72 LORING AVE - BUILDING INSPECTION (2) PuBLIC 11RO111 ":RTY
120 Im I,',% 114111 • �%I \i, \1 III l'l it
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: :% licanls must complete all items on this page
SITE INFORNIA'rION
Location Name Eastern Bank Building
Property Address '� Loring Ave.
Located in: Conservation Area Y/N Historic district
APPLICATION DATE March 9, 2009
Use Groups
(check one)
Group Homes R3 R4_
Residential Q or more Units) R2_
Type ol'improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) Al _
New Building_ Assembly (restaurants & Clubs) A2r_A2nc_
Addition Assembly (churches) Al
Alteration X Business B_
Repair/ Replacement_ Educational E_
Demolition_ Factory (moderate hazard) F1 _
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile M _
Storaee SI Mode:ae 1-lazard
Storaee S2 Low I Lvard
ON'NERS11111 INFORM:►TION(Please N or Print C early)
OWNER Name EasternBank '
Address 5 Market Street, Lynn, MA01901-1508
Telephone (781 ) 5 6-4 16 _
Si,onatur
DESCRIPTION OF WORK TO BE PERFOWMED
Replace windows, new paint and carpet,(
Create office and conference room
ES I EM;%FFD CONS'I RUCTION COST $51 ,000.
CON'U RALA Oil IN6OR>I.\"11ON
Name Development Concepts,"':Inc.
Address-72 Sharp Street, A-11 , Hingham, MA 02043
Telephone (781 ) 337-2725
Construction Supervisor's Lic # 42323 (David F. Parry)
Home Improvement Contractor# N.A.
:%RCI11'I'ECf/I:NIaNEER INFORMATION
Name DRL Associates, Inc., Architects
Address 2 West Street, Suite G, Weymouth, MA 02190
Telephone (781 ) 331-8541
Mass. Registration # 4027____
PERI1 IT FEE CALCULATION
Estimated Cost x $I151,000 + $5.00= $566t100
CON1NIENTS
The undersigned applicant does hereby attest that all irtforrrratiort stated above is trite to the best of any knoivledge
under t4Davii
lti
5igaed -fovMrr) (agent)
F. Parry - tConcept:s, Inc:.
APPROVED BY : /
DATE APPROVED: U
CITY OF SALEM
; ` PUBLIC PROPRERTY
DEPARTMENT
.11.1 . M 1 1 In Ill ,•11
\, I,IN 5IALL1 05.0 1'%4, M%`cS%I 111 %1 IIN 31')7:
I1'.1. Ph'1s93113 01 lx 97111-74C 1.446
Yorkers' Cumpensation Insurance mrsdawit: Builders/Contractors/Electricians/plumbers
l )Iicant Information Please Print Leeihly
Development Concepts, Inc.
V:I ITIC lUu.nwssa�rpam rarinNlnJn olual l:
72 Sharp Street, Unit A-11
�ddres:
City,ScIce./ip Hingham, MA 02043 Phone '!: (781 ) 337-2725
.xrr)nu an employer" Check the appropriate bus: 1')pe of project (required):
4. ❑ 1 :un a general contractor and 1 6, New construeuun
I.❑ 1 am a employer with ❑
e nl,lo ces full anLVur art-woe).• Pace hired the sub-contracture
I } ( P listed on the attached sheet. )• Remodeling
2.❑ 1 aln a sole prnprieux or partner-
,hip and have no employees Those sub-contractor have S. ❑ Demolition
Dorking tier me in any capacity. +workers' comp. insurance. q. ❑ Building addition
No workers'cum insurance 5. ❑ We arc a cniftoration and its
l P officers have cxorciscd their 10.❑ Electrical repairs or additions
I rcquircd') repairs 3.❑ I .on a homeowner doing all work right of exemption per MC'L I I.❑ Plumbin r 6 P� irs or additions
m)sclf tKo workers' comp. c. 152, ¢1(4),and we have no 12.0 Ruufrepuirs
insurance required.) r ctnpluyces. [No workers' 13.❑ tither
comp. insurance required.J
•sm .pphs+tN Ihat chucks but el moat also WI WI Ibc tiaboll lwjuw aluwmy Vert wo,koi compensation fubcy nlhrtnauian.
't lomcownsn who s,Ibmi1 Ibis affidavit indicating Ihcy are doing all work and Ibcn him wDlde contractors must whmil a ne,v alfaavil:n&,,aling—11
-c,nlrxts,n that shuck this box motor Aii uhcd an.u:dllional nlw•et aluwmg ilw nine of that sub:onlrxlun and then wurku ve curnp.prlhcy mGlmlanun
/rtnr mot employer that is pruvidit g workers'curnpeownrion insurance for ory eroplgyerx. Below is the polity and job sire
iufonnwioa
I r..urence Cunlpauy Vmne, A.I.M. Mutual Insurance Co. -- - ------_—,--
police d) I6 AWC-7003864012008 Espirutton Date: 12/1 /2009
loU Site AdJrcss:
72 Loring Ave. City:Slate/Zlp: Salem, MA
---
.Utack a copy ofthe workers'cumpensatiun poke) declaration page (showing the policy nutuber and cxpiratiun date).
failure to secure coverage as required under ScL(iun 25A ul'>IGL c. 152 can lead to the imposition oferiminal penalties of a
line up to i1.5110,00 enlL'ur one-)car imprismmncnt, an well as eiul penalties in the loth ofa STOP WORK ORDER and a fine
of up CO Ss_i0.0(1 a Jay •lguiml 111e "Amor. Ilc advised that a copy of thls ,tntcinenl may be turwardcd Io the 011ice of
I 1a„u,awnD ul '.hc I)IA :or In,w.uxe ,ana,lye lu ltiL.lUon.
