: 00 >
BRUCEA NOVAK ,' _ ; ' -BRUCE A NOVAK 4
9 LIGHTHOUSE WAY 9 LIGHTHOUSE WAY
y' GLOUCESTER, MA 01930 Commissioner 1_" = - „ -^, GLOUCESTER I0193o Commissioner j
�E F,I1
t
a� 1/.'GJAIRf INI/lC[4�� l f�.t�(9.k:l6GlLll iOCt`5 h - °rP ` 4 ✓/w
13oa,d HIF Raiding Regulations and Standards v Board or Building Regulationdss and Standards
HOME IMPROVEMENT CONTRACTOR r. w� - HOME IMPROVEMENT CONTRACTOR
Registration: 12990q *; Registration:, 129904
Expiration: 11/19/2009 Tr# 260716 - i ! Expiration.. 11/19/2009 Tr# 260716
" Type: Individual V� Type: Individual
2.{
BRUCE NOVAK BRUCE NOVAK i +
6
BRUCE NOVAK "t ' BRUCE NOVAK Y 9 LIGHT HOUSE WAY �� 9 LIGHT HOUSE WA
1� I
GLOUCESTER, MA 01930 Administrator GLOUCESTER, MA 01930 Administrator
� � S