72 LORING AVE - BUILDING INSPECTION (3) PUBLIC PROPF.RTY
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APPLICATION FOR PLAN EXAMINATION AND BUILDING PERhIIT
ALL STRUCTURES EXCEPT 1 AND 2';FAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page
SITE on Name INFORMATION 1 r �51 _
Location Name Te s , ve o�5. Buildingi
Property Address 711 La",r Q AyF
Map M 0 — —�
Located in: Conservation Area YiN Historic district Y/N
Use Groups
(check one)
Residential(3 or more Units) R2_
Type of improvement Residential (hotel/motel RI _
(check one) Assembly(churches) Al _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants, recreation) A3_
Alteration_ Business B
Repair/Replacement_ - Educational E_
Demolition_ Factory(moderate hazard) F'1 _
Move/Relocate Factory (low hazard) F2_
Foundation Only High Hazard If_
Accessory Building_ Institutional (residential care) It _
Qthnr(describe) Institutional(incapacitated) 12_
l 2.�ea�l Institutional (restrained) 13
Mercantile M_vf
Storage(moderate hazard) St _
Storage(low hazard) S2
OWNERSHIP INFORMATION(Please type or Print Clearly)
OWNER Name ES+Ljkr RP r ltu Lrto—
Address Tf o
Telephonn $
DE.' 'RIP'1'ION O WORK"10 BE PEBl-URnIF:U
., ,
0 ,5
orl0 , .o
ES'FIMA['ED CONSTRUCTION COST
CONTRACTOR INFORMATION
-rt !Name �CyClAcla',
Addressfy uo a r- 1 , Mh �Z 370
Telephone771-(sto- 7 -2.9 '�
Construction Supervisor's Lic #
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name
Address 16,y g�N5# S hu&, WnrkDnj. r�7.71Q(p
Telephone I-R4I.K�4( -7S� (o
Mass. Registration # 005y__
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 T--
Commercial est. cost x $11/$1,000 + $5.0 , 73
COMMENTS
The undersigned does hereby attest that all information stated above is trite to the best
of my knowledge under the penalties of perjury
Signed
Date O.
r
ACORD,N CERTIFICATE OF LIABILITY INSURANCE °ATE'MMTD YYYY
12/30/OS
PRODUCER 1-800-247-7756 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Holmes Murphy R ASSOC - WDM ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
PO Box 9207 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Dan Moines, IA 50306-9207
INSURERS AFFORDING COVERAGE NAIC# .
INSURED INSURERA Zurich American Insurance Company
Tedeschi Food Shops, Inc.
INSURER B:SC. Paul Fire A Marine Ine. Co.
14 Bo>ard Street INSURERC
Rockland, MA 02370 INSURERI!
INSURERS
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.
TN—SR 001 POLICY NUMBER POLICYEFFECTNE POLICYEXPIRATION LIMITS
L NS ATE MMID MW °
A GENERAL LIABILITY - GL03730939-04 01/01/09 01/02/10 EACH OCCURRENCE $1,000,000
%I CDMMERCIALGENERALLIABIUIY PREMISES eocc"eme $300,000
CLAIMS MADE OCCUR MEDEXP(Anyore Person) $5,000
PERSONAL B ADV INJURY $2,000,000
GENERALAGGREGATE $2.000,000
GENII AGGREGATE LIMIT APPLES PER: PRODUCTS-COMPIOPAGG $2,000,000
POLICY FX LOC
A AUTOMOBILE LIABILITY BKP3730940-04 (Commerica ) 01/01/09 02/01/10 COMBINEDSINGLEUMI7 52,000,000
X ANYAUTO (EeeaideM)
AULOV EDAUTOS BODOLYINJURY
(Per person) $
SCNEOULEDAUTOB
X HIREDAUTC6
BODILYINJURY
$
X NON-OWNEDAUTOS (PareccCe
PROPERTY DAMAGE $
(PersuMeM)
GARAGE LIABILITY AUTO ONLY-EAACCIDENT 9
ANYAUTO OTHERTHAN EAACC E
AUTO ONLY: AGO; S
B EXCESSIUMBRELLA LIABILITY QXOSSO2435 02/01/09 01/01/10 EACH OCCURRENCE $20,000,000
X OCCUR CLAIMS MADE AGGREGATE E 10,000,000
S
DEDUCTIBLE $
RETENTION $ S
A WORKERS COMPENSATION AND WC3730938-09 01/01/09 01/01/10 % WC�0 LIMITS ER
STAN- OTH-
EMPLOYERS'LIABLITY E.L.EACH ACCIDENT $1,000,000
ANY PROPRIETOWPARTNERIEXECUTIVE
OFRCERIMEMBEREKCLUDED7 E.L.DISEASE-EA EMPLOYEE $1,000,000
0 es,desrNa under
SPECIAL PROVISIONS Eenw E.L.DISEASE-POLICY LIMIT $1,000,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES IEXCLU ONS ADDED BY ENDORSEMENTISPECIAL P OVISK)NS �J
