357 LAFAYETTE ST - BUILDING INSPECTION ` I
lat*MINUST$Eft f-� APPROVED BY T44E
IAI�P�JpA ,PRID TO A.PEAMIT pE1N1G GRANTED
CITY OF SALEM
sJ/ 3 Date
No. /b
\l
Is Property Located In Location of
the Historic District? Yes_No_ Building
Is Property Located In
the Conservation Area? Yes No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) J�&, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
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 Name
Address & Phone u �rrr S� marb��� f
Architect's Name
Address & Phone
Mechanics Name
^ 1•-I�v�t� ����
Address & Phone
What is the purpose of building? c . c c c
Materiel of bullding? If a dwelling, for how many families?
WIII Miilding coMortn to law? `( z 5 Asbestos. r
r
o�aS�S
Estimated cost I� 0��� GtY License# N State License #
/ZDI Borne Improvement
Lic. I6,RS03 x Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Re- `01 C'C f l.r_7� � I" ✓t1'C 4 J
1, n V�U[J� S 4C�
MAIL PERMIT T0: k 1k Au-e^I,�,l I vn 19 n iV 3 0
.t.
No.
APPLICATION FOR
PERMIT/PTO
s-�Rip f �eeso�
LOCATION
PERMIT GRANTED
ln,4� E( 17�
APPR VfD
I E „TOR OF BUIL NGS
,.
ClienWC:13716 JNRGLI
ACORD- CERTIFICATE OF LIABILITY INSURANCE 011112f06
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
B.K.McCarthy Ins.Agcy.Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
10 Centennial Drive - HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Peabody MA 01960
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.-
;
978 532.6445 INSURERS AFFORDING COVERAGE .. .NAIC 0.
INSURED, Dsurmk Lexington Inslumm Co .... 39454
JNR Gutters,Inc. nsuBsI it AIM Mutual Insurance Company
114 Hale Street;Suite 204 a Safety Insurance Group
Haverhill,MA 01830 ersIIRER¢
INSURER e
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANOING
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 IB SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE UMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L TYPEOFINSURANCE POLICY NUMBER PoucVeniwme LLGY Tm LSIOM8
A GE ERALUI M LITY 0426742 06121/05 06121/06 EACH OCCURRENCE $10 0 000
X COMMERCMLGENERALLMenJn mom,=�1 s50000
CLAM MADE QOCCm MMED EXP Vjq a NfAll 45,000
X BVPDDed:2.500 PERSONALAADVOLRBTY $1000000
BBIEALAGGREGATE $2 000 000
GEHL AGGREGATE UNIT APPUES PER: PRODUCTS-COMPWP AM $1 000 000
POLICY r
PRO• LOC .
C AUTOMOBILE LIABILITY 3945"1 06/21/05 061Y1/08 comemmSRIGLELADY
ANY AUTO �, $1,000,000
ALL OWNEDAUTOS BODLY WAIRY
X SCHEDUEDAUTOS RM PA ) :.
X HIRED AUTOS
BODILY B1JURy
X NON-0WNEDNITOS_ _.. .. . . lPaAwIYm,U _ _
X Drive Other Car PRO DAMAGE
$
OARAOE UABRK 7 AUTOONLY-EAACODEHT 8
ANYAUTO OTHER THAN EA ACC E
AUTOONLY: AM i
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR �CAW MADE AGGREGATE $
S
DEDUCTIBLE S
REENTION'-_._S.
B WORHERSCOMPENSATNINAND AWC7013435012005 0912OMS 09/20/06
EMPLOYERS LABILITY EL EACH ACCIDENT $5D9 999
ANY PROPNETORMARTHERIEXECU IVE
OFRCERIMEMBER EXCLUDED? F-LDWEASE-EAEMPLOYEE $509 000
B OmaaA 1mdN �.
S ELOISFASE-POLICYUMIIT s599990
OTHER 46
OE3CR V TON OF OPER11710N8/LOtJ1710NS!VEHICLES/EXC W SIONB ADRED BY ENDORSEMFM/SPEC W.PROYB W NS
Evidence of Insurance
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAYfR„LT BEFORE THE EXPIATION -
JNRGutters,Inc. DATEUMEOF.TIIBWSUMGMSURMWUEIBEAVOATOMALL 40_ GAYSWRfm
114 Hale Street,Suite 204 NOTICE TO THE CERTMICATE HOLDER NAMEDTOTHE LET,BUT FAILURE To 00 So SHALL
Haverhill,MA 01830 aSmSE NO OBLIGATION OR LABLLDY OF ANY IBID UPON THE INSURER.ITS AGENTS OR
REPRESEWCATMES.
