101 LINDEN ST - BUILDING INSPECTION PUBLIC PROPERTY vp
DEPARTMENT
KI NME11 EY DRISCOLL
MAC 120 Wwu%GTON NrREET•SnLEY,%L%hL%CHLsE1-ts 01970
TEL 97&74S-959S*Fex:97&740-98"
APPLICATION FOR THE REPAIR, RENOVATION. CONSTRUCTION,j
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
!A SITE INFORMATION
Location Name: Building:
Property Address:
l!/VG�t
property is located in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land (t c-e _
F
I
Addreess: f
101 L I 4,4 Sf-
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING 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
R ief Description of Proposed Work:
OS 30y �L
�G UDi
------ Mail Permit to: -
What is the current use of the Building?
Material of Building? r-J0Od If dwelling, how many units? I
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ 7�O�es Calculation
Permit Fee$ Estimated Cost X$7/111000 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 above stated
specifications. Signed under penalty of perjury X
Date
T NI J
00
O
}� 00
6i 9
o ;;\
CITY OF SALEM
t' PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR 120 WASHQdGTON STREET • SALEM,MASSACHUSETTS 01970
TEL.978-745.9595 •FAx:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aoolicant Information Please Print Leeibiv
Name (Business/Organization/Individual):.
Address: `� �j
City/State/Zip: Phone #: �O 8 IA -0�o J
Arse on an employer?Check the appropriate box: Type of project(required):
1. re JI am a employer with/ 4. ❑ I am a general contractor and I 6. ❑New construction
•//N��employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached Sheet. t �• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4), and we have no 12oof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp, insurance required.]
*
Any applicant that checks box#1 must also fill out the section below showing their workers compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and dim hire outside contractors most submit a new,affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: // a u e44
Policy#or Self-ins. Lic.#, 0 8 S/�2-�I I LYO — S—O e Expiration Date: 0 6 ' old d
Job Site Address: L01 r`//1jG'C.tGf I 6;r,— City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains nd penalties ofperjury that the information provided above is true and correct
Si nature: xzlfavle. Date: / -2S 06
Phone#: 7$ 'L OS61S "
6
Official use only. Do not write in this area,to be completed by city or town official,
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
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 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 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
dwellinp,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, §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 the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(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-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 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 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. In addition,an applicant
that must submit multiple permit/license 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. a dog license or permit to burn leaves 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:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
wemesi sY oti,xou 120 WASMNGTON 5 T•C.'cu
MAYOR %k%SAcHLsgm 01970
'Ixi 978-743-9595*FAX 978-740-9&16
Construction Debris Disposal Affidavit
(required foc all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,780 CMR section 111.5
Debris.and the Provisions of MGL c 40.Building Permit p iss issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111,s 150A.
The debris will be transported by:
tuame of hurtled
The debris will be disposed of in :
name of facility)
(address of facility)
sisnature of pemla applicant
daft
DATE(MM\DD\YY)
0G_qO_nA
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
SMALL BUSINESS INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
542 MAIN STREET* ALTER THE COVERAGE AFFORDED BY THE POLICIE6 B I ELOW.
PO BOX 15022 COMPANIES AFFORDING COVERAGE
WORCESTER MA 01GIS COMPANY
26KNR A THE TRAVELERS INDEMNITY COMPANY
INSURED COMPANY
FIORE, PAUL DBA PAUL JOHN & B
SON CONSTRUCTION COMPANY
P 0 BOX 534 C
REVERE MA 02151
COMPANY
D
v COVERAGIWS
THIS IS TO CERTIFY THAT 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 08 MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFFECTIVE POUCYEKPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM\IDIAYY) DATE(MKDD\YV) LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $
CLAIMS MADE OCCUR. PERSONAL&ADV.INJURY $
E�
OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE
FIRE DAMAGE(Any one fire) $
MED.EXPENSE(Any one person) $
AUTOMOBILE LIABILITY COMBINED SINGLE
ANY AUTO UMIT
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per Person)
HIRED AUTOS BODILY INJURY S
NON-OWNED AUTOS (Per Accident)
PROPERTY DAMAGE $
GARAGE LIABILITY -AUTO ONLY-FA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $-I
UMBRELLA FORM AGGREGATE IS
OTHER THAN UMBRELLA FORM
A WORKER'S COMPENSATION AND _TSTATUTORY UNITS NIA
EMPLOYER'S LIABILITY (UB-521IC40-5-06) 06-06-06 06-06-07 EACH ACCIDENT $ I nnn nnn
THE PROPRIETOR/
PARTNERWEXEC�nVE INCL DISEASE-POLICY UNIT $ 1 ()On non
OFFICERS ARE: Rx I EXCL DISEASE-EACH EMPLOYEE S 1 ,000,000
OTHER
DESCRIPTION OF OPERATIONSILOCA'nONS/VENICLESIRESMICnONSISPECtAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE.HOLDER.-
............
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
EVERETT BRIGGS LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
446 JUDD STREET LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
FAIRFIELD CT 06824
AUTHORIZED REPRESENTATIVE
.. . .. ...... .............
SO I
x Bond of Bnlidipg R,gulatbus and Standards
HOME IMPROVEMENT CONTRACTOR
Registrations 121052. c y
E�_I an 4/1/2008'
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f 1�
PAUL JOHN 8 SON CONST: #
PAUL FIORE
t 1134 FRANKLIN
p MELROSE,MiA 1 6' ,_gdministntor