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4 MARTIN LN - BUILDING INSPECTION (2) �2f A lt%S5,n( � lvS � s( c� t-I The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Budding Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling O (This Section For Official Use Only): 09 Building Permit Number: Date Applied: Budding Official: 'Z W SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) No.and Street City/Town Zip Code Name of Building(if applicable) �> SECTION 2•PROPOSED WORK. ` Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction docu nents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ F B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R; Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ IIA ❑ IIB ❑ 1 IIIA ❑ IHB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone PZone Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outsidIndicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zor on site system❑ permit is enclosed ❑ Railroad right-of-way: ds to Air Navigation: ;\I Vli.rinConto,iat nt la•.u.t,,i r:_ ss; Not Applicable ❑ ithin airport approach area? Is [heir review mmpleteJ? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name Address of P erty Owner - Name(Print) - and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip toad on the property owner's behalf, in all matters relative to work authorized by this building permit application. SECTION-10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If budding is less than 35,000 cu.ft.of enclosed-space.and/or not under Construction Control then check here and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control. Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:womF.I:s'COAIPIiNSA'I ION INSURANCE AFFIDAVIT M.G.C.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No 0 SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE: Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 1.Mechanical (HVAC) $ Note:Nlininmm fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ �S (/� (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this ❑p lication is true and accurate to t est o my knm �dge and understanding. Please rint an/�j/st� ��a_nr�e Title �7Tele hone No. Date pI /rCrN 114 /"�P �tGlf r'y u'P p at�rrU Street Address City/Town State Zip g Aunicipal Inspector to fill out this section upon application approval: " /�0 Name Date aQTY OF SALEM, MASSACHUSE TTS BUILDING DEPARTMENT 120 WASHINGTONSTREET,3"OFLOOR TEL. (978)745-9595 KIMBERLEYDRISCOLL FAX(978)740-9846 MAYOR THOMAS ST.PIERRE DIRECTOR OP PUBLIC PROPERTY/BUILDING COhMSSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date lD -T41-1 C / Job Location I A,el-JAJ Lgc10 S[etyr Al p/F76 Homeowner Address Z/ / 1w",-ri)U Z4,t, ��`le w7 MA Q/Q70 Present Mailing Address q /�leT/"j 4"' �/, -k4 Af 01`Z7 v s.• The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire that does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one=or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official,on a form acceptable to the Building Official, that he/she be responsible for all such work performed under the Building Permit. The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned"homeowner"certifies that he/she understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPEC OR 0W OF SALEA MMAMSEM BcMDMD$MAIMEW 120 W vSDJWT,YORO a 7kL(478)745-9595. BIIwaERIEYDRiSOCLL FAA Alo-9846 MAYOR 7Yi�ssSxP�RRe Dnmc� s:�tcuc /suunn OMaMMM Construction Debris Disposa/Affidavit (required for all demolition and,.renovation work) In accordance with the sixth edition of the State Building Code, 780 CMI, Section 111.5 Debris; and the provisions of MGL a10, S 54; Building Permit 8 is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S lwA. The debris will be transported by. (name of hauler) The debris will be disposed of in: (name of facility) 04 (address of facility) Signature of applicant Date The Commonweakh of Massachusetts Deparbnent oflndustrialAccidents (2(0 1/7 I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia II Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FH.ED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly r Nance(Busmess/Organization4ndividual): 1 _1�J)' LAO'�'I '1� —xz) Address:_ �. City/State/Zip: 4]bVJUk-!