A�RREPR MENTW WE
ACORD 2512001M)1, Of 2 - #49850 - - - t3D0 - e ACORD CORPORATION 1988
✓�ieV/-Oorimp 'fi0n9✓4n/duuwS,W°PdPrdP..
BoPrd of Building RegP ' OR ;zi...
E- CONTRACT.._ `
HOMEIM ROVE,
.A Re9istia8on 08503
on gN912006
i aW ld
element
r
7,7
NRGUTTER
KEVIN FRANCIS
t 114 Hale Sti"
MA01830 ,� +- : Administrator
�s �e 100�11 �(/� o�✓�ama�/uresR�� {
BOARD OF BUILDING REGULATIONS .
'. License: CONSTRUCTION SUPERVISOR
Num!>e =CS, 080515
F y p Birt#id3t9,Q7f �i5 .
007 Tr:no: 14850
Regtntte8:� ;
KEVIN M FRANCI£t
i - 31 LAWRENCE ST:„k , r (ul/
` --",HAVERHILL, MA 018 Commissioner `
The Commonwealth of Massechusetb
Department of Industrial Aeeidents
O,Q7ee Of Investigations
600 Washington Sired
Boston,MA 02111
wwMattanstrivad
Worker'Compensation Instwance Affidavit: Buflders/Contractors/Electddans/Plumbers
Applicant Information Please Print Letaibly
NameEG-
Address: it y W a+
City/State/Zip: t� av�1N�1 . yrn N 3 Phone iY q 3-7 z I,oV
An you a em..,�twerT Ckd�tkrapProP type of project(repaired):
1.Er I am a e foyer with "/r-z o 4: 01 am s geoewl eon6acnr and 1 6. ❑New constrW- don
employees(ibn and/or partrthoelo have hied 60 sdo aemaaon
2.❑ I am a sole pnrprielm of partner- listed on the attached short t 7. ❑ Remodelini
ship and have no employed These sub-aonlncom have S. ❑ Demolition
wodft Sgrmein say capacitih. w"orke;i'gip•' 9. Big addition
[No workers'comp,iostumce s• ❑ we at, eon heir renoacdkI '
1Q0 Moctricalrepain or additim
�.-
3.❑ I am a bomcown rAoing all work rightofeza dgn MGL' I I.O Plumbing rgwid or additions
myself[Nowaskelf'.comp a 1s2, .1(4 arilatehave'no 12 Q Roofrepavi
inaonooe rainieda t. employees.EN6 tw idmit, 13.0 Othercomp.i "regaled j'.
*Any IPPBOMON oheeb Lott mat WLo fip auttlK aectim below&ovioa meir.1wr {�'eMwmn
yso iabey
t HOMMMM abo admit eidt afdavit m HMn do m�4 mk and urn*moth mqp tc0at=xt subn*s nm mffi&vtt ndiatkv sock
rCoonnebn tt�t fruit tMtl+oa'inot anrbad a tdditiaoJ�kaM dnvioa tht nanttif�irabeeeti�Aon sod�ei weloaY'amP try�+*+�. .
l gar gr^entplq'ertltar b p.wldbta worlrers'eoatpeasaatoa bsswnaes jer ntpaipCo, 'below B tha peHej.w�fob aw
r„fa
Mstuantx compaoyNarne 1� 1 iMv Fir c�Q Ste? C,c�
Policy#or Self-im.I.ia# I.uJ L -)0 L 3 4 3�-o L Z 00'5— Expiration Dace q ZZV D
Job Site Addteaa clw/Saftat: Sl, le innT�
Adult a espy ofthe workeW compensation poft declaration page(Allowing the policy number and expiration daft)6
Fafte to secure covaap a required order Section 25A of MGL r 152 can lad to the imposition of criminal penalties of a
foe up to S1,s00.00 and/or ons'-yeer imprisamz%n well ear civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violsaw. Be advised that a copy of this statement may be forwarded to the Office of
Investigatiou of the DIA for hemaoce coverage verification.
I At hereby certo aadarthapabn cad pen&N a ofpetlary that the btforatadon pmvldcd above is low and eorrees
Siaaatttrec l-- - . - Date: 31 j o
Phone 0- 9 ' Z 3`7 a v e TT—
O,BIeJd au owl} Do nd verbs bs thb arse,to ba cowpfeard by dq oiarwn#,pie d
City or Town p � g
Issuing Authority(circle one)t
1.Board of Health, 2.Building Department 3.City/Town Clerk 4.Electrical Inspector !.Plumbing Inspector
6 Other
Contact Tenon Phone#:
Information and Instructions
compensation for their employees.
