5 LINDEN ST - BUILDING INSPECTION (3) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Applicant Information s& t a egaffity
Vametu..i,tesyory.a;:,,;a.rltw4vNa.l►: pp <r��.1JilJl' .e1 .S'y(�r
AtJdreas l n �Yno Mci - aGt��
city/stuwzip: 1��1!7A ) 0*- /�iezi 14W=#:-- 7� GYGD —
Aro y *Mplayar? t approprlsss boas
1. 1:mt a employer with e. ❑ 1 am■Poland cownwor and I rya tdpwjaet(►M1111firOdk
ampkiyeas(full anwor jaw"me).• have hired the sub-corum-ices 6. Q A'a �^'�oa
2.❑ 1 am a seta proprietor or partner• tinted as do atuehsd alsoet t 7• L
ship and haw no anployua Than how ✓L Q Demolition
working for ma is any eapataty. worker'comp,ittniraitoa
(Inn workers•comp. insurvam S. Q We an a Corporation and Its 9. Q euildit additiaa
nquirt�] oAloaa have exarciaod their 10.Q Eloctrieat to or additions
10 1 am a homeownOr Joins a0 work rishe of exemption por MGL 11.Q Plumbing repairs or o"dom
myself.(Ire workers'camp. a 152.#t(4).aad1 we have nix 12.0 Roof repoin utsuraaee requitstd.J ► cmpbycvx(A'o workerq• I1.0 Otbar
'
come inmtrancs rctpsirwLj
'A�9+vPGaar tar ehxta 0oa wl mum she as out dw tsoua IsA w showing thir awlies'cause aarhr IN..,,
iaatratatioa
14okmwmma rho mart rats aAldarii W"dR f Huey aw da4y YI woo mte Oaa No own"comma"emu wAnL a eon amtYve•
C'.,rtgnpra tali aerate era Qs mtm athelnd an additional.ham.a miq en natmr araY ak•aaoaacton erne thou,wwkaa• mJlarina wi
MINIMUMgyp•policy iwasoi aaea
!aw ve dwpfoyv►that It presddfng wor*mI roarpraradon huarones fop wy ewpfoydes Hi/ow 4 the pdHaj and/4f�.+ ..._.
Insuramx Company Vamr Policy a ur Salt•-ins.Lie.* fw/r U //SZ7 Expiration Due: 1�'cidry
Jub Site Ackbeso: nlDlrrJ )— City/Statatzip. W MAt 0,h?740
Aitach a Copy of the workers'compeasatloa policy doclaratba page(showing the policy number and expiration date).
"ai lure to uxun coverage as required under Souion 25A ofMGL c. 152 can lead to the imposition of criminal penalties*(a
rfe.up as$1.500.00 and/or one-year imprisonment,as well as civil penalliul in the form of STOP WORK ORDER and a fins
.if up to S250.00 a Jay al(rinsl ilte violator, lie advised'hut a copy of this statement may be forwarded to the Omce of
Im;,ngauutu uRhe D ''or incurarce cancrao verification.
/Jrr hen•A as t ins ad aul*s o/prrjary thW thr Gt orwwfon
l POWded mbowe it&W dad rO#7rcx
1i••a:tuf•'
d)/Jhiad trse uaiyt /Ja adr wr/re/w rhls orre•to k ruwp/e/d jy cAy or Apww OA.Idi
City or 'rows Prrmit/IJecast M_ _ _
kvsuiag Authorily (circle one):
1. hoard of llealth I. Building Ihpartotent I City/fono Clerk J.Electrical Inspector S. Plumbing Inspector
6. Other
C„n1ac1 Persen:�_ _ Phone p:
1
Information and Instructions
152 requires OnPkY"n to provide workers' compensation for dale employem
all under any coaaact of bier.
