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89 MARGIN ST - BUILDING INSPECTION No. City of Salem Ward trc APPLICATION FOR PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION IMPORTANT-Applicant to complete and Rents in sections:1, 11, 111, N, and/X. I. AT(LOCATION) eel S DIS LOCATION OF BETWEEN �A/ GC_ AM _ �"�StaEEn _--Iu+os5 n BUILDING LOT SUBDMSION LOT BLACK SIZE IL TYPE AND COST OF BUILDING-All applicants complete Parts A -D A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"OEMOUTION"USE MOST RECENT USE t ❑ Now budding Resdar dt NorreamentlY 2 ❑ Addition fit reaidented.enter number of new 12 ❑ Ono lenity 18 ❑ Amisenem rebeeaborw housing units added,it arm in Part D. 13) Or m ta 19 ❑ Chruct,Other fe6giam "7�-1�� 13 ❑ Two mote handy•Enter 20 ❑ melteurr 3 tx neeratun(Sea 2 aEas/ of orals— a ❑ Reber nCpleCMIMr 14 ❑ r ro hale,nnNL a eamday- Ender 22 ❑ Servce station.mow Wage Errr.nirmwr a ands__--� 5 ❑ Wneolusg(e rrnrlelanry resldsneeL ereer armor 23 ❑ flosprw.orstilustonw ' Of units in balding in Part A 13) 15 ❑ Garage 24 ❑ ORfo•.band,prolessonst 6 ❑ Moving trelorahon) 18 ❑ Carport 25 ❑ Publib udif" i 28Iog44brary.otiw eartaioml 7 ❑ Founmtnn only 17 ❑ O9w-SWAV 27 ❑ Stases RteltJtnsse B.OWNERSHIP 28 ❑ Tanks.towers - p 8 ❑ Pmrata Imdi nduaL corrpaatlon,nonprols ❑ offer•SPeOSY ins0hA on,etc.l 29 9 ❑ Public(Federal.Stele.Or brat goeetmwr C.COST (Onat centa! DwrrasnentW-Describe in doted pr000sep use of buaa.rp,e.g..food OrOOMCIO Plana. machrie stop,laundry budding at hospo d.eeenemuy acticol.seconWary echeeL College. 1 O. COST at impmMmMl ..__— S /U tam�. garage ff g oarkwig age for debarent at" meal o ma budds altipe bustling at industrial trend.a use of existing budding is be Wiinged,enter flrWoeed ores. ToMnateasd but not asdfded p ,n dte above test a Eieconol __ r c NstFg.as COMflldleg. ZOI�I-Td� �{C/l1.& 4C- d. Otiter(OWN".ae.l �, — � 11. TOTAL COST OF IMPROVEMENT S n �� - 11'Z ov'i, 'r IIL SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L:demolition, complete only Parts J&M, all others skip to IV E. PRINCIPAL TYPE OF FRAME F. PRNCmAL TYPE OF HEATH FUEL G. TYPEEWAGE DLSPOSAL 1. TYPE OF MECHANICAL 30, Ateeorey feed- 35 ❑ Gas, 40 Or prmM Corrlparry VM gees,be 01w"r 31 ❑ Wood frame 36 ❑ Od 41 ❑ PrNa a Iseptfc tend,or_) condiUalnd7 32 ❑ Strtrciaafsteel 37 ❑ Eholddly "Ayes 45*No H. TYPE OF WATER SUPPLY 33 ❑ RessorW corloele 38 ❑ Cpal WE Olefs,by M 61eer0(1 34 ❑ Ogee-Sawdy 39 ❑ Other-SW.* az�Or P1 wads CamOanY e8 ❑ yes 47No 43 0 PrNete NvelL Chasm J.DIMENSIONS M. DEMOLITION OF STRUCTURES: asNurr er or stories .-.-......_....._.._...................... __. f. . as. Toil square te a poor area a:moors.oasea a..energy - Has Approval from Historical Commission been received s . amensme ........_..__.............._........ U°_..... for any structure over fifty(50)Years? Yes_ No_ 50. Totai wo area.w,e........__._..._._---.-.._..._____ Dig Safe Number K.NUMBER OF OFF-STREET PARKING SPACES Pest Control: 51 Enclosec ...._._......._.—.._._....._..._._._...-..__.___.. HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED? sz. omawa...._..___...__...---.--------_._.-- Yes No L RESIDENTIAL BUILDINGS ONLY Water - 53. Endows_..__ — ,Electric: Gas Full__ Sewer: . . 