-r1L M Phone#: 6 7 Are you an employer?Check the appropriate box: F project(required): ]. I am a employer with employee.,(full and/or time ew construction 2. Ism a sole proprietor or partnership and be,no employees working forme in y capacity.[No workers'comp.insurance requited.] emodeling 3.❑I ens a homeowner doing all work myself.[No workers'camp.immance required.)I molition 4. 1 am a homeowner and will be ilding addition ❑ hiring wntractos m conduct eU work o my property. I will ensure that all contractors either have workers'compensation insurance or are sole proprietors;with no employees. 11.0ctrical repairs or additions nnbing repairs or additions 5.❑I ens a general contactor and I have hoed the sub.contactors listed on the attached Amu. These sub-contractars have employees and have work,,'comp,insmmca.t of repairs 6.0 we are a corporation am its officers have exercised their tight of exemption per MGL c er 15Z§I(4),and we have an employees.[No workers'comp.ft ce requoad.] *Any applicant that checks box#1 must also fill am the section below showing than workers'compausabou policy fnfmmation. r Homeowner who submit this affidavit indicating they are doing all work and than hire outside contactors most submit a new affidavit a indicating tContrumrs that check this box must attached an additirmal sheet showing the tameueb.of sub-conmxators and state whether m not those entities have erployees. If the sub< tactors have employees,they most provide them werksn'comp.policym®ber. I am an employer,that is providing workers'compensation insurance for my employees. Below is thepolicy andjob site Information. Insurance Company Name: Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce the p a/nJ��penahi ofperjury that the information provided above is true and correct Si ature: s4 CAI_+� ate: l Z'.' � Phone Ofticta!use only. Do not write in this area,to be completed by city or town o,Q"uurl City or Town: Permlt/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person• 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 an 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,MGL 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)name(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 date the affidavit. The affidavit 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 the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be 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. Please be sure to fill in the permit/license 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 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.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ^coRv® CERTIFICATE OF LIABILITY INSURANCE °"'�`°`D°°"Y"' 7 11 16 THIS CERTIFICATE IN ISSUED AS A MATTER OF INFORMATION ONLY AND.CONFERS NO RIGHTS UPON THE CERnFICATE HOLDER THIS CERTIFICATE DOES NOT AFFOMMAIMLY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holier is an ADDITIONAL INSURED,the pol(cy(es) must be endorsed. If SUBROGATION IS WAIVED,subject to the tends and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights ts the Certificate holder 11 Preu of such andorsement(s). PRODUCER -- ��! T David J Donaghue Ins Agency PION' Fax N : 345 Hancock Street Ks: Quincy, MA 02171 INSURE AFFORDING COVERAGE NAICP INSURER A:Travelers Insurance OsIAR® INSURER B: . Brad Watkins INSURERC: 9 Queen Street INSURER D: Dorchester, MA 02122 INSUREt E: INSUREt F• COVERAGES CERTIFICATE NUMBER, REVISION NUMBER: THIS IS TO CERTIFY THAT 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 CERTEFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERENI IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN_ MAY HAVE BEEN REDUCED BY PAID CLAM L OG an CE TR TYPEOFURAN POLICY NUI®Et ADDL SUER PNUCY ETT 101111) YWY1 U/A7S— — A GMERALUAINUrY 2680934N218 8/24/15 8124/16 EACH OCCURRENCE $ 1,000,000 X CO MERCIALGENEFALLVIB[UTY DANAGETO FS RENTEDwl S CLAOIS-MADE Fx—]OCCUR NED EKP("am perem) $ 5 000 - PERSONAL&ADVINNRY 5 GENERAL AGGREGATE S 2.000.000 GE►LAGGREGATE LMITAPPLES PER PROOUCrS-COMPATP AGO $ 1.000.000 POLICY PRO- LOG S AUTONOBILELIABurr C MBINEU N ELMIT $ . ANYAUID BODILY INJURY(Per person) $ ALLOWED SCHEDULED BODILY INJURY(Per adtlerd) $ AUTOS N�ON-0WNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS (per eoadam S UMBRELLALIAS OCCUR SUCH OCCURRENCE $ EXCESS LIRE CLAMS.NAI)E AGGREGATE $ DID RErBfnONS S WORKERS COMPENSATION VYC STATU- OTH- AND EAPLOYIRVLIABILITY YIN ANY RROPRIER)PWARTNERIE)EfanNE ---I NIA ELEACHACODEW OFFXERI EMBER EKM DEDY da - _ fdartory in NMI EL DISEASE-EA EMPLOY $ H gas deurft under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LMIT I$ DESCR[FrnONOFOPERAMMILOCA7WNSIVEBCIS (AMCh ACORD101.AAErwal Romdo Sdmdde.Brmrespemrsnq md) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Kevin Sweeney ACCORDANCE WITH THE POLICY PROVISIONS. 4 Martin Lane AUTNOROM REPRESENTATIVE _ Harold Donaghue ®1988-2010 ACORD CORPORATION. AI rights reserved. ACORD 25(2010f05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E-Nail: - : Massachusetts Department of Public Safety �= Board of Building Regulations and Standards License: CS-093642 e Construction Supervisor BRAD L WATKINS 9 QUEEN ST "`1, _ - DORCHESTER MA 02122 yt'f" - (-�J„ uc _ Expiration: Commissioner 0912612677 J �i�� -=_. - V/se-(OanrntaruaN¢[(/z o��NaGtmJ¢CGt 'Office of Consumer Affairs&Bndness Regulation--_i, #; -- - HO#rtE IMPiRQVEMENT CONTRACTOR - "Registra6o`n -176782 Type: '' "Expvatlon-s 9/25/2017 Individual ; - -:BRA© - r ',BRAD,WATKINS . 9 QUEEN'ST „ : ---- DORCHESTER-MA OZy 22-" Uuderseeretary F. us `•This is to .' has slt as[uNY coln"e da.3o-Iwtx t x y=TCauang 6(sa in IN a ,d= a a & k tF tTre LOT 76 j 132,00' .� LOT 212 AREA = 10,560 t S.F. LOT 213 LOT 211 b deck 0 0 o 0 Co00 2 story dwelling #4 30't 132.00' MARTIN LANE REFERENCE: - THIS PLOT PLAN WAS NOT MADE FROM DEED: CERTIFICATE 85605 AN INSTRUMENT SURVEY AND IS FOR PLAN: LCC # 856-13 THE PURPOSES OF THE BANK ONLY. TO: RELIANT MORTGAGE COMPANY, LLC UNDER NO CIRCUMSTANCES ARE OFFSETS TO BE USED FOR ESTABLISHMENT OF FENCES, WALLS, HEDGES, ETC. 1 CERTIFY THAT THE BUILDING SHOWN HEREON IS LOCATED ON THE GROUND AS SHOWN AND IT CONFORMS TO THE HORIZONTAL DIMENSIONAL REGULATIONS MORTGAGE INSPECTION PLAN OF THE ZONING BYLAWS OF THE CITY OF SALEM LOCATED AT AT THE TIME OF CONSTRUCTION OR ARE PROTECTED UNDER GENERAL LAWS- CHAPTER 40A SECTION 7. 4 MARTIN LANE I ALSO CERTIFY THAT THE DWELLING SHOWN IS NOT SALEM LOCATED WITHIN A FLOOD HAZARD ZONE AS t oo`d- ; %'� -: PREPARED FOR DELINEATED ON THE MAP OF COMMUNITY #250102 T f G;11 ''';';`.= ALYSSA M. SWEENEY ..SALEM MA. EFFECTIVE 7/3/2012 Ya/ t.. ,r KEVIN M. SWEENEY BY THE FEDERAL EMERGE14CYY MANAGEMENT AGENCY � ! NORTH SHORE SURVEY CORP 1' = 30' JANUARY 11, 2013 roa �rq > t, // c r .. 1' ro� 14 BROWN STREET . DA /REG. PROFESSIONAL LAND SURVEYOR ' "`, :n,;p B>;`a' SALEM. MA. 01970 6 978-744-4800 111 3851 N � t - i oN- _ I t U VIP. , q ��.�•� Q� Xj ZLV� ` , 7/20/2016 WebPro ,24 http://salem.patri otproperb e .com/PiclureUew.asp.IMG=sketch/22000/832001.jpg 1/1