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60 MASON ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts (� yam►, p Board of Building Regulations and Standards CITY l Massachusetts State Building Code, 780 CMR, T°edition OFSALRevised Ja uary Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008 One-or 7hvo-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: (I? Signature: Irma Building Commissioner/Inspector bf Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers L 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 11) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.ao,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Qw ner of Record: / Mo r ) , 9 f.,-e_ fll o S Ax 5 Name(Print) r Address for Service: ,u-c— yam,— Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Workt: 5 4—r 'r• a ff � �. SECTION J: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S I. Building Permit Fee:S Indicate how fee is determined: �. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S ` Check No._Check Amount: Cash Amount:_ 6.Total Project Cost: S /49 00 j) ❑Paid in Full 0 Outstanding Balance Due: 1 r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) Is-?9-? ) \. A /Z E( ` W- 0-- ,^.mot License Number Expiration Date Nam CSH I Iu1dgr List CSL Type(see below) T Descri lion Addres u Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Signature M Mason Only Q7 T 7 �/�-g RC Residential Roofing Covering relephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) l�+J f c.--�c—+h�A 'ac L. GL L HIC Company Name or HIC Registrant Name Registration Number Address / �r Expiration Date Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 Issuance of the building permit. Signed Affidavit Attached? Yes..........❑ No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I &-yl I c[,-t- /" 5 , as Owner of the subject property hereby authorize T Lr,V\C W. nab to act on my behalf,in all matters relative to work authorized by this building permit application. SianatunFof Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATIO7herebydeclare as Owner or Authorized Athat the statements and information on the foregoing application are true and accurate,to the best behalf. c,) n Print Name ' 6 Signature of Owner or Authorized Date (Signed under the Rains and penalties of perjury) 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&of have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11016 and I IO.RS,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" EIG Fax Server 4/6/2010 3 : 15 : 24 PM PAGE 2/003 Fax Server i ACOR CERTIFICATE OF LIABILITY INSURANCE oaio6/2010 PRODUCER (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 West Central Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Natick, MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURED Atlantic Weatherization LLC INSURERA Arbella Protection Ins. Co. 41360 61 Rear Jefferson Avenue INSURERS: Arbella Indemnity Ins Co. 10017 Salem, MA 01970 NSURER c: INSURER D: INSURER E: COVERAGES 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 AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERALUABLRr 8500042816 03/20/2010 03/20/2011 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGETORENTED $ SO.DD CLAIMSMADE OCCUR MED EXP(Any we Person) $ 5,00 A PERSONAL dADVINJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 PCLICV X JE6T LOG AUTOMOBILEUABILRY 93827400003 03/20/2010 03/20/2011 COMEINEDSINGLELIMIT MY AUTO (Ea acddi $ 1,000,00 ALL OWNED AUTOS BODILY INJURY $ X 5CHEDULEC AUTOS (Per person) B X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC $ AUTO ONLY'. AGG $ EXCESSMMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMSMADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 9111820309 03/20/2010 03/20/2011 X WCsrATU- CTH- EMPLOYERS'UASILMY E.L.EACH ACCIDENT $ 500,00 A' ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERNEMSER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 500,00 (SPECIAL ROVISONS*.I. E.L.DISEASE-POLICY LIMIT $ 500,00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATEO CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, CITY OF SALEM BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 120 WASHINGTON STREET OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. SALEM, MA AUTHORIZED REPRESENTATIVE RosemaryFul halry/PMA ACORD 25(2001108) ©ACORD CORPORATION 1988 �A CITY OF SALEM PUBLIC PROPRERTY �• DEPARTMENT .I lli:' MI I1 "Nlv 1'l1 I.Q%,.