LEGGS HILL RD - BUILDING INSPECTION ---- ------------- fhr l ,nnnt,nr.cc•,tlth ni \1.u,.nhu,cll>
r. Board of HuddinQ Regulation, and S(andmds I t II<
Nil %I( II' \1 i I 1
l y \lu>sachu>ens Slaty Iikiddinc (',ode. 'Stl l MR. ? cdlrhvt �I
I Iuilding I'enntl :APPliratirm Tu (�omtnlct. Re Pau. Rrnrn.nr ( )r I>rntr,li,h ,t
(brr- ,rr /tin-1 runllt /hr e//I11�
l'hu Sren,rn Fr'r :)tfia_dl l',r Unly -
'�J i - ------- -IiudJin Parma V mhrr i I)ur \pphrJ-
� BwIJ n. ('omnu..irhra Impecloi nl I1wlJ nie+ UJic
SF( HON 1: .S1 FE INk'C1RMA I'ION
1.1 Properly \ddress: --- -- --- -� 1.2 .\uessors Map & parcel \umber. - --
La9gs Hill ^Pr] - -_-
- -- - -
1.la I, Ihu a❑ .R eple,l •Ire l tr, X 11'rp \I mhe;
1.3 Lao:ink lnfurmalio:;; 1.a Property Dimension;:
n/a n/a
1 -,rn: - 1r i, 1 r y ii) 1 ...___
11.5 Building Setbacks {fti
Y r, r Pi
Lo Later Supply I\t (IL. a 1.7 .';uod Love Enformalion: LS Sewage i)r.posaf
FPUMiL) - Pn ❑va': I 7 ...__- Chcrk '(vn❑ Nhuu- fd 0 On .ur. Jul.r r!
(AusrJe Flood Lone.' -.-1
SEC'S?(:N 2: PROPERTY OW'NERS111W
2.1 U»ner�(If Re}'ord, - 1
S37-anY(`TT1\ (,ikkAcC4&AAIZV�.`.�_toti�_�- --rans_HillRct-s3_--
cgz� cf a a-Octq D --
_ Fels h, ne —_
11 fir:wry P_ -
SECTION 3: DESCRIPTION Or PROPOSED WORK'(check.all that apply)
New Cr nstrurlion 0 Fr!snnv Building ❑ -If—U.,ner 0 :upied ❑ Rap:oT i O ter:rt nr,l \ Ir'r r._ Li _.
De;nolitirm ❑ Acces o t u,.ig. ❑ `lun,l.e! ill(fnkl . Other J n«-)---
Briel Dascnpuon ill Proposed _—
Ataxo2c ately
i
SECTION J: ESTIMA'!ED CONSTRUCTION COSTS --- -_- --
hsn mated Casts:
❑ern i (Official Use Only- llabror and Matrnal,l
I ItudJing ) 95,000.00 1. Building Permit Fee: i lndr::;iu Inrs, lee n delc1nl,;I,d.
0 Standard CaWl'own Apphcaurrn Fee
' Flectnwl b -x 000•00 I
-_ ,.1__- o rota) Project cost' (item 61 s inulonlrrr ,
I Plumbine 'S 18,E - �. Other Pees: 'S _
4. Nfechanrcal Illy:\CI 5 41r000.00
ew
Nlec hameal !Fire -- - _
S 10,000.00 f,-t,Il AH Fee, 1
_- 190,000.00 ( heck No 'h leck Ammint'
h filial Project Cost 7 ❑ Paid ill Full 0 Ow'i'rndii1v .d tit.c Uur
SECTION 5: CUNSTRUI"PION SEK%II'FS
5.I Licensed Cotlstruction Supervisor IC11.)
� - CS 078163
Lt,:na \uwhcr I`wo,alml 17.ne 9/155/0
\dot:ul ('tit. I IulJer List l St. l\pe i,cc he!ow I _U
491tcal�trr'=cet._Par�M9-0)- 0------ - -- --- ----j
1.1JI e,. I t1><• De„,II.I I,4t
r I nt r,u i.IrJ pup nt � INIII(L PI
___—
R Re,ut.Icd IN,.' Fanuk I711.I1hiie
Si:9 w ',n-3s39
Rl tteini`—
f:Irphnnr_—____—_ Ito �J;n I i,J \1 u.J,-,, .Ind I:J__n --_
it Re aJ.nu.J SnIiJ I n.l ISuinu`\LLi_ii
I7 INesiJ:no.tl Unnulw,m
5.2 Registered Home Intpruvement Contractor I I IICI —
lit(' Congv.up Xdute or tI1C Regl,uam Namc 2n—
XddrcN, on Nuniher -
Fvtvu soon Date .