hiais nhusctw General Laws chapterle defires'ea-..mm<Y person r the service of armother
Pucsmmaen m this amaarte.m ese/fie)er
e%pras or ugpli A Ural or wrWW06
asttiatiet►aorporasiaa«other legpl entity.at�two se enter
r dedind 0-W Wdividttal ' representatives of a deceased employer.or do
Aa ssn/1ge! sad ioelmrfbt{td�legal gal
of the faeiloteg entailed m a J�snsarprirr• aseoeiatioa�other legal
wary,
empinYingamployam
klovtavar tha
neusiver et tttattw of ter itdividud.pasarrsltp. and who resitlss tlatairt.ar the ooeuPw Of"
owtut of a dwelling house bavin{mat sacra tlsa drag aparatteda d who W or repair work on such dweltiag house
dwelliv hOOse or boildim PPttre�pe deco s�so�auae of seal atopkW mm be doMW t°be as empbyer"
or on the gtetmad• s
htGL ebapter 132.;2SC(b)also stores d to"w�area W Meal Meet s ag/my shag wMYMY Me Nuseaeo or
se opwab a bttdares w m eomswud btdldhW la tba eesaseaaweaMk for arty
reswWal a/a Yeettse sr Petmk evWw of cemprsaee wMh am Insurance eoverags tr*q§* rhsU
ap�ieaat wbe bus set predaed aeteptabM Amweaftnor any of its political mbdivriem
Additioanity.MGL chapter 1S2.t2SCt7) work undl atcales W evidence ofcaopdiaoce with the insurance
°°ese loan my comtau dt bow�presented the contracting au wriq.
requirements of this ehepes
ApplMsaa
Please fill out dts workers• conVense�affidavit Completely.by checking the boxes that apply to your sitti aj
aaoa sad.if
nmb eaateaetat(s)�+).��es)and phom ouruber(s)along with deir cartifica�s)�than the
necessary.supply Companma(LLC)or Limited Llsbilky PatwrsR+pe ILLP)with no employ
age
Limited am oat required m carry eraeabilitykara'CO1aPeOee�°ttaun°er' if an LLC or LLP does have
members or potency6 uimd. Be advised that this affidavit racy be submitted to the Deparosuter of [adusQid
employees,•l7elley te9 of irrursme eovetep. Aloe be sun to sign and date the ofndavM. The affidavit should
Accidents for confirmation the application for the permit a liCeasr is being requested.sat tba Deparamea of
be returned to the city Or town have pity gwesdod regarding d6 law or if you an required to obtain a workers•
conspe Industrial tion policy.
pS��l dw D �td numb listed below. Salf-inand camPaaias should eater their
camnpatsatiea policy, nmabse oa die
uelfinw*stw license
City or Town OtRelats
and printed kgiby Tbr DOPE at
has provided a space at thr.boao4-.
please be sure that the affidavit is completethe lieatn.
of the affidavit for you to fill out in the event the Office of Investigation has to contact you regarding AW
r' in addition,an applicant
t'Icass be sun w till is the per viiecenee number which will iv near.neeed reference submit one affidavit indicating current
,hat must submit multiple pstmitllieans application is any T Y c, tar
policy information(if necessary)and under"fob Site Address' the applicant should write"all locations ia_--( h
townp A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant L proof that s valid affidavit is on file for Rrtmrre permits ter licenses. A now affidavit tarts befitted out ash
year. When a ham owner a cidana is oMainiag a license or pcnit not related to any business or commercial venture
Iteetw or
own r r barn leave stir.)said pereoa le NOT required to complete this at'lidavit.
(i.e.a dog '
i ha Ot lice of Investigations would due,o thank you in advance for Your cooperation and should you have any questions.
picaaa du not hesitate to give us a call.
The pcpartmrnt's address. telephoneand far numbs.The Commonwealth of Masmhtuem
Depetament of lndust:ial Accidents
Odhe of[nrtudpd$M
600 Washlo0lots Street
Boston.MA 02111
TeL #617-7274900 en 406 or 1-977-MASSAFE
Fix 0 617-727-7749
t.vixd 5-26-05 www maw.zov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTNCEW
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Tu.vW0494•Cut 97N�61hM
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Construction Debris Disp"af Aft1davit
(required for A dmn dwm and rmwvad"wort)
in monIfiWA w ith du auth adidien o[the Sett 8uiWag Cod@,730 C161A seedost 111.S
pebr*wad*w provisions of NGL a 40.3 A
gwidiq Pon 3 _ I _ is lsmad with the condition that this debris rewldns Qto
this wort shall be disposed otin a properly lica mml wawa disposal Witty as defined by.%!(R.a
1L1.9ISO&
rho debris will be transported by:
,aatae�r t,tt„tn
the c)cbris will be disposed ofin :
G p S/frnv�^,w
(1taaw of fxtAty)
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I® SKETCH Contract Date___ s 0 Sales Representative-slgnatore__
ATTACHMENT Customer Phone._._ __ f1y yy�p Contract Frire.___-_____ off _.__.__ m
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L NOTES: 'Lace hox equaFs,Ine toM un?,s Oloom nMad.This skolch isa dmO tolth 0
mpresa•nteaen M rhs work In be dnno,it of dndpls I Iperi i WI all ltlaclKlpns Kc
drlvvv;d from ads rkelrJr are arllllOxrzMt3.and mat all kKJlipnG Of ryJl[15.Ilgnl O
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• SKETCH contract Data1/�a�s C� Sales HepresentativaSlgnaluro__ u
ATTACHMENT
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acoRv_ CERTIFICATE OF LIABILITY INSURANCE OF ID S DATE(MMDD/Y M
BAYST-1 05/24/07
R THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Andrew G. Gordon, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
680 Main street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
PO Sox 299 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Norwell HA 02061
Phone: 781-659-2262 Fax:781-659_ 4725 INSURERS AFFORDING COVERAGE NAIL
I Bay State Basement INSLIRER A Renaissance Group -
Systetns, I.LC INSURER B: _
dba Owens Corning Finished INSURER
Basement System -
Canton�t02021 uRsx�RD
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE PhlIED NAMED PROVE FOR THE POLICY PERIOD INDICATED.NOTVWTMSTANDING
ANY REOUIREAENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCU.ENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAJH THE IISLRPHCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.IECT TO ALL THE TERMS.EXCLUSIONS AND C06UMONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOYM ANY HAVE BEBI REDUCED BY PAID CLAMS.