Massachusetts General Laws chapter 152 requires allemployers:la�ivice another.under any contract Ofht%
Parsuant to this statute, ao employes iS defined a<"...every person
esiness or implied,oral or,1Vriu ."
Y aS80elati0n.eorpma�or other h;gtti entrly.��taro Or rnnr0 � ..
An employs%defined as an iidivsdual,p er+ of a decen d tmtploYW,Or the
th eforegoin`ctl 1°apintenterprise,ands including l�
of pawllohe
receiver or tsmtee of ester iadlvidttol, association or other legal entity,emploYn�g emph�yetawevest
of that`'
owner of a dwelling boast Uvimg not more than three and who resides therein.or on �m
dwelling house of another wbo employs pessom w do maintenance.COnatraennn m rent b eel so be an employer•"
ar on the gro»nds or bui]ding ihaeb shall not because of sack employment
MGL Chapter 152,425C(6)also states that"every mate or local tleeado g Iraq
shad whhldd the lasesu a or
renewal of a license or per'mk to operate a business or to contract bafidings la the Comsmoaw"M for any
applicant who has td producedevldenee of Compliance witY the Wviaea coverage required."
Additionally,MGI.cot o 15%, SC(7)estates"Neither the commonwealth�anY of its Political sobdivw ms shall
of public work and acceptable evidence of eompHance w�the insurance
enter info any comssct Sot the b the contracting ao>b*.*
requuementa of this chapter have boa presented
r
Applkaots _tat apply 10 ym f zA if
alo Please Sq out the worker'compensation affidavit coeaplete]y,by checlveg�e �their cerdflcatda)Of
neaSSNY,Supply ems)name(al addre* Fhow mmiba() ng with no employes other than the
maur m saine(LLC)or Limited Lrabrlit'yParmershipr(UP)
Limited 1,age,,no Come 10 wad, �insurance, if an LI.0 or 1.1.8 does have
are not irea cant be submitted to the Department
members or partms, of hrdostrial
�loyees,a policy,is rai°>red Be advised Ibat this afBds}q swe t
Accidents for o ngsmatron of itnaraneC coverage Alen he lane to dgn and date re afsbcd,g The epartr it should
Of
be returned to the city or town that de applia*u fr the permit or Hecate is being re4nated+not the Dep t
hndnnstrial'Accidenti, Shgnld you have airy Pala a rW& thts law or if you an required to obtain ld co then
at ft nnmhar*ftd below. Self-i=*.aompaald
compensation pokey;P an the Dep lines
Self-ioaarantx>icrose iismrba on
City or Town Offidal s
be that the affidavit is o�leta and printed lathy Tit Departmentlos provided a space at the bottom
of the surrit for you to fill out in the event the Office of investigatiom has to contact you regadiag the aPPb Please be sor
daN
Please be sure to fill in the pamwficenw mamba wbkh will be wed as a refaoce Iftmim. In addition,an applicant
that rout submit>mldPle perm>t/Lceate aPDlicadom in any given yea.need only submit one affidavit indicating current
information(if necessary).and m�"Job Site Address"the apphcam Sboald write"all loadons m to—(city of
P°lmY}»A. df2W`dN vh dkd has hoes ofiicialbtstst> Hcasa A newchy�afBdsvit unit town my �eat
applicant asptoof*0 a valid affidavit is.on fiin for fhmre pesmtls not refitted m any bttaineas of commercial veamre
ytar.Where a home owner or eitiva is obtaining s Homee or permit
(L&a dog Hume or permit 10 burn leaves etc)Said Pa son is NOT required to comDlde this affidavit
The Offs of lavatipdom would Ike to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call'
The Depaomem's addreW telepbaae and fees numbs
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigadons
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF 'SALEM, MASSACHUSETTS
• • PUBLIC PROPERTY DEPARTMENT
120 WASHINGTO14 STREET. 340 FLOOR
SALEM. MASSACNUSETTS 01970
STANLEV J. USOVICZ. JR. TELE►MONE: 978-745-9593 EXT. 380
MAYOR FAX: 978-740.9848 .
S
B�IIlnl Id na De rtmant
Debrh Dlsposl l ii'nnw
In accordance with the provisions of MGL c40 S 549 a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in: voje4k e45�- �e`Yc/ ors
(Location of Facility) k tk("Jo
Signature of Applicant
Date