600 LORING AVE - BUILDING INSPECTION (8) • =�, + ,s' Pum Ic 1)w )1'1 .1Z'1'1'
.::1 . :tln, i,I 1
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APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
:kLL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: Applicants must cum lete all ilenu on this page
rSITEFORMATINamt �� O/'//VC�'/I!/�Buildirq,Address it
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Humes 123_124_
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly(Theaters) Al _
New Building_ Assembly(restaurants & clubs) A2r_A2ne_
Addition Assembly(churches) A I _
Alteration J/ Business B JG
Repair/ Replacement Educational E_
Demolition Factory(moderate hazard) FI _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile NI _
Storage S1 _Moderate I-I:IZllyd
Storage S2 Low I Lazard
O\N'NERSIIII' INFORMATION(Please tv'pe nr Print Clearly)
1-a OWNER Name u /"/ e 430 t"/✓E' S'
Address ATO.UNf{ /I,
Telephone /67 /B//,2QOlo
Signature
DI':SCRII''I'ION OF VIORK TO BE PERFORMED
Ajr,n��jjr � �dc�:a a
7o
ut�u/'P%oye �Pq/ iN4 Aid a,r e 7-
1 S I LNIA['ED CONS I RUCTION COST'
CUNT tt.%C 1014 INFORMATION AName
Address
Telephone
Construction Supervisor's Lic #
Home Improvement Contractor# 106;Zh5
.utcurr►•:crniNc:►Net•:►t INFORDL%TION
Name .]ulr X c J?01VQ
Address ,J,7L/ Mft' IV sW A.4 rLaT, 1rA
Telephone YZ6,-i-76 ,99/J
Mass. Registration # 3/1 J7
PERMIT FEE CALCULA'r►oN
Estimated Cost x $1 U$1,000 + $5.00= Od
COMNIENTS
The undersigned applicant does herebyattest that all information stated above is trite to the best of my knwvfedge
under the penalties of perjury
Signed (owner) (agent)
APPROVED BY : �
DATE APPROVED:
I -
f�
CITY OF SALEM
J. PUBLIC PROPRERTY
�o
DEPARTMENT
,.,.I x'11. 1911l,-11
12: Wd>111.M.Io.\513LL'I' 5AlI'\t, tit.\a,1At III ,1 I I,J197:
fr.l. )7/-71i-9393 • I:,.x 979I4C'1346
Workers' Compensation Insurance ,%flidaxit: Builders/Contractors/Electricians/Plumbers
%imlicant Infurmalion o C / //�• Pleeasssea Print Leeihly
,�>. V:IInC t lhl.un:cs.1)rsmr.uinlc�Indl,�duo11: /1 fI S.S4 L/ f�u�/�� \ /r�/u)/ l (7/tl/�QC�Or
/7 �� ST
%tldross: T
_ PsT�r/� �j
Ciry,Scaca7ip ✓� / - D I'hunrr!' sld
an employer! Check the appropriate box, Type of project (required):
1. ❑ I :on a employer with 4. am a general contractor and 1 6. ❑ New construction
employees(full 4nd,,ur part-time).• have hire,!the sub-contractors 7
2.❑ I am a sole pmpricux or panner- listed on the anuchcd.sheet. ❑ Remodeling
,hip and have no employees These sub-contractors have 8. 9e)entolition
working for me in any capacity. workers' comp. Insurance. 1). ❑ Building addition
No workers'comp. insurance 5. ❑ We arc a crn-poration and its
I P 10.❑ Electrical repairs or additions
I required.] officers have exercised their
3. ❑ I ant a homeowner doing all work right of exemption per NML 1 I.❑ Plumbing repairs or additiorts
myself (No workers' comp. c. 152. ¢I(4),and we have no 12.0 Ruuf repairs
insurance required.) t unployces. LINO workers' 13.0 Other
comp. insurance required.]
•,n> buul Illat chucks boa 01 marl Aso II It ,sit IbC KChJII Ib'luw showlna Ihelr wwkais'cvn,pL•nL ioI1 NJKy iris liuM1
' I lomauwnf:rs who ua,...a this anldavit indiealina Ihcy are Joins till.sork mW then him uuwde coturmlors muss.uhmil a new alCdavil indiW ma w,h.
that tk,k this box mass.machcd.m adddiunal.,h vt>huwioa Iho n:mu:of Iho sub-contr ctors and lhnr wurken'camp policy mfurmanun
/uw tin employer that is pro riding Ivorkers I conrpeuvation insurance for ttty eutp/uyees. Belnty is the pu/ity and job site
iufornoatina.
Ir.,uramv Company Name: "7 P_ r/On'tP ��K S_L'u PSs' rt/S4(Af1V Ce '/
Policy it ur Sulf-ins. Lic. R:XYjA r1-?� N �A� 0� .7� 7 Eapirutlun Data f • �t'j
lob Site Address: om Coy.Slater"Lip: s2k/2z./w
Attach a copy of the workers'-cui penxallon policy declaration page(showing the policy number and expiration date).