CERTIFICATE HOLDER CANCELLATION
//q SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIfUTK)N
To Whom It May Concern�/ /yTDATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,95 AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001108)tahoykhe twdem - - - QACOIRD CORPORATION 1988
107uee0
Certificate Delivery by CediBcatesNow-www.Confj"Net.onm-877.669.8600'
MAY-08-2009 15:47 P.02i02
CONSTRUCTION CONTROL AFFIDAVIT
Project Number:—{- T'dPSCV!( — Sad Date: I�7 ���
Project Title: I�� � 00� S�G _
Project Location:T ,2. Uy I V14,
Name of Building:
Scope of Project: pynaU0ficy) 0� �1CISfIh omedigiq `( 0 mns1017 N'9' 1
IN AC O NCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I 1�
_ MASS. REGISTRATION NO. BEING A REGISTERED
PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY
SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCE ING"
Civil rchitectural Structural Mechanical
Electrical Fire rotection Other(specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING
AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix 1.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDIN I SPECTOR. UPON COMPLETION
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO HE SATISFACTORY COMPLETION
AND READINESS OF THE PROJECT FOR OCCUPANCY. -
6 Signature
S4CFAD AND SWORN TO BEFORE ME THIS I"5 DAY OF /%W V 200�9
!C,d My commission Expires:
No l
nFF C3r+1JCAl _
NOTARY;FwcUC
F v rpMMC M1WC� ^���rAi35ACIiUSEnS q �
��� L1y i;cmm.Exptr2s�ulY 2II,2011 _, ll .
TOTAL P.02
CITY OF SALLM
PUBLIC. PRoPRERTY
L
DEPARTMENT
cons
truction h'on Debris Di
sposal osa I affidait
(rctluircd fur all demolition and wwk)
In accordance \%itll the sixth edition of the State Building Code, 7S0 CbIR section I 11 5
Debris, and the provisions of MGL c 40, S 54:
is issued with tile u
e condition that the debris reslting front
Building Hermitt
this work shall be disposed of in a property licensed waste disposal lacility as defined by MUL c
111. S 150A.
The debris x%ill be transported by:
lu�mc ul h ul�r)
I he debris will be disposed of'in
I namr ul ny) n ` /,/ 1 0
ro
I:ul,lrcv. ut LS1111v1 V
aL:nullue nt pa nut .ipllhi unt
mr
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,1111 M'I SNAP I'II
\I\:wNl 12^�\y.Nfli.\CIV^51 ALL 1' • 5AlI'sh, M.\>%\w.111itii
li.1.978-7$5-9395 • 1:s.x 1174-74C.'1846
Workers' Compensation Insurance \f jdavit: Builders/Contractors/Electricians/Plumbers
1 tlicant Information // Please Print Leeihly
VdITC lDu.uasy1)r,lj anvatioNlndisiduull:
ltldross:lZ f
City,SC.ItC.%ip' /7- G/ n� �� D2;J7� Phone „/-/ia' Lr
\re sou an employer:' Check the appropriate box: 'Type urproject (required):
i 4. ❑ 1 sun a general contractor and l (i. ❑ new construction
1.�1 ant a employer with
c nployccs(full andvur part-time).• have hired the suh-contracturs 7. [�Reinodeling
?,❑ 1 am a sole pmpricnx or partner• listed on she coached sheet. :
ship and have n r emplo parVus These subcontractors have g. ❑ Demolition
working for me in any capacity. workers' comp. insurance. g. (3 Building addition
5. ❑ We are a corporation and its
I No workers' comp. insurance officers have exercised their 10.❑ Electrical repairs or additions
I required.] 1 I. Plumbing ,e airs or additions
3.❑ 1 an,a homeowner doing all work right of exemption per MGL ❑ b P'
myself. (Ko workers' comp. C. 152. g 1(4),and we have no 12.❑ Rew1 repairs
insurance required.) t employees. [No workers' 13.0 Oliver
comp. insurance rcquired.J
•4n. .ytphcanl tlurt checks box 01 muyt:dao till out the w,lion Iwluw slowing,heir w•urke,i eumpunvnion Ioli y inlium:ttiun.
