38 MEMORIAL DR - BUILDING INSPECTION (3) . . -70
n Sri £L 'a
lV ' The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and St;Mfyr V 25 P 12. SALEM
Massachusetts State Building Code,780 CM evised alar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish it
One-or Two-Family Dwelling
This Section For Official Use Only
10 Building Permit Number: Applied:
ry , Building OlTrcial(Print Name). Signal , - Date
Lf J SECTION I:SITE INFORMATION'
IL— ,.I Property Address: 1.2 Assessors Map&Parcel Number -
3? �7�,�r��,6[ D/7.
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
s � P 9,
"Coning District Pro osed Use Lot Area(sit 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Reyuirod Provided) Required Provided Required Provided
1.6 Water Supply:(M.G.L c.ya,§Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesM
SECTION 2: PROPERTY OWNERSHIP!':
2.I�QweofRgc "r
y7 0R "0* 7U
e¢ uih�,q S s� P Yr
t�shm�e(Print�)/ City,Stale,ZIP
TA,
- ap ///pmi ayt..� C �dz., S'7(f -`I Y Serf 7 y7
No and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building P4 Owner-Occupied X Repairs(s) Altemtion(s) ❑j Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': S-' r�I
SECTION-1: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building $ l� !�ree'o- I. Building Permit Fee:S Indicate how fee is determined:
❑Standard CitytTown Application Fee
2.Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) S List:
5. Mechanic d (Fire S Total All Fees:S
Su «ssiml)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: r y y o I ❑Paid in Full ❑Outstanding Balance Due:
,1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supetvisor.Lic nse(CSL) C2 900,5>
//ray License Number Expiration Date
Name of CSL flulder // List CSL'rype(see below) /L• /0/S
Type - - Description
No. :md Street
U Unrestricted(Buildings tip-to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
Cityll'os State,ZlP M Masonry
�/Y�1f RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone - Email address D Demolition
5.2 Re istered//Home Improvement Contractor(HIC)
`rclDm 'ems HIC Registration Number Expiration Date
11IC2nnp�N i g R gtT at Name
N0.and Street •3 �) 7 7 ��S-f+ Email address
o =,,,, � or9 f 7Y-
City/Town,State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.G c.ISL¢23C(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 .........AMc,, No........... O
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED.W HEN'
OWNER'S AGENT OR CONTRACT,,O��R APPLIES FOR BUILDING PERMIT1,,as Owner of the subject property,hereby authorize e4,,f
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT.-DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best o my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Flee nic Signature) Date
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
program or guaranty fund under I.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
www mas;eov:'oca Information on the Construction Supervisor License can be found at www.mass.aov:'dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basemenUattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
rypeof cooling system Enclose) Open
3. "total Project Square Footage'may be substituted for"'fur.) Project Cost"
I ,
Q'TYOFSALEA MASSAQMn
Brno�l7eraa>�rr
12DWA9AN&7UNSUWgJWRM
Hi1�BiRiBY FAr MD-Xff
MAYOR DMUS7JWW
Dmummca►runrc /BULOMaaeSUSDaea
Construction Debris DisposidAffjdwit
(required forall demolition andrenovation work)
In accordance**h the skm edition of the stale Bull W Code. 780 a^ Secdon 111.5 Debriy
and the provisions of MGL o90,S 54; tioNdhtg Pemdt it is issued wfih the
condign that the debris resulthtg from this work sha0 be disposed of in a properly licensed
waste deposit fadity as defined by A4GL c 311,S 150A,
The debris will be transported by:
(name of hauler)
The debris will be disposed of In:
//(name of fadlity)
�(OGGPaf'7`P✓1
(address of facility)
Signature of applicant
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govldia
Workers'Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organizatiioovn Name: /�/�i� o�m t� �• / y
Address: ✓� L- S/—
City/State/Zip:/ l ,yV 5 �/t d/9�9 Phone#: 0-2- S-f
Are you an employer?Check the appropriate box: Business Type(required):
L❑ I am a employer with employees(full and/ 5. ❑Retail
or part-time).* 6. ❑RestaurantBar/EatingEstablishment
2.�l am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] S. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑ Manufacturing
no employees. [No workers'comp. insurance required]* I1.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers, f
with no employees. [No workers' comp.insurance req.] 12.❑ (/Other r 4% z s
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation polic information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy information.