Failure to score coseruge as required uudcr Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to il.500.00 and/ur one-)ear Imprisnuncnt, as well as cis it penulhes in the Turin of a STOP WORK ORDER and a fine
of up to i250.00 it day .lgainst the violator. Be advised that a copy of thu siatcuicni may be forwarded to the Oltice of
Im:,ugau m>ul :hc UL\ :or i j,urarcc .,,scrape tcrilic al:un.
/do hereby t croft umler die poin>turd pent tiev of perjury that the iufurinution provided above is true turd correc4
�----
F1,,uinL
ul use wily. Do tint rrire in this urea, to be runtpleted by a it),ur town o//ir ia/.
Permiul.iecnse 4.%whurily (circle one):rd of Ilr.dth 2. Bwliu� Mparuorot i. l.ih.'Ibwu Clerk 4. Elvctric.d In,pcctor a, Plu of bing lay vector
er _
(l,utact !'mull: .. .- Phone it:
Information and Instructions
Iu�sa I,usetis Gcncral Laws cI,apta I i2 requires all el plo)ers to provide workers' compensation for their employees.
f'unu.ult to this statute, am emplurre is Joined-is" e,cry pclson in the service of another under any contract of hire,
e%press Jr unplicd, oral or wi then."
.kn e,nPluy.-r is defined as "an Individual, partnership, assoclatlou, corporation or other legal emiry, or any two or more
rr the t„aguu�g engaged in a joint enterprise. and including the Icgal representatives of a deceased emplu)cf,or the
receaver or trustee of. individual, panncnhip,association or other legal cnnty,employing cmplo)ees. However theAs'
o wner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
Jwellrrlg Iwuse of another who employs persons to do maintenance,cunstruction or repair work on such dwelling house
or sir, the grounds or building appurtenant thereto shall not because of such employment be deemed to be in rmplo)er."
.1.IGL chapter 152. �25C(6)also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or pertnil 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."
kJditionully. :MGL chapter 152. J25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ufpuhlic work until acceptable evidence ufcunipliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Ple:lse 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), addresses)and phone number(s) along with their cerlificatc(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
memhers 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 aflidavit. The affidavit should
he 1e
tamcd to the cry
i 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 ore inquired 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
Please he sure that the affidavit is complete Ind 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:asc be sure to till in the penna/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permiblicense 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 Icily or
town)." A copy of the affidavit that has been officially stamped or marked by (lie 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 tilled 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 dug license or permit to burn leaves ctc.)said person is NOT required to complete this affidavit.
I ll: a)iliec tit would llne no thank )ou in advance far your cooperation and should you hash .my questions,
please Jo no, hesitate to give us acall.
File Mpartincnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investfratfons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 eat 406 or 1-977-MASSAFE
Fax M 617-727-7749
i www.mass.gov/dia
04,03/2009 08:50 FAX 603 626 1011 ADVANTAGE BENEFITS 4 001
OATEImmmINYYYYI
AV-OR-P. CERTIFICATE OF LIABILITY INSURANCE 04/03/2009
peTDlwceR (603i 262-3300 THIS C TIFICA NI i SUED AS A NATTER OF INFORNA710N
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Advantage Auto, Home 6 Business InsuranCe AHOLLTER THE R. IS
CERTIFICFFORDEOTE DOES V TR POLICIES BELN NO. NOW.Oa
393 Denial Webster Highway
NH 03054- INSURERS AF ROING COVERAGE NAIC#
Merri-meek INgURERn TraV6lere Indemnitv Co
INSURED -
bg%gK $STEP CONSTRUCTION INSURER D.
51 LAWRENCE RD MURE-RC:
IN RER
MERRMHACK NH 03054— INSIAIERE
C G
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE-NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWROR MAY PER ANY
REQUIREMENT,TERN OR CONDITION OF ANY CONTRACT OR OTHER 000UMENT WPM RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POUGES DESCRIBED HEREIN IS SUB.IECT TO ALL THE TERMS. EXCLUSIONS AND CONDIUONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. UGy LIMITS
Nra OD'L TYPE OF NTSURANCE POLICY NUMBER �TEIIA ATE M
o1/12/2009 01/12/2010 ROCCURRENCE s 1,000,000
GENERAL UABILITY ET tE ED S 300,000