/Ju herrhy a.'rtif ut.lc•r d that the infurtnattion provided above is true and correct.
March 9, 2009
\1•"I IInI� -- --
1,h,, . . , (781 ) 337=2725
tl//iriu!rut mt/y. /)d nln lvrite in this ura•u, to bet ulup/<•trd by city up/o,vn.I//ir iu/.
( itv it
fno'n: __.. Ycrmipl.iccnwe tl -
I,,uintI ."Wllo1'l1Y (circle noe):
1. II1,u rJ Of IIe.JIh Z. Hu Jdin� Ilcpartulcnt ih."I'ulcu Clerk J. Electrical In;pcc rot i. Plumbing luvyrctor
b. Other _
('unl:lcl Phone t/:
Information and Instructions
N Lhe,.ie huscitb Gcncral Laws chapter I i2 requires all employers to provide workers' cornpen,at Pon fbr their employees.
I'u r.u.mt to taus suwre, an rmplucer is defined as " ew cry poison in the service of another oroler .ury contract of hire.
e♦press Jr mpllcd, ural or %%linen."
%n ,•,npluyer is defined as "an individual, partnership, associauou, corporation or other Icgal entity, or any Iwo or more
a the torero O;g enraged it a joint cnrerprsc. and iiwluding the legal representatives Ora deceased employer, or the
receiver or trubtee of.m individual, paititership, association or other legal ennty,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, cunatruction or repair work on bush dwelling house
Of on the.,rounds or building appurtenant thereto shall not because Of such employment be deemed to be in emplo)er."
MGL chapter 152, ;t25C(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."
\ddimunally, hIGL chapter 152, 425C(7)sratcs"Neither the commonwcaldi nor any of its political subdivisions shall
enter into any contract for the perfomiance ufpuhlic work until acceptable evidence ofcumpliance with the insurance
r . requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill Out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors)namc(s),address(es)and phone number(s) along with their cenificate(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
he returned to the city or town that the application for the permit or license is being requested, not the L4-partment 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 Omclals
PICasc be sure that the affidavit is complete:md printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit icense number which will be used as a inference number. In addition, an applicant
that must bubiit multiple pennit:licensc 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 rile for future permits or licenses. A new affidavit must be tilled out each
Year. Where a hone owner or citizen is obtaining a license or perinit not related to any business or commercial venture
(i.e. a Jug license or permit to burn leaves etc.)said person ib NOT required to complete this affidavit.
I he i)nice of hincstigatiuns would lime to thank you in ad%ancc fur your cooperation and should you have .iny questions.
please do nut hesitate to give us a call
(he Ucp.rtinent's address. telephone and fax number
The Comrnonwealth of Massachusetts
Department of Industrial Accidents
OMCC of Iovest/gattans
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
x:•.:.:d 9 `u.ui
www.mass.gov/die
WORKERS COMPENSATIQN AND,EMPLOYERS LIABILITY INSURANCE POLICY q - 2 72008 INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
Burlington, Massachusetts
(800) 876-2765 NCCI NO 26158
POLICY NO. I AWC 7003864012008
PRIOR NO. I AWC 7003864012007
ITEM
1. The Insured Development Concepts Inc
Mailirig Address: 72 Sharp Street Unit A-11 Hingham MA 02043
(No. Street Town or City County State Zip Code
❑ Individual ❑ Partnership ® Corporation ❑ Other FEIN 04-2474204
Other workplaces not shown above:
2. The policy period is froml2/01/2008 to 12/01/2009 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 eachaccident
Bodily Injury by Disease $ 500,000 policylimit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating plans.
All,information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No Total Annual of Annual
Remuneration Remuneration Premium
INTRA 182241
SEE EXT NSION OF INFORI 4ATION PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 7,413.00
As indicated,interim adjustments of premium shall be made: Deposit Premium $ 5,888.00
❑ Annually ® Semi Annually ❑ Quarterty ❑ Monthly
MA Assessment Chg.
$6,932.20 x 6.3000% ///l $437.00
//n,,
This policy,including all endorsements,is hereby countersigned by G�l.X W, 09/30/2008
Authorized Signature Date
GOV GOV I KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Berry Insurance Agency Inc
MA 15437 16 1704 1 1 1 Crown Colony Office Park
WC 00 00 01 A(11-88) 300 Congress Street Suite 306
Includes copyrighted materiel of the National Council on Compensation Insurance, Quincy,MA 02169
used with its permission.
Subcontractors
Noll Electrical, Inc.',
1068 Washington Street
Weymouth, MA 02189
(781) 337-5900
Policy#W C7264477
Expiration: 4/22/2009
Selective Ins Co. of Southeast
O'Brien & McKenney
10 Jane Drive
Saugus, MA 01906
(781)231-2636
Policy#IHUB8568L91009
Expiration: 1/4/2010
Travelers Indemnity of America
F .
Board of Building Regulatlons and Standards ,
Construction swerylsor License -
ut�CS 42323
010 Tr# 24242
DAVI. D F PARRY
3 HILLSBORO ST Comudsai -
T` QUINCY,MA 02109 / -
1
CITY OF SALEM
PUBLIC PROPRERTY
'S,K DEPART'.MENT
:,I
III: '/'s '4i.7 j'/i 1' \5. j7X.V: /,i4e
Construction Debris Disposal Affidavit
(required liar all dcnwlition wid renovation work)
In accordance ith the sixth edition or the State Building Code, 780 C'h9R section 1 11.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
'DyA1I4mic.
(name of haular)
I he debris will be disposed
of in
(name of facility) -
(address ul lacilitv)
\ILIIa101'L' If p:Wait .ytplicant
:, .,.. .,