Slgnawrr telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance altidavil must be completed and submitted with (hit application. Failure to pnrvtJe -
this affidavit will result in the denial of the Issuance of the building permit.
Signed Alfidavil Attached? Yes .......... ❑ No .. .. . ❑ -
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN -
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
iauthorize R. C. Criffin, Tnr to act on my hehal I. in all Inatil'r1- j
ee!ative w w,.nk authorized by this building permit application
Ste tureul'Ownv _—
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION —�
I.
ClaLde- R. g2anl C. CYiffin Trr• , as Owner or Authorized Agent hereby declare
that the statements and Information on the ti7regoing application are true and accurate, to the bestof my knowledge and
behalf.
kiSimed
lams . Dan
Val •�
tu ner or Authors ed Agent Da11(L under the ants and enalties of era INOTES:An Owner who obtains a budding permit to Jo his/her own work. or :m owner who hires an unregnleled cocas. for
(not registered In the Home Improvement Contraclor(HIC! Program), will writ have access to Ine .uhitratitat j
program or guaranty fund under M.G.L. c. 111A. Other Important inhumation on the MC Prngr:un and
Construction Supervisor 1_Icensing ICSI_I cam he found In '8(1(.'\IR Rrguluuons I Iq.R6 .mil 1 II) It S, re,pcvnvile �
' When substantial work IN planned, provide the )ntormation below:
Fatal Iloors area i Sy. Ft,I I mcluJing enrage. IinoheJ hasentenU.uucs. Jocks nr Por:h�
Gross living area I Sy. Ft.) Hahuable room count ..
Number of hreplaces Number of hednuan, _
Number or hmhntonts _ NWnhel' tit 11a110',nh,
I\pe of he.Itine ,v,tem --— .---._.- Nwnhcr of Jc,k,/ p,a.hc, -
I\pc of „ling ,v stem I`n,lo,eJ _. open
z 'T,aal Protect Square Fonl.Ige- rnav he suhstltulyd tar "Fot.d I'rti!ect Cost"
Client#:56130 RCGRIFFI
ACORDa CERTIFICATE OF LIABILITY INSURANCE M22anooa
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
USI Ins.Services of MA,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
12 Gill Street Suite 5500 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 4043 _
Woburn,MA 01888_ INSURERS AFFORDING COVERAGE;: . NAIC#
INSURED -. INSURER A: Transcontinental Insurance Company 20486
R.C.GRIFFIN,INC. INSURERS: Crum&Forster Insurance Company 42471
49 CENTRAL STREET INsuRERc: Valley Forge Insurance- -- 20508
PEABODY,MA 01960 INsuRER D: Notlonal Fire Ins.Company of Hartfo 00000
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.
IFIM on POLICYEFFECRVE POLK:YEXPIRATION - LIMITS
LTR mqnr TYPE OF INSURANCE POLICY NUMBER (MMtDDfM
A GENERAL LIABILITY C2088930335 03/01/08 03/01/09 _ EACH OCCURRENCE $1000000
X COMMERCIAL GENERA LIABILITY DPREIAMESAMAGETO RENTED Ewoo,000
CLAIMS MADE 51 OCCUR MED EXP(Any we parse,) ES 000
PERSONAL&ADV IWURV E1 000'ODO GENERAL AGGREGATE s2,000,000 -
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E2000000 '
POLJCY51 PRO- LOC .
D AUTOMOBILE LIABILITY 2088930321 03/01/08 03/01/09 COMBINED SINGLE LIMIT
(Ea accident) $1,000,000
ANY AUTO.
- _. ..
ALL OWNED AUTOS �- � BODILY INJURY $
X SCHEDULED AUTOS - - (Perperson)
X HIRED AUTOS - BODILYINJURV $
X NON-OWNED ALTOS - (PeraoddeM) -
PROPERTYAGE E
' (Per accident)
ideM)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT E
ANY AUTO OTHER AUTOO HAN ONLY.
ACC EA E
AUTOONLV:
AGO E
B FXCESSIUMSRELLA LIABILITY 5530897053 03/01/08 03/01/09 EACH OCCURRENCE E4000000
OCCUR CLAIMS MADE AGGREGATE 0000000
E
DEDUCTIBLE E
X RETENTION so - - E' .
C WORKERS COMPENSATION AND WC2088930383 03/01/08 03/01/09OTH-
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT E500 000' -
ANYPROPRIETOFVPARTNENEJ(ECIlTIVE _ -
OFFICEF0VP REXCLUDEDr E.L DISEASE-EAEMPLOYEE E500000
N yyes,cWcnbe under E.L.DISEASE-POLICY LIMIT ESOO OOO -
SPECIAL PROVISIONS beb
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
For operations normal to a general contractor.
