LORING AVE -RAINBOW TERRACE - BUILDING INSPECTION i.
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APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: %pplicants must complete all items on this page
SITE INFORM, ION n �
Lor.ItiunNaune11i�� 1�r�ty �rvr� r� Building �'l- vi / VrrS
Property Address .
Lor1 h =,r. I�✓r�y, vQ
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes R3_124_
Residential (3 or more Units) R2
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) AI _
New Building_ Assembly (restaurants & clubs) A2r_A2ne_
Addition Assembly (churches) Al _
Alteration _ Business B
Repaid Replacement Educational E
Demolition Factory(moderate hazard) F1 _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard 11_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12
Institutional (restrained) - 13
Mercantile N1 _
Storage S1 Moderate I-laurd
Storage S2 Low I laz; id
I IN'NI•:It3111P INFORMATION(Please type ur Pri t Clearly) I�
OWNER Name a 7�
Address 4 of 76
Telephon —
Sign: re
DESCRIPTION OF NYORK 1.0 BE 1 iNIED
jW1,4-cEM6AT of eZ70 coN6fz4=TrZ-
si E`er -r ��yztZ+cS
I•S T1JlA FED CONS'I RUCTION COST
CON I'RAC'rOlt INFORNIA rION ` /
Name A/y.W CV, r (i1 ��i iC�Ca rs f�n act-r
Address oZgo fro Leva- i S lb i"U MriGlevr.n HI/ o � 94
Telephone a ? P 6845 '2>9 40
Construction Supervisor's Lic # 6;5>/(Oo
Home Improvement Contractor#
.%RClll'rECT/IiN(;INEER INFORDIA}'y�ON
Name Kr e� F / M ) hn t k ,T ,
Address 11 rWga F St Oer- cesdcjc M/� of 9311
Telephone 978 .763 25D 7
Mass. Registration # _______""_..."
l'ElCNlrr FEE CALCULA'riON
Estimated Cost x $11/$1,000 + $5.00=
CONINIE'NTS
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the penal ' of perjury
X Signed (owner) (a_ent)
APPROVED BY :
DATE A13PROVED: /o?I 30 /OR
CITY OF SALEM
,,. -_', i, PUBLIC PROPRERTY
' DEPARTMENT
:J\W;RMN:IHisCOLL
\1 oft
12^�W asrtLNi:Tom STReET 0 Snu_M.M.wAa trsr:n s 01970
Tla.:978-745-9595 is F:\x:978-740-A46
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectri cis ns/Plumbers
Applicant Information n / Please Print Leribiv
Nine (l3uciness/Oro,aniratinn/Individuul): /yl'k4-1 rinrYi cn el /Z Ae p — S1 eon girt
Address: �' ?c2 >/� t7�
Cily/StatciLip: / /" I c11-4�( 7 Hit alS 49 Phone ''.': o F .5 -3 q ct-r
Arc you-au,employer? Check the appropriate box: 'Type orproject(required):
4. ❑ I am a general contractor and I
1. 1 am a employer with� G. ❑ New construction
employees(full and/or part-brie).' have hired the soh-contractors
2.❑ 1 :un a sole proprietor or partner- tt listed on the aached sheet. �- [L]�flemodeling
- ship and have no employees These subcontractors have K. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
INo workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] o8ieers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MG!, 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, g 1(4),and we have no 12.❑ Roof repairs -
insurance required.] t anployecs. LNo workers' 13.0 Other
comp. insurance required.]
-Any applicant that chucks box ill must also Iill out the suction wow showing their workets'cumpensution policy ininrmuliun.
't lumeowm a who submit this affidavit indicating they are doing all work and then him outside contractors must euhmit u new al'r:davit indicating such.
'C,ntrnctu( Ilm clock this box trang attached in additional,heal showing the 1;nine of the subKontractors and their worken'comp.policy inrormanon.
l ant car employer that is providing workers'compensation insurance for my eutplapecs. Be/nty is the policy and job site
iufonnariam
In,urancc Company
Policy 8 ur Self-ins. Lie. t: irL t f 5 36.$.3(6 /0.3. Expiration Dater o=o
Job Site Address: / r-i n� AV,-- h A City'Stateizip:
AMA It copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A uf.tlGL c. 152 can lead to the imposition of criminal penalties of a
tine up hr SI.500.00 and/or one-year imprisonment,as weil as civil penalties in the form of a STOP WORK ORDER and a fine
of lip to S230.00 it day against tine violator. 13e advised that a copy of this itutument may be 11arwarded to the Office of
Iacc,ligaliuns ul the DIA fbr insurance covcragu vcrilicalion.
l do hereby certify under.d�ie,�pains and prnulticx'of perjury 1ha1 the information provided above is trite and correct.
'T Date:.
Sienalurc /
Official use atdy. Do not write in this area, to be completed by city or to lvn officiuL
C'ily or Town: Permit/License#----__
Issuing Aulhurily (circle one):
1. Board of Health 2. Building Department 3.City/'fowu Clerk 4. Electrical Inspector 5, Plumbing Inspector
6.Other
Contact 1'ersou; __-._ .. __-_ Phone #:
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 ;m 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
dwelling 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. NIGL 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) namc(s), address(es) and phone nunmber(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 afldavit 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(lie number listed below. Self-insured companies should enter their
.self-insurance license number on the appropriate line.