54. Number or oaueooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED Far. --- BEFORE A PERMIT CAN BE ISSUED. IV. COMPLETE THE FOLLOWING: Historic District? Yes_ No-2� (If yes, please enclose documentation from Hist. Cont.) Conservation Area? Yes_ No (If yes, please enclose Order of Conditions) Has Fire Prevention approved and stamped plans or applications? Yes_ No_ Is property located in the S.R.A./district? Yes_ No z Comply with Zoning? Yes✓ No_ (If no,enclose Board of Appeal decision) Is tit grandfathered? Yes_ No_ (If yes,submit documentabonllf 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 x/CS o19646S Salem License # Home Improvement Contractor* l`T 1 T-3!f 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: p / If an extension is necessary,please submit ( I, in writing to the Inspector of Buildings. V. IDENTIFICATION - To be completed by all applicants Name t MadrQ a/tlO�ress-Number.Soviet coy,aeo aNM ZIP Codeq Tel.No. rooeerer or .iU/-r f-l' 3 /t'�•Ir'-'(.e-! /V s� � ��.11"l �(.vv�- "-il�71/ Lasses Lv.. z. s. 6 rem oDSr� �� S7 contractor L ewNo. oB64G� 3. Archtect or Enpia er I hereby certify that th ro is authorized by the owner of record and that I have been authorized by the owner to make this application as his authorized a nt and we tee to conform to all aooliceble laws of this jurisdiction. Signature of Add Applicationding l ,Sys DO NOT WRITE BELOW THIS LINE VI. VALIDATION Building FOR DEPARTMENT USE ONLY Permft number Building use Group Permit issued /J 1�/ O—zo-a6 Fire Grading Building Permit Fee $ ZS Live Loading Certificate of Occupancy $ App Occivarcv Load Drain Tile $ Plan Review Fee $ YZ TITLE NOTES AND Data •(For department use) PERMIT TO BE MAILED TO: DATE MAILED: Construction to be started by. Completed by: VI ZONING PLAN EXAMINERS NOTES DISTRICT I USE FRONT YARD SIDE YARD SIDE YARD - REAR YARD NOTES SITE OR PLOT PLAN • For Applicant Use i ON The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Businesss//Orrganizattiioonn,/tndividual): Address: C 7 G?-G"� i5lr Xt52 n� � City/State/Zip: ��17� v/� .t L- Phone #: 7lf J�� d19 Aire:, an,employers(Checkithe,apprgpreatelbox: 'Type Ooflproject((wequired,): I, O plo, er wath a(employer / 4� JE3 l:am a enteral(contractor l 'y Ig t6_ 1Q New(eonstnucLon �employees((flill,and7.oripart-time)):* have hired ithe sdb-contractors 2.1 ;am:aso'le�pr-oprletorOorpartner- Gsted(onitheattadhedsheet.<t �- ��Remodeling � I :ship;and have noOemployees IDhesesdb-oontractershave B. JEJ Demolition working ffonmeniany(capacity.. workers' comp insurance. 9.. JE Buildin :addition �[No workers'(comp. 5 � ( an intsurance l0_[]Eleatecalepars(oradeidione d its uequired;] offieers have(exerdisedtheir :3-l❑I 0�am:3lhomeownerOd6ing;Alwerk !rght(of(exemption per MGL IL!E 1'lumbingiepa7ws(or:additions myself i[Nowofkers'Oeomp. (c. 152,{§➢(()),:andwe have no T2j,0Roofirepairs nsurancemequired.]''t (employees.JNow.ot1ker§' 13,13(Other (comp.iinsuranceregdired:] *My applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub- ontracmrs and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 0e) / J CrI� S Policy#or Self-ins. Liccc.��#: U/ �U6 2 7 0 z4�!a—ok Expiration Date: Lip Job Site Address:/T - S ��Lem l City/State/Zip:�/ ( C�^� ./� 0�p Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. a advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insure c overage verification. I do hereby certify under th ai s and penalties of perjury that the information provided above is ue an orrect Si ature: Date: r 0 Phone#: fc['aZusemn7y. UoOnolnerrsteinOtliisrarea,RobeOeorrtp7etedbyrcityOo itownoffi 1 (City(Or Town: Berniit%JJicense# Issuing AnthoMy((,circle:one): I.Board(ofHea'lth 2.Building Department 3.(City. '(own(Clerk 4.Electrical Inspector S.Flumtiing Inspector A.(Other (Contact Berson: Phone.