600 LORING AVE - BUILDING INSPECTION (6) NS City of Salem ward
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete all items in sections:4 It, Ill, IV, and IX.
L AT(LOCATION) Do koe/')G Ave- ZONING tGT
LOCATION aNd' (STREET)
DIST
OF BETWEEN c AND
BUILDING CROSS STREET) caos9`STRUT)
SUBDMSION LOT_BLOCK SIZE
H. TYPE AND COST OF BUILDING-All applicants complete Parts A -D
A. TYPE OF IMPROVEMENT D. PROPOSED USE•FOR"DEMOLITION"USE MOST RECENT USE
1 Q New Wading Readmitted Nonresidential
2 rl Addition tp maidemnl.enter numON of new, 12 Q Oro fw* 18 ❑ AmtmamenL recreational
loading units aI e I it any,in part D.131 19 i] ChncK Oaer re gidn
13 ❑ Two or rtore larrlay•Enter number
3 @/Aeeraton/See 2 above) of unit— 20 ❑ 1rldaitrW
21 Q Parkn91W49e
Fme
a Repair mplrenant /0 D 7renews hotnumber
o units L a dbrrnabrY• 22 Q SeMre station.rew gtesp
rmmbei ofuna ___�_
5 Q Wrecking(a mWteamay residenete,anew number 23 1:1 110epitaL Monsoonal
of units m building in Pan D. 13) 15 Garage 2412 01 Offlod,bank proleasrmW
S Q Mp^ng Vebratonl 18 ❑ caw 25 ❑ PUbW ufasy
7 Q Fou 4MW Only 20 ❑ S&AW hO"Case M*CaeorW
17 ❑ cow•Spridy 27 0 SIbres,nwmentile
S.OlnERSNIP 28 Q Tanks,mwsn .
B J0 Private undividuak wrporaton,nonpdR app�_S
ireowbon.eta)
9 Q Pubic lFedwal.Sale,or Crap govemnwnt
C.COST IoomCBrlts# Nbrresidenual.Deebnbe n detail proposed use of buiangs,e.g..tom processeg pates.
machine eroa Wundry buadirg at hoetmai.eMinerd"School.Secondary 3:11001.codop
10. Cost of imprevenars .._-_ S 4 taltoenw adlodi,parking garage w tlrlptearam store.rental office buadin%oeaba bui thng
at eadretrol plant.s USe Of eselkg W**M a berg Ctonged,enter proposed ues.
To be mountedmr mpiuded &&2 2UI i-Z o LCT `I'� D r� h,ef9'A�C�/-1
'"a.te ova bcoatu �0 40(].
a EMetroal
a PMnbelg Da�� e BI�I.t7K lU/� C rN
a Stands aU mMisonirg
d. odor tebvelor.oral
11. TOTAL COST OF IMPROVEMENT It
III. SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L,'demditn,
complete only Parts J R M, all others skip to IV
E PRINCIPAL TYPE OF FRAME F. PRIM;! TYPE OF NEATM FUEL G. TYPE Oy�SEWAGE DISPOSAL I. TYPE OF MECHANICAL
30 IY] Mosom Mall beat ng) 35
Goa 40 Ptrblk or pnrala cornowin, Will Bars cteeel ai
31 iU Wmd Sams 38 Q Oa 41 ❑ Privala ISOOW wort etal
32 0 Strucaaaa dW 37 0 Elebtraily 4s Yee 45 ® No
33 ❑ Rew*xced oorraae 38 ❑ Coal H. TYPE O�'�NATEl1 SUPPLY 0j,tep ey�n /
34 [] OIMr-SperJy 39 Q Ogw.Speesy 42 Private(wak la carnpow 46 0 Yes 47 tJ0 No
43 Q PrivateIwsS.cislatnl
J.48 Nur,K)NS M. DEMOLITION OF STRUCTURES:
.ta Numcer or stones ................. ,
49 To aI square tear of near area Has Approval from Historical Commission been received
a:: oases on.. UFO . _ for any structure over filly(50)years? Yes_ No_
50. Toraf Lana area M.n......__Q.1 �/._._____..__ Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES
Pest Control:
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
52. outdoors........_......_.......__--.---_...__ Yes No
L RESIOENnU BUBDINGS ONU' Water ..
53. EIBCfrIc:.
— Gas.
Feu_.— Sewer.
5e. Nwioer of
aeueooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
Pawn -- BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ No_ (if yes,please.enclose documentation from Hist.Corn)
Conservation Area? Yes_ No_ (If yes,please enclose Order of Conditions)
Has Fire Prevention approved and stamped plans or applications? YesZ No_
Is property located in the S.R.A.district? Yes_ No_
Comply with Zoning? Yes_ No_ (If no,enclose Board of Appeal decision)
Is lot grandfathered? Yes_ No_ (If yes,submit documentabonld no,submit Board of Appeal decision) !!
If new construction, has the proper Routing Slip been enclosed? Yes_ No_
Is Architectural Access Board approval required? Yes_ No_ (if yes,submit documentation)
Massachusetts State Contractor License# CS 640%-5 Salem License
Home Improvement Contractor# Homeowners Exempt form(if applicable) Yes_ No
CONSTRUCTION TO BE COMMENCED WITHIN SIX(6)MONTHS OF ISSUANCE OF BUILDING PERMIT
CONSTRUCTION IS TO BE COMPLETED BY: ��0� If an extension is necessary,please submit
�O in writing to the Inspector of Buildings. 1{
I
a
V. IDENTIFICATION • To be completed by all applicants j
Name ry Maeig address•Numoer wrest crry,and Mft LP Code TeL No.
t A& J /4LIM
erme.�,
Lie
2. eu (Lee/
\\ canreoror C,� (��7 d 30�-q ea+de
—'r c1 Uce,ee No. z
3. L S ( 3
AS5t)Q.I W-T4S
0 0.2 11LO
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application
as his authorized aaent ano we agree to conform to all molicble laws of this iunsdiction.