x COMMERCIAL GENERAL LASOM E6 Ee DRxDVmb�
MEO EIIPA Arm eTAP S B,000
CLADAS MADE ❑OCCUR 1,000,00 0
PERSONN.AADY NUURv s
REGATE $ 2,000,000
R TS-COMP/ A
GENL AGORSGATF pLIRMpII.i.APPLIES PER
LICY JECT LOC
S*
AVTONOBAE LIABILITY IS*
a mED SINGLE LERR S
Ee AccpanU
j ANY AUTO BODILY INJURY
ALL OWNED AUTOS (Pw pmT ) $
SCHEDULED AUTOS
BOD
HIRED ALTOS AV INJURY $
(PxaceMNx)
1 NO"-0 OAUTOS
/ / / / PROPERTY ORMAGE $
I (PAr eeeNenp
GARAGE UABILTY AUTq OrAY-EA ACCIDENT $
OTHER TNPW fA ACC $
ANY AUTO ALTO ONLY AIRS $
OC U ENCE
EI,,W"IMBP&AA UAIMUTY S
AG TE $
OCCUR F-1 GLA646 MADE $
DEDUCTIBLE
RE N $
X Yp 05 LIOOMPEpgATRIN AND LACRUD^110BN80-5-OB 01/12/2009 of/la/ao1D IS ER lOO,000
El EACH ACCIOEM s
AMY PROPRWTORMARTNERiExECUT1YE 100,O00
OFFICERVAMBER EMCLUOW? / / / / E.L.WSEASE•EA EMPLOYE 6
NY¢p,dvvlEeuMv EL DISEASE-POLICY lIA1R $ SOO,OOD
SPE IAL PR IONS
OTHER
DESCIMPRON OF OPEMTIONWLOCATIONBMERM SJOICLUSIOND ADDED BY 9MCDRSEMCNTPl--PROVISIONS
n
. Ggv-IJOJAN/G qCJ -09 i°;�G.-%old
CANCELLATION
CERTIFICATE HOLDER
SHOULD am' OF THE ABOVE pESCRIBFD POLICIES B! CANCELLED DEFORE THE
ETWRA WN DAIS THEREOF. 1HE ISBUINB INSURER VALL MIEAVON YO MAIL
15 DAYS WRTTEN N"CE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT.BUT
FAD.URE TO DO SO SMALL IMPOSE NO DBUGARDN OR LIABILITY OF ANY WND UPON THE
RUSS GOURLEY INSO In G£NTSOR ra
A
17 cHlas$aD2 sx
NEWSURYPORT NFL 01950— OACORD CORPORATION 1900
ACORD 25(2MISS) PAAA I crx
INS025(oloo/0S EL6cTROme LASER FOAMS.INC.-IDOD)ExT
APR 03,2009 12:08 603 626 1011 Page 1
rAC4RD,M CERTIFICATE OF LIABILITY INSURANCE oa%oz/z o9
PRODUCER (978) 363-5285 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
West Newbury Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
322 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 150
West Newbury MA 01985- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A.NATIONAL GRANGE MUTUAL
Russell W Gourley Jr INSURER B:
17 Chestnut Street I INSURER C.
INSURER D:
Newbur Ort MA 01950- INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING AN'
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 POLICIEf
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(M1WDD/YY) LIMITS
GENERAL LIABILITY / / / / EACH OCCURRENCE $ 1,000,0(
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED SO,0 C
PREMISES Ea occurrence $
A CLAIMS MADE OOCCUR 719991 04/02/2009 04/02/2010 MED EXP(Any one ersan) $ 5,0(
PERSONAL&ADV INJURY $ 1,000,0(
GENERAL AGGREGATE $ 2,000,0(
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGE $ 2,000,0(
17 POLICY JECT LOC
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OWNED AU fO S / / / / BODILY INJURY $ _
SCHF-OULED AUTOS (Per person)
HIREDAUTOS / / / / BODILY INJURY
NON-OWNEDAUTOS rPROPERTY
P accident) $
DAMAGE
accident S
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $
OCCUR 71 CLAIMS MADE - AGGREGATE $
$
DEDUCTIBLE / / / / S
RETENTION S S
WORKERS COMPENSATION AND / / / / roar uMlis °Ea
EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIFXECUTIVE El EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED' / / / / E.L.DISEASE-EA EMPLOYEE$
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THI
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAII_
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,SU
CITY OF SALEM FAILURE TO O SHALL IMPOSE GATION OR LIABILITY OF ANY KIND UPON TH
CITY HALL INSURER,I A NT RREPR
BUILDING INSPECTOR AUTH IZ T VE
SALEM MA 01970-
13�i�g Re ulla�fOns an tan ar s�
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvemenf bntractor Registration
:'- Registration: 106775
r, Type: Individual
Expiration: 7/27/2010 Tr# 271650
RUSSELL W. GOURLEY JR z `;,.
Russell Gourley Jr --- —_— — —
17 CHESTNUT ST. 4 -
NEWBURYPORT, MA 01950 ti -- ------
I '
ri
Update Address and return card. Mark reason for change.
Address Renewal [-] Employment F- Lost Card
DPS-CA1 0 50M-07W-PC8490 —
,A T {iomr„smat.,ealAe o�✓Cfaaead,T�aetta
�\ Board of Building Regulations and Standards License or registration valid for individul use only
lug HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration:, 106775 Board of Building Regulations and Standards
Exptratton; 7127/2010 Tr# 271650 One Ashburton Place Rm 1301
T e: Individual
Boston,Ma.02108
RUSSELL W.GOURLEY.JRi's '
Russell Gourley Jr�' " '`
17 CHESTNUT —
NEWBURYPORT, MA 01950 Administrator Not valid without signature
ar a m ng egu au an tart ar s
CotfstruallonSupervisor License
s LVOnSe; CS 15813
ti t ' Tr# 10855
EW275F2009
a.fir
RUSSELL
17 CHESTNUT STD\ -
NEWBURYPORT.M7fil$T950 Commissioner