20 LINDEN AVE - BUILDING INSPECTION (6) -PL-*NS-MOST-9EfiLfG-4111rW APPROVE{) BY T+IE
,UN,S,PECTM PRWR TD.A.PE MT.I39MG GRANTED
CITY OF SALEM y
S
� T;,�,
t`" kA
I� Date
Is Properly Located in Location of the Historic District? Yes_No_ Building do G,'*fie
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Constr ct DM Shed, Pool,
Repair/Replace, Other: t4AaroA atin a V1
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 t✓� �� C
Address & Phone 20 GVUc ,A �JlL (GIB )2yt? 4 5�i
Architect's Name
Address & Phone (( 1
Mechanics Name
Address & Phone 439 R���n�S�"mil w� � ay 18�D'ZI� b
What is the purpose of building? U -���✓lcS�
Material of building? �'-A If a dwelling, for how many families? 5i
Will building conform to law? Asbestos? �1
Estimaatedd�cost �?J,Mb City License n N A state License a CS 015 2q
Home Imp ��
Lic. / I
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
E4ll-240, -L,udcdi�A u5,V►!4
V7o Lw- ;Af jnl1e� 4ampp9 P(g�
MAIL PERMIT TO: n �-b4t< (r
No.
APPLICATION FOR
PERMIT TO y�
LOCATIO
PERMIT GRANTED:
s � 20
APR ObFD
INSPECTO OF BUILDINGS
1
1
t
4 �
v
The Commonwealth of Massachusetts
Gad: r =3 7 Department of Industrial Accidents
O/fco of i0Y0suga1100s
600 Washington Street, 7 h Floor
Boston,Mass. 02111
Workers'Compensation Insurance Affidavit: Buildin lumbing/Electrical Contractors
_ADalicaritl1mform/ation:--'^ Flease PRINT teetbly '" "
name: rtrl � ��1T-uN�-1�
address:
�I �tY1f '7 ��] (yl�(9
city 17`Q 11A�e'� state zip o( � �y phone# 7U)—U 7 U )I0
work site location II address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction�Itemodel f ��"
❑ I am a sole ro rietor and have no one workingin an capacity. ❑ Building Additio
I am an employer providing workers' compensation for my employees working on thisjob.
comoanv name: rk
// . I I��'' ^nV (l� 1(o
address:
city: F2 01 1k
phone#.
insuranceco. je r,%c y t 1 Italia# - 352
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address: :.
city: Phone#:
' M15, . i� . try r• i' ,i
insurance co. olic 51#a
company name:
. w . - "o-w j. wL d.`' .;^5,'[rxW iw $'�*.j+! ` ±aS�,t-.,'*"h r�u'w•p.�.��
address: '4
city: . _ .•:- . Phone#. r's' �" ,rwrr."
insurance co. - �lic #
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby
/ceelrr ify un �r th 'ns and per at{'s of perjury that the information provided above is tru annd�cc rect.
Signature l�/'�� Dale '�"f,�9�p
Print name Phone#
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Otlice
❑Health Department
contact person: phone#; []Other
Qn'ised Sept A ul)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the`law",an employee 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 ajoint 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 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 because of such employment be deemed to be an employer.
MGL chapter 152 section 25 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 the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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.
City or Towns.
Please be 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 has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
.c� _ � _>� . gym•»_ t� f„� � �a:r
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street,?h Floor
Boston, Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406
{
�o CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
s A.
120 WASHINGTON STREET, 3RD FLOOR
1 SALEM, MA 01970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S 150A.
The debris will be disposed of at: Ili-GAL k4�( ck
Location of Padility
C 1I Z o-T
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
agik &Ghl1
Name of Permit Applicant
Firm Name,if any
2�3� /���i AST•
Address, City & State
The above statute requires that debris from the demolition, renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
{@
rn
N
C-0' g"� -' w ::A
D and
L1Y+QRyT rwafe'R/ C
6�2� r �O-2' �RoFbS�D 6ffi4(-R- m
Fq Sl 3S� poudDR?rant &z
Jr'•2 t1otA5C f-ouNDAT100 E
y4 -t140 0 -O — —
� I
t i
I
2
2N-o °12 23 24 1 I
Iq Q
_ t
3 ('1f,A$NREQO' �a.R�rn11�L �iITLL'(+K+Nti• i3 I !.