#; 05/08/2006 13:05 7815935928 DUFFV INS AGENCY PAGE 01 A-C-OR CERTIFICATE OF LIABILlrif INSURANCE 05/0E8/2005 PRODUCER (781)593-1200 FAX (781)593-7260 THIS CERTIFICATE IS ISSUED ASAMATTEROFINFORMATION Duffy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 317 Broadway HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Wyoma Square ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lynn, MA 01904 2602 INSURERS ArFORDING COVERAGE NAIL B m uRED Rektech Inc INSURER A: PiI rim Insurance Company 0045 196 Haynes Road INSURER Travelers Insurance Company 0056 Sudbury, MA 01776-1345 INSURER C. INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE US BELOW HAvE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTNRfHSTANDING ANY REOUIREAAEMr,TERM OR CONOMON OF ANY CONTRACTOR OTHER DOCUMENT WITH REZPCCT TO WHICH THIS rff?mFICATE MAT 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. IitR ADM cR TYPE OF INSURANCE POLICY NUMBER POLICY TRIE POLICY ERPIRKRON uNET4 GENERAL LIANLTY EACH OCCURRENCE E COMPERCIAL GENERAL LLAWUTY DAMAGE TO R84M E J CLAIMS MADE � OCCIIR N!D lXt Wpwm V�IeaV E PERSONALS ADV INJURY E GENERAL AGGREGATE E GENL AGGREGATE LIMIT APPLIES PER: PRODIJGTS-COMPOOPAW E PoucY D JECTCTf—1 Lot AUTONOBE.E UASRM PVC7194539 01/27/2006 01/27/2007 ppNBINED SINGLE LIHIT E ANY AUTO (Ea Arad) ALLOMIED AUTOS X UTOR I Oa ^I'bW�)�Y E SCHEDLltDA A ... 250,00 X HNEDAUTOS BODILY INJURY - — . X ND"VAIEDAUMS (pa-mddwQ E 500,0 PROPERTY DAMAGE E (FW-dden1> 250.000 GARAGE LImmy AUTO ONLY-EA ACrJDFNT S ANY AUTO EA ACC E OTHER THAN AUTO ONLY: AGG B l lxCEF:NMDREDA UADILm EAGNOCCVRRENCE E OCCUR F—ICLAIMSMADE AGGREGATE E E GEWCTIBLE E RETENTION E E WORKERS COMPENSATION AND 6KUB7402A34-3-06 04/08/2006 04/08/2007 X I 49TTATH= AI- E MPLOYERs•LUB1uTY E.L.EACHACCIDENT 8 100,000 6 ANY ETORIPARTN-eRIEXEGUTIVE OFyFN:ERMEERMEMBIUt EXCWOEV/ EI.INSEASE-EA EMPLOYE 8 10010 8P"IALPRCMSIONSww E.L.T45EASt-P UUY LMII E 5oO,OOO OTRER DESCRIP N OF OPERATIONS I LOCATIONS IVEHICLEGI EMOLUSIOMS AOOW BY EIIWRSEMENTI WECULL PROVxiIONS eneral contractor Subject to standard policy terms and cenditions ,CERTIFICATE HOLDER CANCELLATION SHOULD ANYOF THE AROVE NWRI13ED FONLTES BE CANCELLED BEFORE THE Rektech, Inc t"INATIOM DATE THERI201,THE ISSUING INSURFJfUWplII)'lWATwA DEAVOR TO MAIL 196 Haynes Rd O DAYS WRITTEN NOTICE TO THE GENTF CASudbury, MA 01776 FAILURE TD MAIL 9UCN NOrm B IM roSNYIINDY NTNEIHSURER, EMSOR III III IIII II III IIIIIIIIIIIIIIIII AU P T C ACORD 25(2001108) FAX: (978)745-3018 ©ACORD CtYOWION 19 a BOARD OF BUILDING REGULATIONS - License: CONSTRUCTION SUPERVISOR tti Number: CS 086465 Birthdate: 02/19/1955 Expires:,02/19/2007 Tr.no: 86465 Restricted: 00 STEPHENJ DEFRONZO 196 HAYNES RD - - � SUDBURY, MA 01776 Administrator - Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR _- Registration: 141434 i Expiration: 4/22/2008 Type: Private Corporation REKTECH, INC. �- STEPHEN DEFRONZO j 196 HAYNES RD. SUDBURY, MA 01776 __ Administrator� CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASH INGTON STREET, 3RD FLOOR SALEM, MA O1970 TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition of-Building-Permit# , all-debris-resulting-ftom the-construction-activity— - — governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, S 150A. The debris wil disposed of at: 41/ o GiJ Location of Facility Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant Firm Name, if any Address, City & State The above statute requires that debris from the demolition, renovation,rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S k 50A, and the building permits or licenses are to indicate the location of the facility.