29-31 LEACH ST - BUILDING INSPECTION (2) r. . _Crry-or —
' PUBLIC PROPERTY
L; 00 DEPARTMENT
KMIFA.EYoMCOLL
MAYOR 120 WAsH1NGToN N RFEr•SAL.LK WA15AcHLsm-M 01970
nL,97&74S-959S*FAx 97&74o.9M6
APPLICATION FOR THE REPAIR. RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
rPropeny
INFORMATION
Name: Q-3� C(� �� Building:
Address: a9_3 ty is located in a. Conservation Area Historic District Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: not
Address: o 1-31 Lf-�)d1 Sf 4)
_ S j,, Mk 01170
Telephone: Ce 7- 633 - /(603
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation x Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation acN� New
of existing building
Brief Description of Proposed Work:
4re"3 Cr6J 7<-fs
Mail Peet to: 27S�on
lm
Q ..
What is the current use of the Building?
Material of Building? ('% If dwelling, how many units?
Will the Building Conform to Law?X t S Asbestos? �J
Architect's Name
Address and Phone l )
Mechanic's Name
Address and Phone 10 /4 i15d le 5-f 0-,Ld
Construction Supervisors License# CS OMYtg HIC Registration# f y7 $f
Estimated Cost of Project$ 3(COO Permit Fee Calculation
Permit Fee$�t�__ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the abo a stated
specifications. Signed under penalty of perjury
X
Date
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"CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ttnraeattaY Duscou
MAYca 120 mAstmoGYONSTU"a SMM4 jL%XAC*V_W 7S0IW0
TEL:97L745.9S95 a FAX 9M740.9W6
Workers' Compensation Insurance Affidavit: Bnilders/Contrac tors/EleeMcia
A ntt/Phrmhers
T ( �
PlcPrint
Name(Businesworsaniaaodndividw): fep
Address: !S Cigc,-,' P
City/statd7ip�� /t 19 00�m Phone# jR/- 7a7-59/,f
Are you as employer?Check the appropriate best
1.❑ I am a employer with 4. ❑ I am A general contractor and I Pe d Project(regatred):
employees(tWl and/or part-time).• have hired the std:.constactors 6. ❑New camatnscdoa
2.❑ 1 am a$ole proprietor err parmer- listed on the attached sheet t 7. PC Remodeling
ship and have no employees Than sub-contractors he" g. ❑Demolition
working for me in any capacity. workers'comp.inamaoce. g Building
[No workers'comp.insurance S. X We am a corporation and its ❑ g addition
required.] otllurs have exercised their 10.13 Electriical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repair or additions
myself.(No workers'comp. a 152,41(41 and we have no 12.❑Roof repaint
insurance required.]t employees.[No workers-
;Any
Othar
comp.insurance required,]
;�r wvuoss err eeedu boa al mvr arse Ni as tea axoaa two.rhea leer tbok wwkws
Hauwmv rho subob tkb amdwk i4mndoa they a ddy or rpk and t�hka amdda a�6oh i ewe al�v1�rConuw ors that cheek this boa mast sthebad ere ddidaod shag shwARS tb.eons Otte subcaeaadm and drk WON bn'eon*Poft iehn=dmL
an an In ormadasr�es �is provWlnj workers'co
mpewad"tnsrsoner jor my employees Bshrw is the popes and j tth
l
Insurance Company Nam:
Policy M or Self-ins.Lie.err Expiration Date:
Job Site Address: Ci /S ry tate/Zip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and esplradea dab
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the ' &
fine up m 31.500.00 and/or One-year imprisonment of STOP
of criminal penalties RDER and afi
P Y against the violasor. Be advisedwthat a ell as oroPY of this statetaem may be forwarded to theOORlce of a tine
of u to f250.00 a der
Investigations of the DIA for insurance coverage verification.
I do hereby a ander and prna/tim ojprr/ay that lire in/ormradow provided yr is or"and comet
77
Phone 7-�7- fk
OW'd usr on'A Do not write is this are;to be completed by ctry or tows o,Oletal
City or Town: Permit/Ideen"N
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone 0:
Information and Instructions
ensa6n
Massachusetts General Laws chapter 152 requires all employers t in the servicovide �other under any ctic empYoyea.ontras of
pursuant to this statute.an earploYee rs defined as ...evay person
hit0.
express or implied.oral or wrttten."
associadM corporation cc o�legal entity,or any two or more
An ea i;104tr is defined as"an individual,parmershup, va of a deceased emploYet.or the
of the foregoing engaged in a joint enterprisem end mchWieg the legal represmtati mHowever the
of en individual,Pains rsbip.saceianon a other legal ashy.employing employees.