_ o
_. 2, o 0 Ls
---
, u iy'o"
14 0 rd"o
(j-Li 42'-O' m o m
<
_I
TrtsT Fxa�nK.,
LO(RTteN
s 7YLoPo5�0 Pilaf I,AYot,�T- PNl-`+iAt, UNOFRPINhutX� �
I
i
VEITASWEITAS
engineers 7
Client N Job No. _Sheet `-' of
Subject t�k 1S4( AA16"Pi A)U1,t/C, &,411N By R U Date 18 o
1 1 � CKe. tL ag-biMAJCe- , 5"A AA+ Ckd Rev
I � �
I
I
I g
ST EITU _
t
g
--* -- U -- -- - -...
- + 340
- --
• � I
f �
t i t cSjJ K
I
_ 102ljs �
I '
i
PIC
—
lp
Is
4(1. S
F
It I
S (
I
I. ti
f
i
Ey
dMO�y�
_ o
--i
and
/
F�q Sl 3S ? ? pro von KI0 &Z
w
Dose foudDATro�-1
5.2 N "I �97F
15 I(o
1 1
II
n � I
2y-o" 2 22 73 -- 24
feu nor:y 1q
tI
3 (1 *\AR5p O+rrRfZrPrIL `.Fivmmaor 13 1 f
A 11
m o
>w"', z _ 2r 20 I o
Z, o„ Q tr
H 5 6 A cg
ty' o,
i
•1-C1 W �� yd n5�
(it
Scot rt; TEsrPxa I n
f
IY�oP05(�O Pilaf. LAeoUS UNOFR(�INNNK. o
VE ITAS.OVE ITAS
engineers : 7
Client - A Job No.
Sheet of
`1''
1, Subject�1�f 4A/A4(C.P1/R/I,11C 1 PLA-- By 2 V Date I 18 fl
CX4 U a,<5 MJCe-j 5 AL6 A AAA Ckd Rev
I
cn-snQ-
1
� I
y I y
p
1 ' �
y ..1.
j
s 9 �{NO
Z �ti, VEITA
3 -
IR
40
Y
i 5
M1
k
i I
{ 5
I W >
c
iV --
k...
S I I u1171f � 6 A)
L
MAT
- - --
—
° -
Sf1�0_. & ' IM I.S. iF_
S
1
I i
I
_ na ,
DRIVER'S LICENSE Cl
S33181783
wTEGF Oqm CLASS REST HaGHT Set ` 1
f' 07-26.1971 DM 500 M ,7
k3 07 26.2006
E GRAYBILL
i� CHAD A Z/
Lr 200 SUMMER STREET
Y ROCKLAND,MA '^' >�
02370w12r �
rpm 92e t°jooirroiu:rolAi 6�
�.\ Board of Building Regulations and Slaw 0' 4M �
- HOME IMPR;OVEMEN7 CON7RAC70R
Reglatratlon 117851
Expiretion: 12,",b'2004 - gee,
rpOlaon
L DRILLING,INC
CHAD GRAYBILL
1i99 GRANITE,@RAIN"fREE;NIAA 02184
4,4'
(f P VO'//NNIOOEIIbr�fN! �'�lrf4J,P�uMta
BOARD OF BUILDING REGULATIONS
.icenw CONSTRUCTION SUPERVISOR
i
i Number: CS 075634 1
Birthdate: 07126/1971
Expires:07/26/2005 Tr.no: 3128
Restricted: 00
CHAD A GRAYBILL
200 SUMMER ST
ROCKLAND, MA 02370 Administrator
r
G
N
• • a
N
p
r
1
N
v
c
(✓.F,e r°'x nnnrw+..... r-
9
Beard of Bnlldia " - - - �
. � 8Re$alatioaa and Slrndprdr !I
HOME IMPROVEMENT rnu Liecose orregistratiou valid for lndfridd-use only
\ TRA..TCR _ baore the expiration dole. if f000d return to: _
Re Is.DaQpp?��17861 _ Board Of Bodldlog Regulations and Standards
006 Oae-sODwtabPlace Rea 1301
ale Corporation Jlopton,lNa.D2109
- HELICAL ORIlLI -
1
.. - .. . CHAD GRAYBILL � 7 : _
_ - 639 GRANITE
BRAINTREE.tr1A 02180
Qat ffValled wlthofl jIgoalufe
P
p
\
P
_ o
)ate : 6/3/2004 Time : 3 : 32 PM To : @ 1-781-849-2065
Page: 002-005
' AC -RQ CERTIFICATE OF LIA81LITY INSURANCE 06joiz 4