Insurance Company Name: /G/1 C
Insurer's Address: S'< (fo
City/State/Zip: 441 v t,izf- 49Z U/ram 7
Policy#or Self-ins.Lie.#1�7ee_ Z(o0.7o,2G;Z1j- LG/G A7 Expiration Date: C a 17
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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penaltiessoof perjury that the information provided above is true and correct.
Sianature _���. vrt-,�� � ��-Z Date
Phone#: 9 76F52 ;>Y—O,;L 5719
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 your insurance company's name,address and phone number along with a certificate 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). 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
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax#617-727-7749
www.mass.gov/dia
Fonn Revised 02-23-15
®[b �ol0np �rriY�er�, �Sr�t.
s 13 SEWALL STREET
PEABODY, MA 01960
�,,,R <„r•' OFFICE: 978.922-6120
SPECIFICATION SHEET 7 -
Home Phone: . 1.1. 7 S. . .. ..
Owners Nance . . . . . . . Work Phon : . . .'.. . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . !� . . . City v State !1. . . Zip . . . . . . . . .
JobAddress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SIDING
1.Siding Tipe .7. . . . . . . . . Color. . ? .' ' . . . . .
2.Area to be done.lain House . Breezewav . . . . .. . . . . . Garage . . . Additions . . . . .
. . . . . . . .
Dormers. ..�. / . . . . . . . . . . Oilier . . . . . . . . . . . . . .L. . . . . . .
3.Insulation . Q. . . � .�. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Trim cover er}e:' ❑No Color. . . . . . . . .. Trim to be done: Soffits. Fascia.
Rakes . . . . . Ceilings . y� . . . . . . .
4'1
5. Window and Door Frames • • •V
6.Gutters and spouts Cr}Y¢S ❑Nn Use heavy gau eamless . . . . . . • • • Colora� . . .
. . . . . . . . . .
7.Shutters QYe�s ❑No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. WSndowsand Doors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . .
ROOFING
Material Type . . . . . . . . . . . olor. . . . . . . . . . . . . . . . . . . . . . . .
Areasto be done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . .
Remove existing shingles ❑ es ❑No 15 lb.felt. . . . . . . . :. . . . . . . . . . . . . . Metal E ing . . . . . . . . . . . . . . . . . . . . . . . . . .
Chimney at vents tc. . . . . . . . . . . . . . . . l7
. . . . . . .
�`
NOTES. .! ��
. . .� �� . .� • � C . .fir,-2fe . ..�• � -�r�•u' �%�'L�tt-r�-��i
. . . . ✓. . . . . . . . . . .
. . . . . . . . . . .
. . . . . . . . . . . .. . . . . . . .✓. . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. .
ol
/ C, $. . . ? f.0. ,'.Deposit .f K/il y7
Material and labor to cost$.r.Q .j. J. .LIO. . . . . . . . . . . . . . . .payable as follows: $. . . . . . . . . . . . .lst Installment
DO NOT SIGN THIS DOCUMENT IF THERE ARE ANY BLANK SPACES. $. . .'. . . . . .2nd Installment
$. / //. 0 aO �.Bnlance at completion
Contractor will do all said svork in a goer!workmanship manes You may cancel this agreement if it has Seen coasurnniated Inl a parrs therein ar a place
other that an address n/'the seller, which nay be his wain office or brunch thereof,pravided you nonfv the seller in writing at his main office or branch
!n•ontinan,mail posted, by telegram sent or by delisers•,not later than midnight of the third business Aar following the signing of this agreement.
a'grer'eement. l
IN WITNESS EREOF the parties n•e hereunto signed their names this. . . . . . . .,1..,,]. . . . . . . . .dip . .