City or Town Officials
Please he 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.
['lease be sure to till in the penniulicense 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 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Ot)ke of Investigations would like to thank you in advance for your cooperation and should you have :my questions,
please do not hesitate to give us a call.
'rhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Rcviscd 5-26-05
www.mass.gov/tile
ftVM
CERTIFICATE OF LIABILITY INSURANCE 10/13/zw°`W&
PRONICED (603)224-2562 FAX (603)224-8012 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION
The Rowley Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
139 Loudon Road HALTER OLDER.THIS E COVERAGE�DOES
NOT
THE POLICIES NE LOW.
P.O. Box 511
Concord, NN 03302-0511 INSURERS AFFORDING COVERAGE NAIL 0
NwREO New England Builders III Contractors, Inc. BreaMERA Union Insurance Calpany
290 Broadway, Suite 137 BLSURERs: Acadia Insurance CoMany 31325
Methuen, MA 019" INSURERS Liberty Mutual Insurance Co. 00701
Nsuam o:
NMIRER e
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED."NOTVWTHSTANDINGGANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO NMICH THIS CERTIFICATE MAYMAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I8 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND COPOLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR TYPE OF INSURRAMCE POLICY NUMBER LIMITLEE oENERALLIAauTY CPA002835522 10/13/2008 10/13/2009 EACHOCCURRENCE COMMERCYLLGENERALLWRm 70 DLAfNS MAC OOCCUR MED EIGP(Aldan prwl)
A PERSONAL&ADV 04ARY f 1.000.
GENERAL AGGREGATE f 2.000,0001
(R?HL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AM f 2P000,000
POLICY LOC
AUTOMONI E LIABILITY MMIS0042924 10/13/2008 10/13/2009 COMBINED SINGLE LSRT
f
ANY AUTO MA °ddard) 1 000,
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (P�GPawn) f
A X HIREDAUTOS
BODB.r fuuRr f
X NON-OWNED AUTOS (PRE
PROPERTY DAMAGEf
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT f
ANY AUTO OTHERTHAN EAACC f
p
AUTO ONLY: AGG f
EXCESSNMBRELLA LIABILITY CUA008438316 10/13/2003 10/13/2009 EACH OCCURRENCE S S.0001000
OCCUR O CLAIMS MADE - AGGREGATE f S 000 00
B s
DEDUCTIBLE S
X RETENTION f S
INORNERS COMPENSATION AND WC231S308361038 11/01/2008 21/01/2009 X A oTH•
EMPLOYERS'LIABILITY - E.L.EACH ACCIDENT f SOO
'• ANY PROPRIETORIPARTNER/EXECUTAAi
OyFFFIICERAAEMBER EXCLUDE - -' -- E.L DISEASE•EA EMPL f SOO O
If SPECIAL OVISIONS ENPw .......___ _ E.L.DISEASE•undw POLICY LMR f SIIO OO
OTHER
ESMPTION OF OPERATIONS LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY BNDORfBMBiTG SPECIAL PRUMIOMB ..
ERTIFICATE HOLDER CANCELLATION
8NOIB.D MY OF THE ABOVE DESCRIBED POLICIES W CANCELLED BEFORE THE
Salem HouSinq Authority SIMATON DATE THEREOF THE BURNING BOURER WI.L ENDEAVOR TO MAIL
27 Charter Street 30 oAvswmr ENNDYKETo TmEGEIRFI ATEmnam'AYEDTOTNBLwr
Salem, MA 01970 BUT FAILURE TO MALL SUCH NOTICE 8NALL WPM NO OBLIGATION OR LIANLITY
OF ANY KIND UPON TR Wailk ITS AOENTB OR FWPR ILTATVEO.
AYTMORIIEDREPRESENTA
Susan Siegel 20
-ORD 25(2001/08) CACdRD CORPORATION 1888
lilassachusetts - Deparlment of Public Safeq
Board of Building' Regulations and Standards
Construction Supervisor License
License: CS 60600
Restricted to: 00
ERNEST E RAMEY
64 LINCOLN ST r> "
BELMONT, MA 02478
Expiration: 12/V2010
( mnmhsionrr Tr#: 7270
CITY OF SALEM
PUBLIC PROPRERTY
'< ^, DEPARTMENT
t_'% u.\iI II\i,.iI\'Sf;ila'T 4 1.\I I'\I, \t.\,i\\ :I', ii I :
-
I'I:I. 'P, ♦ 1:\S:V,8.743- 9846
Construction Debris Disposal Affidavit
(re(luired litr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 Ch9K section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
111_ S 150A.
The debris will be transported by:
_ . �eXrve, ram/ hGleP c�yi eS
(na to of hauler) -
I fie debris will be disposed
l/of in
Paine ut facility)
(address of lacili(y)
s ignalurc of par i applicant
o SD 0
date ---
o �
J-37 -70 0