Signalpfept applicant Address 4,3[7 OLumel / C'Le- Application date
/�72e�ilyige� J-)W 0,30W
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0.
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building Use Group
Permit Issued 19_ Fire Gmdmg
Building
Permit Fee $ Live Loedug
Certificate of Occupancy $ y Load
Approved by
Drain Tile $ Gf
Plan Review Fee $
TITLE
NOTES AND Data •IFor department use)
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by. Completed by.
i
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
I
USE. .
i
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
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STE OR PLOT PLAN -For Applicant Use
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MoDuffee, Insurance, Date: 12/01/04 Time: 03:07 PM To: Laporte Construction B 4230369 Page
'' DAM(MMIOD/YYYY)
ACORQ CERTIFICATE OF LIABILITY INSURANCE 12/01/2004
PRODUCER (603)424-9901 FAX (603)424-3203 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
David H. McDuffee Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
309 Daniel Webster Highway HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
9 y ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P 0 Box 1S10
Merrimack, NH 0 30 5 4-15 10 INSURERS AFFORDING COVERAGE NAIC#
INSURED Laporte Construction Corp INSURER A: Peerless Insurance Company 24198
2309 Columbia Circle INSURER GUARD Ins Company 14702
Merrimack, NH 03054 INSURER C.
INSURER D'.
INSURER E
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADD'LTRTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY CBP9400302 03/20/2004 03/20/2005 ffOCCURRENCEENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY ENTED $ 100,000
CLAIMS MADE OCCUR one person) $ 51000
A DVIN.RIRY $ 1000O0REGATE $ 2,000,00GEN'L AGGREGATE LIMIT APPLIES PER'. OMPIOP AGG $ 21000,000
POLICY JEC LOC
AUTOMOSILELIABILITY BA9409701 03/20/2004 03/20/2005 COMBINEDSINGLELIMIT $ -
X ANY AUTO I (Eeaccident) 1,000,00
ALL OWNED AUTOS BODILY NJURY
SCHEDULED AUTOS (Per person) $
A X HIRED AUTOS BODILY NJURY
X NON OWNED AUTOS (Per accident $
PROPERTYDAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY.EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: ASS $
EXCESSIUMBRELLALIABILTTY CU9404710 03/20/2004 03/20/2005 EACH OCCURRENCE $ 1,000,000
X OCCUR CLAIMS MADE AGGREGATE $ 1,000,000
A $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND SAWC52S645 06/03/2004 06/03/2005 X 0c'IMM s I OR
EMPLOYERTUABILRY EL.EACH ACCIDENT $ 500,000
B OFFICERIMEM ER EXCLUDED?ECURVE E L.DISEASE EA EMPLOYEE $ 500,000
rcyes,descibe under
SPECIAL PROVISIONS be. EL.DISEASE-POLICY LIMIT $ 500 000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL
_0_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
City of Salem, MA BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
120 Washington Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Salem, MA 01970 AUTHORIZED REPRESENTATIVE
Pat Rath CM6 „� —
ACORD 25(2001108) OACORD CORPORATION 1988
McDuffee Insurance, Date: 12/01/04 Tina: 03:07 PM To: Laporte Construction F 4230369 Page
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s),authorized representative or producer,and the certificate holder, nor does it
affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon.
ACORD 25(2001/08)
1
C.ornmonurdfstt7t o`�aa,nchwsf�e .
e00 w.A1.r..,Sw
arlera l c a..+ lades Me..dLa A 0.2111
Workers' CompetwtioIII nce Affidayk
b
- wkha prbKw platy of badness an
d�o/hereby*cerJq under the paters and pimikin of pw* slop
W 1 an an employe► provUing workers' compensation covePde for my sinploSra wonting cm
Insurance comps y Po Nurnbor
I an a sole propriesor and have no one working fdr ram in any eaadq.
() 1 am a ask proprietor, teneral contract or homeownw (drde one) and hwe hind da
contractors lined below who-hove the following workers' compensation po8dw
Conaaetet insuranie Compsay/Pe Nunbw
Contraetor insurance Company/Po Ni;i—w
Cosuaoux Insawance Compasy/Poky Nunbor
0 1 am a homeowner performing all the work myself.
1 ree.nu"wr a can of di aaeeen.a.e iorwrmd .a err Ofee A M.a#awes of er MA he ee.w+r."ras"ere on lire a rve
C~AP y newre ener Seed"2fA of MC L 15 2 cis lead es or Woux im of oiednr ee.edo eerwd" M a 4e of A n4 IJ00"wwor arras
ream•ir.ereermrie a no a drt esdda in the leas of a STOP W ORK ORDER awe s erne of s 100A0 a an 4*0 ue.
Signed this . �� 7, day of
.,ccr, e ' rmiuee ` iiwloanf Geparsn,enc
�jcensinf Eoarc
Selectmen Office
=calth Geprmer:
gppap OF BU11A� {gQA , .
�' Ll �• -^w �gOT¢
f gIN! ° 07118H851 ..560 -
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'} GARY R k
1 HUDSONR 0 Admmiwo
51