Areepred: r 2 Signer...,. .s:�l. . . . . . . . . . . . . . . . . . . . . . . . . . .
® Signed Ia C010rip 3511I[5�rs, 111t. O. . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .
Owner
Per. . . . . . . . . . . .
4 .1 . . . . .
Represew tine Authorized Re
Strikes. labor disputes. inclement weather. or material supplier delays resulting to work stoppage are hesond the control of the compam.
THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFUKMA I IUN ONLT ANU CUNFEK3 NU KR01IJ UI•vN tric �cm nrl�AIC TIULUCK. Inw
CERTIFICATE DOES NOT AFFIRMATIVELY 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 holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsements.
PRODUCER CONTACT NAME: Dan Hurley
)an Hurleyy Insurance Agency PHONE FAX
)hestnut Green,Suite 24 Fax:978-777-3306 ANC-No E,11.978-777-93 No,978-777.3306
Seven Federal Street EMAIL s:dan@hurleyinsurartce.com
)anvers, MA 01923-3620
)aniel J Hurley INSURER S)AFFORDING COVERAGEI NAICk
INSURERA:AIM Mutual Ins.Co.
INSURED Kiley Brothers Construction - INsuRERe:Preferred Mutual �115024
Bartholomew Kiley DBA INSURERC:
56 Conant Street
Danvers,MA 01923 INSURER D:
INSURER E:
INSURER 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE rA�Slle-R MMIODM'YVLICY EFF MMIDDI YXYY LIMITS
POLICY NUMBER
GENERAL LIABRfTY EACH OCCURRENCE $ 300,00
DAMAGE TO RENTED
B ��� COMMERCIAL GENERAL LIABILITY BOP0100720147 110/16/2016 10/16/2017 PREMISES(Ea occurtence) $ 100,00
I CLAIMS-MADE E OCCUR ME EXP(Any one person) $ 10,00
PERSONAL$ADV INJURY $ 300,00
GENERAL AGGREGATE $ 600,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 600,00
. X � PRO- LOC 1 I 1 $
1 � POLICY
I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO BODILY INJURY(Per person) Is
ALLOWNED SCHEDULED ! BODILY INJURY(Per accident) $
L AUTOS AUTOS
NON-OWNED I I PROPERTY DAMAGE $F HIRED AUTOS [AUTOS j Peraccitlent
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIM$-MADE AGGREGATE $
DED T7RETENTION$ $
WORKERS COMPENSATION X TVtrC STATU- IOTR-�
AND EMPLOYERS'LIABILITY 100,00
A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN I , IAWC-400-7026218.2016A 0612012016 0612012017 E.LEACHACCIDENT $
OFFICERIMEMSER EXCLUDED? �INIA
DMandatory In NH) SEE NOTES E.L.DISEASE-EA EMPLOYEE $ 100,00
yes,describe under
ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addldonal Remarks Schedule,If more space Is required)
window 6 Siding installation. Bart Kiley is exempted from workers
=ompensation policy. WC insurance coverage applies only to the workers
:ompensation laws of the state of Massachusetts
CERTIFICATE HOLDER CANCELLATION
0000000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
� w_ '
01988.2010 ACORD CORPORATION. All rights reserved.
ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD
l{ - Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
� 0
Registration. ¢`12417: -Type:
Expiration � 9I3l2O17 Individual
Badholoma Kileyl
' Bartholomew Kiley S
u
Danvers,MA 01923 1 UnHersecretary
Massachusetts Department of Public Safety
•Board of Building Regulations and Standards
License.,CSSL-O9885,9 ,
Construction Supervisor Specialty ;
BARTHOLOMEW C KILEY
56 CONANT ST t]} a
DANVERS MA 01921 t 4 I
(�..nn r Expiration:
Commissioner 01101120'18