22 LEMON ST - BUILDING INSPECTION What is the current use of the Building?
Material of Building? If dwelling.how many units?�
Win the Building Conform to Law? Asbestos?
Architeas Name
Address and Phone ( )
Mechanids Name E VA)A/G E4U1 e-iA9 PJJ
gas �wFa sip -C)9 /-�y M A- 0/760
Address and Phone I5 y32L
Construction Supervisors License# G5 LI Z- S HIC Registration#
Estimated Cost of 01 $ f ql T Permit Fee CalcuM n
Permit Fee S Estimated Cost X$7I111000 Residential
Estimated Cost $11131000 CormrmerciaI` ----------
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersignedapply for a Building Permit to build to the above stated
does hereby by
e u
s ific
P�
atlons. Signed under penally of P d rY
• l
Date
o
O N
r
� lJ
°oc J V r
y
3r N a
— x -k—
EITY�OF+`�ALEb - _
PUBLIC PROPERTY \
DEPARI'TAENT
K1%d*Y-KV DRISCOLL / C�
e
%%Yca 130 WASHMwzc U Smear•S LEK W$L%CKL5hTM 01970
TEL,M74S-9S"•PAZ M740.96N
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY FMSTINGI
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: D Building:
--- --
Properly Address—
Property Is located in a:Conservation Ares YIN Historic 01s4lot Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: 1V1wL1(-A Mln/c'
Adder: 2-2 (EMC)A/ S7P. S 44L EM
Telephone: Cj: ff- 2--ES - 3Mg-
3.0 COMPLETE THIS SECTION FOR WORK IN EYtSZINLi BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Bret Description of Proposed Work:
Mail Permit to: 5/5- S7?. /-"B0/>Y
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
n.\I:::M I r.Y 1'AyA I L
TO.-)W45.45" •F.M-OMAC-944
Construction Debris Disposat Affidavit
(required for all demolition atsd renovation work)
in accordance with the sixth edition of the State Building Code, 780 C1`IR section 111.5
Debris, ud the provisions of M. GL c 40. S 34.
Building Permit M _ _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defused by%1GL c
111.S 150A.
The debris will be transported by:
CH4RC0 6Eon6&
— — (Imma of hauler)
fhc debris will be disposed of in :
Pf'* 0V Y 9VA10
In cne of("llity)-
PE�tBv�Y NJ�
ra.iL[Y)
-AW
ACORD CERTIFICATE OF LIABILITY INSURANCE DA7Et")"1DDA
FOSAY
M. ." 1 06/28/2007
: (517)6575110 F8i (617)B57-5117 THIS CERTIFlCATE IS ISSUE° AS A MATTEATIONAL INSURANCE GROUP R OF INFORMATION
OAD ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES E;ELOW.
171
) INSURERS AFFORDING COVERAGE i NAIC#
INSURED -INSURER A: FIRST MERCURY INSURANCE COMPANY
ALPINE PROPERTY SERVICES CO.)NC. INSURER 0: HANOVER INSURANCE COMPANY _
11 STREET
SALEM !INSURERC: ATLANTIC CHARTER MA 01970 R INSURANCE COMPANY
M j I .._
l INSURER D: 1
IINSU�RER E: .. ...._— _ .
COVERAGES
r� REO'.U-IREMEN`r.
OLIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR YHE POLICY PERIOD INDICATED, NOTWITHSTANDING
TERM OR CONORION OF ANY CONTRACT OR OTHER DOCUMENT MATH RESPECT TO WHICH THIS CERnRCATE MAY BE ISSUED OR
ERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
ES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
tn TYPEOFINSURANCE POLICYNUMBERR DATE DATE w UNIT
cENERaL � 'FMMA 001186 OB/+4107 06/14lOS 'EACH OCCURRENCE Is 1,000,000
X GOMMERGIALGENERALLIA81U1Y' OMIAGETORENIEO i
CLAIMS NADEt ' _ I✓11LMGL5lra amxaoe) :S ..SO,000
I X OCCUR: ;MED.EXP(My one Pt Wj) . . j5
' S
100A I Ble Add0m1 Ia itc PERON -$AOVINURY ' ,00,00
JWErvH H SAAao 4xxAd
I GENERAL AGGREGATE is 7000,000
CENL AGGREGATE UM IT PER: C
PRODUCTSOMPIOP AGG. 15 2,000,000
' 1 POLICY ) JL II ACT LOCI i I
i
AUTOMOBILE LIABILITY AFN8671588-00 I 01/09/07 O1l09lOS
1 j COMBINED SINGLE Umn
ANY AUTO ! ; �(EBIlxidenl) 's 1,000,000
ALL OWNED AUTOS j I I ;BODILY INJURY --__——_-
i ' SCHEDULEDAUTOS ; I (P«veKOx) s
B ° X HIRED AUTOS . .-
7 J I j BODILYIMURY
X i NON-0WNeD AUTOS ytPat eociOerJ) S
!.• j .. ._ I ! I :PROPERTY DAMAGE is
I (PvxddoDO
'GARAGE umam 5
. I AUTO ONLY-EAACCIOENT
ANY AUTO
! OTHER THAN EAACC S
AFRO ONLY: AGG �S .
EXCESS I UMBRELLA LMBILRY CUMA000++7 06l14/07 06/14/08 1 EACH OCCURRENCE !S - 5,000,000
X OCCUR J CLAIMS MADE AGGREGATE _-
6.000,000
A i i.._..... _. is
DDUCTIBLE 1 T.
jL rr RE ET ON
5 10
,0
0
0
)
(WORKERS COMPENSATION AND WCV00754900 , 01/05/07 I 01,05,08 j X TDRYuwtls ' iOTr@q .
IEMPLOYERS-LIABAJTY __..
C
TINY PROPAEIORIPARIHEILEI�MAlE I IEL EACH ACCIDENT .S 500.000
IOFRCERITIFA®PA GI[CLIIOEDT ___
! I E.L.DISEASE-EA EMPLOYEE S 500,000
IDpn,6Mel�veapr ...
DPECYLL MtOVI81DA4mb. I 1 1 !E.L DISEASE-POLICY LIMIT S 5001000
I OTHER:
1 !
DESCRIPTION OF OPERATIONSILOCATIONSfVFHICLES/EXCLUSIONS ADDED SY ENDORSEMENT!SPECIAL PROVISIONS
'C ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOvE MSCRtBLO POLICIES BE CANCELLED BEFORETHE
EXPRAMON DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MNL 10 DAYS
WRITTEN NOnCE TO THE CERTIFICATE HOLDER NAMED TO JJ4rIE LEFT.BUTFAWRE
TO 00 SO LIMPO5E.NO OBLIGATION OR LIABILITY OF No UPON THE INSURER.
ITS AGENT r
OR REPRESENTATNES.
AUTHO REPRESE
Attention:
ACORD 25(2001108) Certificate# 5918 0 ACORD CORPORATION 1988
CITY OF SALEM
PUBLIC PROPRERTY
•�~z..y it
DEPARTMENT
S 14RVIt EY UNISt:uLL
MAyoft IY'Wnsl,11INGfOteSTREET 4 SAL".MAS5AQnv-t-lS0197'J
Text.978-745.9593 •FAX:97M•74C•9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anniicant Information Please Print Leeibly
Name tduaiiwWorgxni:atinNindiv,duuu: 4/_0/it/C 0,e6)19 P 7-
Address- S COeUECG S% to
City/State/Zip: ��y/BUD M4 01262 Phone #:
Arc you an employer? Check the appropriate box: 'type of project(required):
1.❑ 1 ant a employer with f r 4. ❑ 1 am a general contractor and 1 6. [3 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : 7• ❑ Remodeling
ship and have no employes These sub-contractors have S. ❑ Demolition
workingfor me in an capacity. workers'comp. insurance.
Y9. ❑ Building addition
(No workers'comp. insurance S. ❑ We are a corporation and its 10. Electrical re
required.] officers have exercised their ❑ pairs or additions
3.❑ I am a homeowner doing all work right of exemption per MCL l I.[] Plumbing repairs or additions
myself. No workers'comp. c. 152. '14),and we have no
4 (Y I P 12.❑ Roof repairs
insurance uired. t employees. N'o workers'
� 1 [
co 13.0 Other
comp. insurance required.)
P q
•Any applicant don checks box 41 main also tilt"the.ecliun hutaw thowina nbeir workmi cumpensatiwt policy infurmutiwt_
r I Wtrtantwnism who Manful this affidavit itldicalin t are doing al wo I rk and thtan h' t 'a �Y a ue ou side contmcton mtwt sutanG a new affidavit indicating uaA.
�CcanxYun that chid[this bar must attached an additional since[showingthe name of the mbaomr t aetas and hen worktm'comp.policy information.
fain (in employer that is providing workers'compensadon insurance for troy employees Below is the policy and job site
information
Insurance Company Name: A/%/G CH 9 97L--e CCt41-'e4n,—
Policy#ur Scl6ins. Lic.#: W C V 0U75 q`TGCJ Expiration Date: t U el
JubSi1CAddress: 22 LEMf)rtJ S74efE7 City/Slate/Zip: L'EA4 MA
Attach a copy of the workers' compensation policy declaration pate(showing the policy number and expiration date).