For Insurance Verification Purposes Only.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
R.C.Griffin,Inc. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 'An_ DAYS WRITTEN
49 Central Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT;BUT FAILURE TO DO SO SHALL
Peabody,MA 01960 IMPOSE NO OBLIGATION OR LIABILRY OF ANY KIND UPON THE INSURER,R$AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
e. A e
ACORD 25(2001/08)1 Of 2 #S187180/M186891 - GZGCD 0 ACCORD CORPORATION 1988
r ,
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it
affirmatively or negatively.amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-S.(2001/CS}. . 2-of 2. 8S 187180/M186891- --
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'.,I.Pd RI 11%':)KN 0.4l I
\I a't to 12'�W nsrltvi:Yu.�STREET • Su E.M.Ma55AO n srl'I IS 01970
'fill.:978-745-9595 • Pax. 978-74C'1846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ce Print Leeilb v
L t licant Information plea
V 81T1C l0ucincxslOrBaniz:nionrindrvlduall:�C� �����" �y
Address: 49
City,Stater/.ip! Phone
A
Are ya an employer! Check the appropriate box: 'Type of project(required):
i
I am a employer with 4. ❑ 1 am a general contractor and 1 6 El New construction
1.
employees(full and/or part-time).` have hired the sub-contractors 7. [ remodeling
listed on the attached sheet. :
2.❑ 1 am a sole proprietor or partner-
These subcontractors have S. ❑ Demolition
ship and have no employees
working for me in any capacity.
workers' corps insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are it corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
rigIn of exemption per MGI. I l.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work c 152, 1(4),and we have no 12.❑ Roof repairs
myself. [No workers' comp. employees. (To workers'
insurance required.] 13.❑ Other
comp. insurance required.]
'All) applicant that chucks box til must also rill out rile scclian below showing{their workux'cumpan:auion policy information-
' Ilumou mtn who sunlit this affidavit indicating Ihey am doing all work and dmn him outside conirncton muss euhmil a new at'r.davit indicating much.
:ContM. t n that chuck this box must attxhcd can additional sheet howing[Ile mmne of the subcontractors and their workers'comp.policy infurmariun.
l tun at,employer that is providing workers'compensation insurance for uty employees. Below is the policy Undiob site
information
Imurancc Company Vame; tsi-. - _.._-
2 Expiration Date: 3 Via
I'olicv is or Self-ins. Lic. *: swc- 0!��3_>f3 3
Job Site Address: t llie ED -- City;Stateizip: A iA 014
Attach it copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
failure to secure coverage as required undcr Section 25A of`IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 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. Ile advised that a copy of this statement may be forwarded to the Office of
Iocealigaliuns uftile DIA for insurance coverage ecritieation.
I do herc•hy certify under die ) u s tot lent cs ofperjary that the information provided above is true and correct.
9
Official use only. Da not ts•rite its this area, to he completed by city or town afficial.
City or Town: ----... . _ Permit/License#.----... - . .
Issuing Authorily (circle one):
1. hoard of health 2. Building Department 3.City'rfosn Clerk 4. Electrical Inspector 5. PI
wnbing Inspector
6. Other
Contact Person: ___.. __-_ Phone ti:
Information and Instructions
;Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an errtplut•ee is defined as"...every person 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 at) 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.,becaur of such employment be deemed to be an employer."
`iGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in'tlic coiarnionwealth'for any
applicant who has.ndt'prodoced-acceptable evidence of compliance with the insurance coverage required."
.additionally, biGL chapter lit, 25C(%) states"Neither the conunonwcalih nor any of A P' dliiical subdivisions shall
enter into any contract for the perfomwnce of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
.-accidents for confimiation 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' -
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he 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 h$gNo`contact yo regarding the applicant.
Please be sure to fill id•ihe permit/license number which will be used as a reference,number. In addition,an applicant
that must submit multiple permiUlicense applications in any given year,need only submit one iiffidavit indicating current
policy information(if•necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)."A copy of the aih&vit that has been officially stamped or marked by city or.town may,bc�provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he OI lice of luvestigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents , r<.
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
R,viscd 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
=l ► A PUBLIC PROPRERTY
DEPAR'I'�IENT
Construction Debris Disposal Affidavit
(required lirr all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 CAIR section 1 1 1.5
Dcbris, and the provisions of.MGL e 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
(his work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be hansported by:
GNUS Gt���
(name of hauler)
The debris will be disposed of in
(name of facilit))
laddreas of facililvl
uatmc of p:nuit apphcanl
late