receiver err trustee house bavmi not more than thra apartments and who resides ther'elsi.or the occtupsa c the
dweplitia house of amtens who employs Pawn to do maimtenanes.c�^x°p° work on such dwelling hotus
owner of a dwelling or repair
thereon shall not because of such employment be deemed to be an employer.-
or on the grotinds or budding epp�1°t
MGL chapter 152.12SQ6)also stater that"every stab er lecal Ikensing seamy shsa w►thbold the Issuance or
rcaswd of a&enes or per au to operate s business or to construes buildings in the aommesweakh tar say
y
applicant who teas set produced acceptable evldsses of eompgsses with the Insurance eovercp requlrsd"
Addidoway,MGL chapter 152,125CM staoen"Neither the commonwealth nor any of its political subdivisions shall
pOrformance of public work until acceptable evidence of compliance with the inaaranee
du b of thisscchapter have him prC°E6ted to the contracting authority.-
Applicuts
Please fill Out the workers•compeoset1OII affidavit completely,by checking the boxes that apply to-your situation and.if
sub conauwr(s)name(s).address(a)and phone number(s)along with char cernfioate(a)of
necessary.supply with im employees otba then the
ware. Limited Liability Companies(LLB or Limited Liability Partnerships(i LP)
a or pacoaa I.are not required to carry workers' compensation insurance•MCU& If en LLC or LLP boa have
is
]3s advised that this affidavit may be submitted to the DepsrtmcM of 1mdustria1
IU affidavit should
��for Policy of inn¢snce coverage. Abe be stun to sign and date the dffda�the Department of
be returned to the city or town that the application for the permit or license is being requested,m obtain a r rorkaes'
have any 411e OOe regarding do law or if you are required
Industrial Accident& Should you common policy.please call die Depsstmmt at the number listed below. Salt-insured eompania shoals eater than
self-insurance license number on d1e
lime
City or Tows Offkiab
le b The Department has provided s space at the hottom
Please ff sure that the affidavit is complete and printed gi Investigations has to contact you regarding the applicant.
in the event the
tea sure to fill in the permi
of the affidavit for you to fill out tthceose numbs Office
ch will be used as a reference cumber. In addition,en applicant
Please applications in any given year,need only submit one affidavit indicating current
that must submit madtipla PWMW Beaune ape ltcaat should write"all locations in_--(city or
policy information(if necessary)and under"Job Site Addrese" or ate by ho city ri town maybe provided to the
town)."A copy of the affidavit that has been file
f officially urn permits
or licenses. A new afu-&vu must be filled out each
applicant as proof that a valid affidavit is on file for license
a por po not related to any business a commercial venture
yeas.Where s home owner a citizen is obtaining a license or permsit
(i.e. a dog license or permit
to bum laves 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.
TM Commonwealth of Massachusetb
Department of b ttiUW AW&Mts
00"of Iavadgadons
600 wabMgft SVW
Boston,MA 02111
Tel. #617-7274900 Cd 406 of "77-MASSAFE
Fax M 617-727-7749
Revised 5-26-05 *-wwxiasLgov/dia
ACORO. •CERTIFICATE OF LIABILfTY INSURANCE D1ATE(MM
1107/2006)
PRODUCER 781-393-4321 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONO,
LOPRIORE INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
394 MAIN STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTENDeOR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
MEDFORD, MA 02155
INSURERS AFFORDING COVERAGE
INSURED INSURER A: VERMONT MUTUAL INSURANCE
T&G ENTERPRISES INC INSURERB:
95 CIRCUIT ROAD INSURER C:
MEDFORD MA 02155 INSURER D:
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 LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00
COMMERCIAL GENERAL LIABILITY LIABILITY 6/9/06 6/9/07 FIRE DAMAGE(Any one fire) $
CLAIMS MADE OCCUR MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GENERALAGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $
POLICY F7 PRO LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $ r
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EAACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $ -
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WC - OTH-
WORKERS COMPENSATION AND TORY LIMISTATU TS ER
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $
E.L.DISEASE-EA EMPLOYEE $
E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONWVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTr PECIAL PROVISIONS
't
F
CERTIFICATE HOLDER X I ADDITIONAL INSURED;INSURER LETTER: _ 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
CITY OF SALEM NOTICE TO THE CERTIFICATE DER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
93 WASHINGTON STREET INFO O BLIGATION LIA ILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
SALEM MA 01970 REP ESENT IVES.
AUT ORIZED EPRE§ENT TIV
ACORD 25-S(7/97) O ACORD CORPORATION 1988
BOARD OF BUILDI G RE.GU.LATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 08486
Birthdate: 03114/1975
Expires: 03/142007 Tr. no: 84848
Restricted: 00
ROBERTO A GRIECO
95 CIRCUT RD
MEDFORD, MA 02155 Administrator
CrrY OF SALEM
PUBLIC PROPERTY
DEPARTUENT
Ilu M746.M 0 h„asn?4&"
Coas&ucdoa Debris Disposal AM&Vit
(requited hat all dstwU st and mwvWm wecidl
In aeoadsnms wish dw c ddwStm
BoUAWS Cod%7SO CWM seedm 111.5
e 44 S
BundbS pwmk M
Is tmad wbk Ow eondtdm that dw ddwb cemild"be
this wmtc drill be dimpam d of In a popft l osuM waft d wmd&dltgt as dented by Alf L s
1t1.�tJol1.
The dents wig be woVarUd by:
(creme d>talsrl
Tim debris will be disposed of in:
rl�55
(mme of f'W M
(yfder a!heility)
si�wq�of prmut�ppliaat S,
4i
10 duo(Q
esre