Failure to securecoverage as required under Section_SA ul'.MGL t.. 152 can lead to the imposition of criminal penalties po pe of a
tine up to S1.500.00 and/or one-year imprisonment, as well as civil wriallics in the form of STOP WORK ORDER and a fine
nfuptoS'50.00a day against t vio
lator. lie advised that a copy of this statement may be Curwarded to the Office of
luvcsu.-ations ul'de DIA for insurance coverage v:riticatiun.
1 do hereby certify under Ifpains u'1d�zfaldrf of perjury that the information provided above is true and correct
tiie�tantrct -- r/ Dat • ,4r U7
Pht we:i: g761..53 S-O7 t l7
00c ia/use only. Do not write in dds area, to be completed by city or town ofjlriuL
City or Town: _-- Permit/I.lcense#
Issuing Authority (circle one):
1. duard of licalth 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: __ Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees-
Pursuant to this statute,an employee is defined as"...every parson in the service of another under any contract of hire.
express or implied,oral or written."
An errrpfoyer 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 an individual,partnership.association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartment&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 because of such employment be deemed to be an employer."
MGL chapter 152,¢2SC(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 is the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, 325C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance 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-contractors)name(s),address(es)and phone number(s)along with their certificatc(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 confirmation 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 be sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom.
of the affidavit for you to fill our in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense applications in any given year,need only submit one affidavit 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 affidavit that has been officially stamped or marked by the city or town may be 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I'hc Oftis of Investigations 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
O®e a of Invadgations
600 Washington Street
Boston, MA 02111
Tel. 1i 617-7274900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
Revised 5-26-05 www.mass.gov/dia
HIC#154326
EIN#56-2618812
OLYMPIC
Painting,Roofing& Siding
515 Lowell Street—LeabodL MA 01960 office 978-535-0943
facsimile 978-535-2008
Nikolla Mino
22 Lemon St
Salem,MA 01970
978-265-3386
Dear Niko, August 15,2007
The following estimate is for the installation of three skylights for the property located at the above address. The foll
paragraphs describe the work that will be performed. owing
Insta!/atl in Procedure
4 Strip existing roof around the area that the skylight is to be installed
4 Cut hole in existing roof deck
a 4 frame rafters to the existing rafters with a header for skylight curbing
4. re-sheath the area up to the new curbing
06 install new Velux skylight with flashing
4 re-roof the area up to the skylight
4. finish off the interior ceiling to match the existing
4, We will remove all of the job related debrisditiona!Specifications
4 All work will be done in a professional manner, and timely basis
o Exception: weather
4 ak We are not responsible for any of the cracks that may arise in any walls or ceilings
f & Please cover all your floors in your attic to protect from dust and debris
$$ All Roofer are OSHA trained and Master Elite Installers from GAF
4 Permit costs are included in this bid
Initial the options you are choosing below.•
Cost for Labor& Material for skylights: $1 995.00
Payment Terms: 113 deposit$ ,113 work in progress$ and 113 upon completion$
Total Amount Agreed To Be Paid: $
Please make payments to Alpine Property Services Company Inc.Alpine will hold this price for 90 days from the lasted date stated above
Warranty: Olympic Painting and Roofing guarantees all work performed for a period of one year. If any problems occur we will cover
the cost of all labor and material to correct the problem and meet the customer's satisfaction.
Do not sign this contract if there are any blan s aces.
(additional provisions follow and are " r o ated r b is referent
David Ranson,Construction anger ikolla Min
Alpine Property Svcs. Co., Inc. d/b/ °a Olympic Homeowner
I
w Board of Building Regulations and Standards
` Construction Supervisor License '
:Li"cans,C$: 84795
S.Rlhdate 6J13/1967
t�ttlom k009 Trlf 13916
r.
EVANGELOS LIAR f
3 LEDGEWOOD. ....
PEABODY;MA 01960 Commissioner
r'/ee �nonr�:oneoealdc o�./L/.aaaarJtuaeds
,. Board of Building Regulations and Standards
HOME.IMPROVEMENT CONTRACTOR
Registration:
,154326
xpi Eration 2%P7l2009' "
r ,Type. Supplement Card
i= -q
A&INE PROPERTY SERVICES!
@VXWGELOS
11 WILSON STREET' _:` y% ,
SALEM, MA 01970 -
Administrator