LTR TYPE OF INSURANCE POLICY DATE(MMIDD/YY) DATE(IO.IIDDIYY) LMT:
GENERAL LIABILITY _ EACH OCCURRENCE f
COMMERCIAL GENERAL LIABLITY MEMISES(Ee ommm S
CLAIMS MADE OCCUR LED EOP(Arty qM P•rsuT) f
PERSONAL a ADV INJURY i
GENERAL AGGREGATE f
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-CC.PIOP AGG f
POLICYEMEET 0 LOC
AUTOMOBILE LMBLRY COMBINED SINGLE LIMB i
ANY AUTO (Ea eock a )
ALL OMEN ALTOS BODILY ARMY f
SCHEDULED AUTOS (Par Px )
HIREDALRDS BODILY PLARY IT
NON-OYrtRm ALIf0S (Pareccl/m
PROPERTY DAMAGE f
-aw 4 (Pv acdAIm
Gam, UABASTY AUTO ONLY-EA ACCIDENT i
ANY HJTO OILER THAN EAAGC i
AM ONLY: AGG i
IXCESSAMBRHIA LIABILITY EACH OCCURRENCE f
Coup ❑CLPJMS MADE AGGREGATE f
i
DEDUCTIBLE _ •i
RtTERRON i IT
VVOR03M COMPEHSATION AND TORYUMRS I I ER
A E.PLGYEW LL48SAY ---- WC 0371527 05/24/07 05/24/08 E.L.EACH ACCIDENT ,i 1000000._...,,.
AJWPROPRIETGR/PAKMERRDECLMVE ..
OFFICEI EMBER EXCLUDED? E-L.DISEASE=FAEMPLOYEE $1000000
tt yyee55 desal�u10er EL.DISEASE-POLICY LIMIT i 1000000
SPECIAL PROVISIONS Eelow
OTHER
DE5CRPTION OF OPERATIONS J LOCATIONS I VEHCT.ES J EXCLUSIONS ADDED BY E DORSE BITJ SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
NSSCELI 8 O4XD ANY OF THE ABOVE DESCRIBED POLICES BE CANCHIID BEFORE THE D(PRATION
DATE THEREOF.THE IS81NG PAUBt WILL ENDEAVOR TO MAL 10 DAYS WRITTEN
Say State Basements NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Uffrr BUT FALRRE TO DO SO SHALL
for record purposes IMPOSE NO OBLIGATMOR LIABILITY OF ANY Nw UPON n 14W03L M AIENTS OR
03 tE 3ElTATNES
MfTNOR®REPFESEJTATIVE
House Account
ACORD 25(2001/08) 0 ACORD CORPORATION 1988
ACORD_ CERTIFICATE OF LIABILITY INSURANCE OP ID BG DATE
BAYS?-1 i1/21/07l/21/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Kaplansky Insurance Brookline HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
114 Harvard Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Brookline MA 02446
Phone: 617-738-5400 Fax:617-738-8214 INSURERS AFFORDING COVERAGE NAIL#
INSURED INSURERA Norfolk & Dedham Group _ 13943
INSURER B:
Baystate Basement Sy INBLRERc
Baystate Basement Sys LLC dba
60 Shawmut Rd INSURERD.
Canton MA 02021
INSURER E'.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
MY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WTUCH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB..ECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOVM MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF CJSURANCE POLICY NURSER PATE(g4pplry) PATE(NLppryy) LIMITS
Gs` LWBILRY EACH OCCURRENCE i lOOOOOO
A CLwsERCIALGErERALLIABILITY R0309626 02/06/07 02/06/08 PREMISES(Ea ocwence) i 100000
CLAIMS MADE OCCUR WED EXP("prre person) $5000
X Business Owners PERSONAL a ADV INJURY $ 1000000
GENERAL AGGREGATE i 2000000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG iEXCLIDED
X POLICY PRO-IIEC LOC
AUTOMOBILE 1.14811-17Y COMBINED SINGLE LIMIT
MY AUTO (Ea eova ) i
ALL OWNED AUTOS BODILY INARY
SCHEDLlEDAUTOS (Per Persm) i
HIREDAUTC6 BODILY KUUPY i
NOHiOWNEO AUTOS
(Per accioerAl
PROPERTY DAMAGE i
(Per K6,NM)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT i
ANY AUTO OTHER THYW EA ACC i
AUTO ON-Y: AGO i
EXCESSMIBRB"LWBLRY EACH OCCURRENCE i
OCCUR CLAIMS MADE AGGREGATE .$
.__.._.__
i
DEDUCTIBLE i
RETENTION i IS
WORKERS COMPBRSATION AND TORY LIMITS ER
EI®LOYERS,LIABILITY E L EACH ACCIDENT i
ANY PiOPRIETORRARTNERoEXECUITWE
OFFICERNEMSER EXCLUDED? E.L.DISEASE-EA EMPLOYEE i
II yes tlBSc N Uqm
SPECIAL PROVISIONS Oebx El.DISEASE-POLICY LIMIT i
OTHER
commercial Applica
DESCRIPTION OF OPERATIONS I LOCATIONS I Wien I EXCLUSIONS ADDED BY ENDORSETAERT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRBED POLICES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAY 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FALURE TO DO SO SHALL
Baystate Basement System LLC MPOSE NO OBLIGATION OR LIABILITY OF ANY HIND UPON THE INSURER,ITS AGENTS OR
d/b/a Owens Corning Finishing
60 Shawmut Road REVRESETATTVES.
Canton MA 02021 A THE
ACORD 25 42001108) ®ACORD CORPORATION 1988
2007-11-2109:96 Page 2
��B o d o ui�ingegulA(n-s-'and tS andar s
One AshburtorrPlace - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: -137943
Type: Supplement Card
Expiration: 1/29/2009
OWENS CORNING BASEMENT FINISHING --.-.-
DANIEL WALSH
60 SHAWMUT PARK
CANTON, MA 02021 Update Address and return card. Mark reason for change.
Address "' ` Renewal Employment Lost Card
SCAT O SOM46I06PC6490
V � g� m mg Ke6o�alloff"Aft.n ards
Construction supervisor License
Llabnse: CS 79893
SirdiBat� 10/S1962
"' pf5/2009 TrC 4794
DANIEL F WAL6'.
488 KENDALL RD
TEWKSBURY.MA 018#8'"� Commissioner
— CITY-OF- LETNf -
. PUBLIC PROPERTY
DEPARTMENT
KIMIMU"DU SCULL
%twraa 13D WASMNGnw SMEEr•S LW4 M,NuaLSLI-M 01970
TEL'9?L7i5-9595•FAr 970-740.99"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EMSTIN
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: 5' L-loos—A( S Building:
Property Address S C.W06J Sr
Property is located in a;Conservation Area Y/N Historic District Y/N A _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: SCo77-
Address: S ( r AI D&O ST
/"4 dl i 70
Telephone: C179 74e(/ C/ VSQ
3.0 COMPLETE THIS SECTION FOR WORK IN FYIATING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: I'l"(Sy n607- t4-VAv6 Ow6;,J-r 4!2)e1UJA-6
&SOWi )C17•✓,skitiG S, -r
)euarn 7-3 &F use
Mail Permit to: e-mWAor � �f!✓17n1 /Yjrt fJ?�l
What is the current use of the Building? 2—
Material of Building? If dwelling. how many units?_-�_
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone D
Mechanic's Name& jj5 '0 lnw��G rllf s � �YS oa 4+Kw/A'ur� / OZQ2/
Address and Phone Tel kzl-
Construction Supervisors License# 7z1SeI 3 HIC Registration#
Estimated Cost of Project S � Permit Fee C"latkxr
Permit Fee Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/S1000 Commerciat
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit uil to th a e stated
specifications. Signed under penally of perjury
Date Z2,212`67
N
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ah. 9 ►.
F 3s � ..
a
C6 � � �