42 MASON ST - BUILDING INSPECTION (2) �5 53 $/cis
Z' The Commonwealth of Massachusetts INSPE C71 J, iR l IES
Board of Building Regulations and Standards SALEbI
�t Massachusetts State Building Code, 780 CMR /ar0� 35
Building Permit Application To Construct, Repair, Renovate Or Demolish15
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D eApplied:
713uildingOtticial(Print Name). Signature � - � - , � Date
SECTION 1:SITE INFORMATION
. roperty Address: 1.2 Assessors Map&Parcel Numbers
y; M61 SrrA-' S/ _
I.I a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yantis Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.0.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal site disposal system ❑
I'ubiicl7� Private❑ al Check if es❑ p p y
SECTION'): PROPERTY OWNERSHIP,
2.1 Owner of Record:
lhme(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owne -Occupied ❑ 1 Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory 81dg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
�g.�rrva t7r�•v.S T SPLIL�-� -G ,�r.
SECTION 4: ESTIMATED CONSTRUCTIONCOSTS
Item Estimated Costs: Of ciul Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S P91her Fees: .S
•1. Mcchmtical (FIVAC) S List:
5, Mechanical (Fire S Total All Fees:S
Suppression)
/ Check No._Check Amount: Cash Amount:_
6. Twat Project Cost: S F� `�� p Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Li rse(CSL) � —G S73b'y�
' ��/_ „� License Number / Espi olio to
N me orrC(SSL� older List CSL'rype(see below)
rr-AC)/'Gs Type Description
No. and Street --
^ ^ Q /� U Unrestricted2 Fr(Buildings u el ing cu. IlJ
PeCI d r ,(/ { l2 R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
INS Window and Siding
SF Solid Fuel Burning Appliances
g1-1-5-35-23 1 Insulation
Telephone Email address D Demolition
5.2 Registered IlomFee improvement Contractor(IIIC)
7e�1 J/t-� HIC Registration umber pi
uti n Date
fC Cum :my ?'r fUC egistr nl N;une `� g 5 b
No. and Ircet / y Email address
�CC/Liv/� ✓i ��
Ci /Town,State ZZPIT Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M,G.L c. 152.g 25C(6)).
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Istuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN.
OWN ER'S AGENT OR CONTRACTTOOAR APPL/IIEES FOR BUILDING PERM1IIT
1,as Owner of the subject property,hereby authorize ` )�// C /7�
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nmne(Electronic Signature) I Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By enter' g nam elow, 1 hereby attest under the pains and penalties of perjury that all of the informa on
contain d in I i a lica' n is true and accurate to the best of my knowledge and understanding.
l
Print it r s o , u it cd r 's c, ignature) biti
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
o „ gran fund under LI.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
program r au ty P
Nv%vw.niass.,,ov!ocu Information on the Construction Supervisor License can be found at w%s %v.mass.gov/dvs
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) '^ "(including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Numbs of bathrooms Number of halt/baths
"fypeofhcatingsystem - Number of decks/porches
I'ype of cooling system Enclosed Open_
1. "foul Project Square Footage'may be substituted tur"Total Project Cost"
> a
CITY OF SALEM, MASSACHUSE M
BUILDING DEPARTMENT 120 WASHINGTON STREET,3'm FLOoR
TEL.(978)745-9595
KIMBERLEYDRISOOLL FAX(978)740-9846
MAYOR lHomAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERT"UII.DING 00hROSSIONER
r
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit#f 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 150A.
The debris will be transported by:
ill Orb J P NGc�yc.-fir/,l
(name of hauler)
The debris will be disposed of in:
( ,me of facility)
��6C r4 , w
(address f facility)
Signature :0fjjp4 ant
/h9�/�
Date
Q-1-Y OF SiULE.Nfll NL"1SSACHf;SETTS
. BUILDING DEPART?IE.\T
r / I to FLOOR 1' O STREET, 3
° TEL (978) 745-9595
FLY(978) 740-9846
KI NIBERL F-Y DRISCOLL A-%YOR THonrAs ST.PIFRRH
5
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LNIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please/Print Leeibly
Name mess Orgyairatioro lmlividuaq: �_ ✓/ /� ( G 2�P�t /C X
Address:
City/slatcaip:�P�wr /1��'0 ��Phone#: M ,��' 22CZ
Are you an employer:'Check the appropriate box: Type of project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
r.neployees(full and/or part-time)." have hired the gala-Cant actoral
2. lam a soic proprietor or partner- listed on the attached sheet. t �• ❑Remodeling
;hip and have no employees These sub-contractors have H. ❑ Demolition
working for me in any capacity. workers'comp.insurance. y. ❑Building addition
(No worken camp. insurance S. ❑ We are a corporation and its
officers have exercised their 10.❑Electrical repairs or additions
acquired.)
).❑ 1 ant a homeowner doing all work -right of exemption per MOIL I I.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.) �.:, z employees. [No workers' 13.0 Othcr
• comp.insurance required.)
-Any upplicunl our dwcks bur rl-must also roll uul the section b,dow,showing their worken'compensation policy inrrnmatlon.
'l lomeuwrwn who submit this atAtlnvil indicating they art doing all work and then him outride roranacte most mhmil a new affidavit indicating such.
<'�nomctun that chsck this bus must attached an addiiiurvrl short showing the name of the subRoninclon and their workers,comp,policy larom abort.
l unt un errrpluyer Ilrat it pruviding lvorkers'compensation insuruneefor my employees lfelow lr dis policy undjob rile
inforrnulion.
Insurance Company Name:
Policy it or Sclf-hm Lie. it: Expiration-Date:
Job Site Address: City/Stan:/Zip:
Attach a copy of the worlten'compensation pulley declaration page(showing the pollcy.numbor and explradon,date).
Failure to secure covenige as required under Section 2SA of NIGL e. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to S250A0 a day against the violator. Ile advised that a copy of lhis stalement may be furwarded to the 011ice of ,
In vesl igalions o 11 Ile DIA A
r insurance coverage verification. -
/do hereby ce r y a e h puinr surd penoltles of per'ary that Ilse h funnurion provide ubuv is true c•arrer4
Ci�L t c I
C 7 Date:
Phone at 3 -- r 6- If
Of/iris!we turfy. no not rvriu in this area,to be curuylrfaJ by airy ur mien n/JleiuL
I
CitynrTuwnt ----
Issuing Aulhorily(circle one):
I. Board of llcallh 2. Iludiling Department tl fiiyawm n Clerk J. Electrical luspcclor 5. Plnmbing Inspector
6. Other
C•nnuct Person: Phone :t _
i
a
KindredrHospitals www.kindredhospitals.com
01-20-'15 15:30 FROM-Phil Richard Ins. 1-978-774-1318 T-685' P0002/0002 F-280
OATB(MMIOCKYYYI
.acc?rrry CERTIFICATE OF LIABILITY INSURANCE � 01/2012 0 1 5
THIS CERTIRCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(B), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,Certain policies may rsqu Ire an endorsement. A stetemsnt on this Certificate does not confer rights to the
eartMleate holder In lieu of such endorseme s.
PRODUCER CONTACT M B Rewson, ISR
Phil Richard Insurance,Inc. NAME:
27 Garden Street PHOIMI (978)774.4339 x113 1AICPAX IN.,(978)774-1318
Unit 15 XAMS& Inery®phliMchmdnsurance.com
Danvers,MA01Q23 INSUR! AFFORDINGCOVERAO! NMC0
INSURER^: Arbelle Protection 41300
INSURED Robert C.Pica USA Bob-Built Carpentry INSURER 8: Safety Insurance CO 39454
11 George Rd.
Peabody,MA 01000 ReuRERD:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 0 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 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 ANDCONDITIONS OF SUCH POLICIES.LIMITSSHOWN MAYHAVE BEEN REDUCED BYPAID CLAIMS.
Ma Or INOURANOS POUMORP
POUCY NUMSER LIMITO
A OINERAL LIABILITY $500035100 09/25/2014 OWM2015 EAOH OOOURRENOE $ 1,000,000
COMMERCIAL GENERAL LIABILITY 100,000
PREMISES(EB xwmma) $
CLAIMS.MAOE M OCCUR MEO EXP A MO ~ $ 5,000
PERSONAL AAOV INJURY $ 1,000,000
GENERALAGOREOATE $ 2,000,000
OEML AOOREOAT LIT APPLIES PER: PRODUCTS-COMPI PAO $ 2,000,000
FOLICY F 71 L00 $
B AUTOMOBILE LwSLITT 0200240 00/05/2014 08/0512015 OMB
LIMIT $
ANYAUTO BODILY INJURY(PapWepn) $ 250,000
ALL USULEDU TC ATO BODILY INJURY(PW SWUM $ 500.000
NON-OWNED PROPE TYDAMAOE $
HIRED AUTOS AUTOS fPwwcidmtl
$
UMBRELLA WB OCCUR EACH OCCURRENCE $
EXCESSLM CLAIMBMADE AOORECATE $
DELI F7 NET TION B $
WORKERS COMPENSATION I WOSTATU- DEAN
AND EMPLOnFIV UABIMTYLIMIT
ANY PROPR1G70RPARTNEMXECUTVE YI1 E.L.EACH ACCIDENT $
(MFEEd1m"1yln NHI E%CLUDEG7 Lf NIA
E.L.DISEASE.Eq EMPLOYEE $
IDE6 rrye$'d RIPdeeCTIONlba UnOFWr
OPERATIONS below E.L,DISEASE POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONSIVIM CUES".h ACORO 101,Aded..i Ren .SahetlWe,Ifman epce Isnwl,.d)
CERTIFICATE HOLDER CANCELLATION
Fax*( 78)741.7030
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Steve Haley THE EKPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
45 Mason St ACCORDANCE WITH THE POLICY PROVISIONS.
Salem,MA 01970
AUTHORMO RMPPJIMNTATIVB �
01080.2010 ACORD CORPORATION. All rights reserved.
ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs &Business Regulation - Mass.Gov Page l of l
The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR)
Consumer Affairs and Business Regulation
Home Consumer Rights and Resources Home Improvement Contracting
Home Improvement Contractor Registration Lookup
To search by registration number, enter the registration number in the textbox below and click the
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REGISTRANT RESPONSIBLE REGISTRATION ADDRESS EXPIRATION STATUS
NAME INDIVIDUAL NUMBER DATE
http://services.oca.state.ma,us/hic/licenseelist.aspx 1/19/2015
Details Page l of 1
Licensee Details
Demographic Information
Full Name: ROBERT C PIZA
Gender:
Owner Name:
License Address Information
ddress:
ddress 2:
City: Peabody
State: MA
Zipcode: 01960
Country: United States
License Information
License No: CS-053841 License Type: Construction Supervisor
Profession: Building Licenses Date of Last Renewal 11/21/2013z„,,,,�,
Issue Date: ExpiratiorFDate :t 1 ;5,11 112015 tw, z"
License Status: Active .. Today's Date. 1/1 912 0 1 5
Secondary License:
Doing Business As:
Status Change: License Renewal'
Prerequisite Information
No.Prerequisite Information
Discipline
No Disci Iine Information
Documentum
http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=242800& 1/19/2015