PRODUCER (781)681-6656 FAX (781)681-6686 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
I Barry Driscoll Ins Agcy, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
600 Longwater Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 9120
Norwell, MA OZO61 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Admiral Insurance Co.
Helical Drilling, Inc. INSURERB. Travelers Indemnity Company
639 Granite Street, Suite 301 [NSURERc American Home Assurance Co
Braintree, MA 02184 INsIRERD. American Alternative Ins. Corp
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 DD' TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTNE POLICY EXPIRATION LIMITS
GENERAL LIABILITY A03AG17412 06/01/2004 06/01/2005 EACH OCCURRENCE S 1,000,000
X CONIMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000
PRFMISFIE too
CLAIMS MADE a OCCUR MEO EXP(AN one pe6¢n) $ Exclude
A PERSONAL SADVINJURY S 1,000,00
GENERAL AGGREGATE S 2,000,00
GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000
POLICY X "' LOC
AUTOMOBILE LIABILITY 8104305W872 MA AUTO 06/01/2004 06/01/2005 COMBINED SINGLE LIMO $
ANY AUTO 810 999A381TIL04 NH AUTO 06/01/2004 06/01/2005 (Ea aatrlenl) 1,0 00,00
ALL ONTIEO AUTOS BODIIYINJURY S
X SCHEDULED AUTOS (Par person)
B X HIRED AUTOS BODILYINJURY S
X NCN.DA'NED AUTOS (Pel acdtlem)
PROPERTY ;IAIE S
(Per accitlenQ
GARAGE LIABILITY AUi00NLY.EAACpUENT I
ANYAUTO OTHERTHAN EA ACC S
AUTO ONLY AGO S
ME'CESSNMA LIABILITY BE3206504 06/01/2004 06/01/2005 EACH OCCURRENCE $ 1,000,00
X OCCUBRELLR F7 CLAIMSMADE AGGREGATE S 1,000,00
D S
DEOUCTIBLE S
X RETENTON S 10,DOC S
WORKERS COMPENSATION AND WC7824512 06/01/2004 06/01/2005 X I TORYLMIT$ ER
EMPLOYERS LIABILITY EL.EACH ACCIDENT S 500,00
C ANY PROPRIETORIPARTlEPoEXECUTIVE
OFFICERRAEMBER EXCLUDED? E L DISEASE-EA EMPLOYEE S 500,00
tl yes,tlesnibe under :::t E L.DISEASE.POLICY UNIT S 500,0D
SPECIALPROVISIo, below
OTHER
noSCRIPTION of OpFp.nn. 1n aTnNS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS _ a.
vidence of Insurance for work performed within the Insureds scope of normal business operations.
otice of Cancellation provision is' 30 days except 10 days applies for non-payment of premium.
CERTIFICATE HOLDER CANCELLATION —�
-- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
3 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION ORUABILNY
R'
OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
B. Driscoll/MCG
ACORD 25(2001/08) OACORD CORPORATION 1988