\M 11]t..•IV sip kcr 9 5.11 I\t.St.Ni\t I❑ 4 1 trl:v,n.74s•ts9s •1'\x:97Sa+sys4fi Construction Debris Disposal Aft7davit (required fur all demolition and renuvatiun work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 DebDebris, and the provisions of MGL c 40,S 54; Building Permit q is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will/be transported by: rr I notrte of hauler) 1'he debris will be disposed of in 1 (nartts ut act ny) Flo /�o��- '�� � • luddma of 11 cilityl �Illnalure of lwrmit applicant date Icb bdl S• CITY OF S.U.&M9 ANLkssmmsEm BL•IIDLNG DEP.%xTNxNT 120 W.lismINGTON Man. )te FLOOR T L (978) 745-9595 F.%X(9718) 740.964 KI,,MER`IEY DRJSCOIL ,rarsYOR � bW O ST.PneRRs DIRWMR OF PC lLIC PROPERTY/gC RDNG CONMOSSION ER Workers' Compensatlon Insurance Affidavit: Builders/Contractors/ElectrlelansiPlumbers %opllcant Information \ ` Please Prf'ntlLeeiblr VaRgioujl c%&Ortamrationlndiv,dual). Ji °� c.._ WL'o.'t�V / 7-0-`Ct0 -n �•�-C- Address: Col .fie FP gJ �— Cily/StatdZip: /Y7,9 . 619 20 Phone M. 9 7 % — Are yo eo employer'Chock the a reprlote ben: Type of project(required): I.L am a.mployer with a a. 1 am a general contractor and 1 L ❑Now constructiom employee(roll and/or part-tims).e have hired the sttlt.carowa re 2.❑ 1 am a sole proprietor tar partner- listed an tIr attached sheet t 7. Remodeling .hip and have no employee Theas sttbeomreteon have N. Q Demolition working fa me in any capacity. workers'comp insurance. 9. Offuillding addition (No workers'comp insurance S. ❑ We ave a corporation and its nquirtxL] otlleas have axaoised their 10.❑Eloctrical repairs or additiotn ).❑ 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or addMons myself.(No workers'comp. C. 152.1110).and we have no 12.0 Roof repairs insurance requited.]► .mployees.LNe workers' comp insunnceregaboi.j 1313 Other -Any appliC M ihn dwrha boa tl rotes airs 110 uY rhr tstim tales thseing elide wahw'cepnttdda palkl infivmake. 'i I.,wwwwnan who sub"etk aAldwie imilk wing they as doino II work ad the like attrrido Cantatas mom slink anew alOdwk indiction wei :C,wm-wm the rhak Ilia beet mete aaaelnd aw addtriael daa Jawing tat iron dran al►pafaWe tad thee wahae'rnq•peke iwfanreaa. /uta ore tarpkyer rhr bPred//nR rwrAtn'rowpnsulen lnsnrrwnjN wh tarployeat Oehrr/s rAe pd/gr ew//a1 s/er /nforarW(tta In.urance Company Name:A f-(7(tJ 1 0, Policy M or Self ins. Lie.M - M q-."b 3° C� Expiration pate; - lob Site Address: City/StawZip:d44a t7 l Ci ) 6 Attack a copy of the workers'compeasauss PWkY dwimlien pap(sbdwing tks polky number and expfrados daft). Failure to secure covanip L required under Scclion 2SA of MOL e. 152 can lead to the imposition of criminal penalties ors nine up to S 1.500.00 and/or one-year imprimnmem,as well as civil penalties is the form of a STOP WORK ORDER and a titre of up to S250.00 a day against the violator. Ile advital theta copy of this stalentcrn may be forwarded to the OIYIce of Invc,ttgaliurui ut'dta MA for insurance covcraee writieatiom /de hereby rrrtijy an the/poains and ytna/Ila ejper/ury that the injorwallow provided ubove is true and varreea tire_ l-!//� C`J\ Date: P. orzc,r: q ) )i % 7 `J;-(W 22 OJJ7eiel uat d,t/ya Oa n tN write in thin area,to be.utnpbtd by city of fawn,t//h•il d i City or ruwn: PcrmiN.lccnse r__. _ _ Ivtuins.1luthurity(circle unt)! I. Ituard u(Iltallh 1. Ruilding Departmval J. Ciiytrowa Clerk A. Electrical Iltcpeclor 5. Plumbing Inspector 6. other Phone e: �.. Board of Building Rcgtdations and Standards i Construction Supervisor License i License: CS 87977 Restricted to: 00 ERIC W PALM 3 HILTON ST SALEM, MA 01910 i Expiration: 412312012 ('onuni.�sioner Tr#: 22214 ✓1. �omvmaouoaal!! o� �amac%uaelta Office of Consumer Affairs&Business Regulation . HOME IMPRQiU 42089 CONTRACTOR Registratiol>;' y42089 ExpIratljor� t422012 TrM 292T74 TypevL,;' ahi6ty'C rpor ATLANTIC WEA1fF�l i 9 4 .C. ERIC PALM ` 61R JEFFERSON(jNEy w: SALEM;Mq 01970. "'�._�%' Undersecretary