'I lameuwmn whu stihmil this affidavit indicating rhut ate doing all work ails Ilicn hire WbIdc conirmtors must auhmil a new affidavit mdiuling%twh.
-f'ontrannn that cheek this tax morn aowhcd an addilton+l.Axel.hawing the none of the suh• tsnlraerors and their wurkers•comp.gmllcy Information.
/out an employer shut is providing workers'compete Vision in.rurunce jar my employees. Belch is the pa/icy and Jab.rife
information. i
Insurance C'on,paoy Name: �a � •'!cap,-
1'olicv a or Sclf-ins. Lic. 0: - 14���(� 0 ExpirgIt n Dine: �0
y
� F M_. City,-Stale/Zip:
Job Site -\tlJress: �•
Attach a copy of the workers' c riper ion policy declaration page (showing the policy number and expiration date).
I;injure to secure coverage as required under Scaiun '_5A of>lGL c. 152 can lead to the imposition of criminal penalties of a
fine up to i1.500,00 ansl'or one-yearimprisunment, as \cell as civd penalties in the furor of a STOP WORK ORDER and a fine
Of it,,to 5250.no is Jay Ig❑ir,51 the violator. He advised that a copy of this slutcmcnt may be lurwarded to the 011ice of
Ins csm,auuns it :hc MA :or u„iu:uxe arvcr.tge ,cfilic.tl:on.
7do-�'hi.,,ere by califs under the r n'a enah, c afperjn that she imfurnation provided above is true and correct. i: "--
Official use only. /)o not ivrile its rhix area, to be cumpleled by city or lorvn aflicia/.
tv or fur n: —__ _— Ycrmitll.iccnse �.
Issuing; .\ulhurily (circle onc):
I. 14,urJ mf IlaJth 3. Iluildiuy Dcparunvot 3.Cih.'1'uno Clerk 4. L•'Iecerirtl luspcctor ;, plumbing luspcctor
6. Other _
Cannel l'c nun: .. _ Phone 0:
Information and Instructions
.%Liebachusetts Gcncral Laws chapter I i2 require)all et nl)fo)ers to provide workers' compensation for their employees.
Punu:mt to this ,tatuie,an employee is defined as"...every prison in the service of another under any contract of hire,
express or implied. oral or written."
.\n employer n defined as"an individual, partnership, associaliou, corporation or tither legal entity, or any two or more
,,r the t„regomg engaged in a joint cmerpnse, and including the legal representatives of a deceased emplu)er,or the
receiver or trustee Of an individual, pwincnhip, 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 at) the grounds or building appurtenant thereto shall not IXcaase of Such employment be deemed to be an employer."
.',IGL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license nr permit to operate a business or to construct buildings in the co' nimiinwr6lth foeany
applicant who has, not produced acceptabre evidence of compliance,with the insurance coverage required."
Additiunully. �IGL chapter 152, §25C(7)states"Neither the cominoiiwcaltli nor any of its political subdivisions shall
enter into any contract for the performance of puhlic work until acceptable evidence ofconnpliance 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) namc(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 dale the affidavit. The affidavit should
he retmmd 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. Sclf-insured companies should enter their
self-insurance license number on the appropr(atc line.
City or Town Offlciuls
Picric be sure that the affidavit is complete and 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.
Pl.::uc be sure to fill in the penniulicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitAicerse applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address'the appiicant.should write "all locations ip, (city tar
town)." A copy of the affidavit that has been officially stamped-or marked by the city or town'iriay;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 dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I ho i)iiix of Investigations nwuld lice w thank you in advance fur your cooperation and Should you have:my questions,
please do not hesitate to give us a call
The Deparonent's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia