77 MEMORIAL DR - BUILDING INSPECTION _J16 GlLtzSZ c( �°''
The Commonwealth of Massachusetts
ECEIVED CITY OF
i� Board of Building Regulations an ft,' kONAL SERVICE SALEN I
4YI / Massachusetts State Building Code, 780 CM Revised.Llar 2011
Building Permit Application To Constntct, Repair,�90 C,r�er�ol
One-or Two-Family Divelling
This Section For Official Use Only
Building Number: Date Applied:
l0 13 t.f
Building Otlicial(Print Name). -- Signature . . Date
SECTION 1:SITE INFORMATION'
I.1 Property Address: 1.2 Assessors Alap&Parcel Numbers
77
L l a Is this an accepted street?yes d no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy tt) Frontage(It)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Reyuimd Provided Required - Provided Required Provided
1.6 Water Supply:(M.G.L c.40,g 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP"'
2.1 Owner'of cord: G
pqC O/ZNHC{TJO
�hme(Print) ///J City,State,ZIP r,
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 0 Repairs(s),d Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
Gv t%WQ0ztu f riT3P/z f T/2 'm
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building S G j- 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2`?9ther Fees: S q 5
(f
4.(Mechanical (I-IVAC) $ List: U
5. (Mechanical (Fire S Total All Fees:S
Suppression)
c Check No._Check Amount: Cash Amount:
6. Total Project Cost•. .S (�0 5� ❑Pail in Full ❑Outstanding Balance Due:
fYl(�i �t�Tj �p 't 1p
SECTION 5: CONSTRUCTION SERVICES
5.1 Construct//ion Supervisor License(CSL)
License Number Expiration Date
Nome of CSL Huller /�c,
List CSL'rype(see below)
5Z
Type Description .
No. and Strect ��
U Unrestricted DuilJin s u �to 35,000 cu. R.
?a,y UY,7I-r . CJ/9�? R Restricted 148 F;unil Dwellin
Ot fr m,State,ZIP M Masonry
RC Root Covering
X� WS Window and Sid in
S�, SF Solid Fuel Dunning Appliances
9 '7�y' I Insulation
Tole hone Email address D Demolition
5.2 tegtster/ed Home Improvement Contractor(HIC) y
led. It. /, HIC Registration Number Expiration Date
III�Cump:mxNamc or HIC Registrant Name
Nod Slrcel 7t�� -0a YS Email address
City/Town,State ZIP Telephone
SECTION 6:'WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,U c.152.$ 250(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 AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT'
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
/vPyq/
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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 of my knowledge and understanding.
&- Al"XI"° /O —/3—/ S
Print Owner's or Authorized Agent's Name(LIectrunic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or as owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program);will Lilt have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
wmw mass eov.'oca Information on the Construction Supervisor License can be found at ww �dns
2. When substantial work is planned,provide the information below:
'rota) liner area(sq. It.) '^ .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of lireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
rype of cooling system Enclosed Open
3. • Fotal Project Square Footage"may be substituted fur`Total Project Cost"
CITY OF SALEA MASSACHUSEM
BuiDjNGDEPAKnem
120 WAStIIICMNSURT,3`RMR
UL(978)745-9595.
FAX(978)740-9846
KIIvlBF.RLEYDRISQ7LL
MAYOR 7)101Ms ST.PEM
DntEcrcgi or pmjlcrxorERTr/BuuDm ocummcgm
Construction Debris Disposa/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 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 150A.
The debris will be transported by:
(name of ha ler)
The debris will be disposed of in:
TKO
//(name of facility)
(address of facility)
�C
Signature of applicant
�� - ice is
Date
The Commonwealth ofMassaehusetts
Department oflndustrfalAcciderrts
1 Congress Street,Suite 100
Boston,MA 02114-2017
wwnamassgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumben.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Udbl
Name(Bosiness/Organ 7ation/lndividual): �112 4/m e
Address: L v Ry T
City/State/Zip:,��,yy t',,v-.f' 4;� o/-'-2 -7 Phone M f 7, -7 7
you employer?Check the appropriate box:Are o ao era to ofset r0 " l Ured TypeP J (+e9 )=
1.O I am s employer with .employees(full anni/orpart-tvm).' 7. []Now construction
2.ry,am a sole proprietor or partnership and have no employees wodthtg for me m
�y capacity.(No workers'Comp fnaannee required] . Q Remodeling
3.Q 1 am a homeowner doing all work myself.[No workers'comp.insurance tequked.]t 9 ❑Demolitio'n..
4.E]I am a homeowner and will be biting contractors toconduct all work on my property. I will 10 0 Building atklltiUn.
assume that all contractors either have workers'mmpensabon insurance or are sole 11.0 Electrical repairs or additions
psoprictors with no employees.
12.0 Plumbing repairs;or additions
5.Q I®a general contractor and I have hked the suli-mntraorars listed on the attached sheet
These sub- mmcbrs have employees and have wodress'comp.nammomf 13.QROOfrtyairs.
6.E]Weane a corporation and its offices have exemised theirright ofexereption par MGL c. 14.QOther UV IX( 'C/BLc,,S
15Z§I(4),and we have no employees.[No workers'camp:insurance required.] - -
-Any applicant thin chechs box#1 mast also fill our the section below ahoartg they workers'compensation policy b6imoatlon.
t Hommrmers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a sew affidavit indicating such
tContracmrs that check this box must attached an additional sheet showing the name of the sul*mmmerora and state whether or not those"emftres have
employees Ifthe sub-contractors have employees,they must provide their workers'.mmp.policy nuttier.
lam an employer that isproviding workers'compensation insurancefor my employees. Below,is thepolicy and job site
information. �y1
Insurance Company Name:
Policy#or Self-ins.Lic.#:/ 042 4Y0o 70 26'?_/� - 1 o/J9 Expiration Date:
Job Site Address: 7 ///rnrrro�/A� �iZ city/Statemp: 509le-;?7 0/a O!q 26
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 cabmnal 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 cerrd finder the pains and penakies o per'ury that the information provided above is true and correct.
Sian____
Phone#: '1�777y�U2 Sf
Offwial use only. Do not write in this area,to be completed by arY or town offwW
City or Town: Pern imeense#
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#: 11
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 empoyers. 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 insirance
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-cormuctor(s)narne(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 perrrit/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 dqg license or permit to bum 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
HIC # 126-356
SO C01011p jouilberg, Int.
I 13 SEWALL STREET
PEABODY, MA 01960
OFFICE: 978-922-6120
SPECIFICATION SHEET (7 f
Home Phone: J > �
./rz• . . . . . . . . . . . . . P . . . . . . . . .
Owners Narne .� � �`��` � • • • • • • • Work Phone: . . . . . . . . . . .
.7. . . . . . . . . . . . . City �j. . . . . . . . . . State . . . . . . . . . Zi
JobAddress . . . . . . . . . . . . . . . . cri'^4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SIDING
1.Siding Tipe . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Width . .. . . . . . . . . . Color. . , . . . . . . : . . . . . .
2.Area to be done. Main House ..—=. . . . . . . Breezewav . . .' .:.?: . . . . Garage . . . . Additions .' �. . . . . . . .
Dornwrs. . . . . . . . . . . . . . . . . . . . . . . . . . . .. Other . . .`. ._ '--� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3, . . . . . . . . . . . ./ ¢ :. . . . . . . . . .
4.Trine cover es ❑No Color. '. 16. . . . . . . . . Trim to be done: Soffits . . . Fascia . .�� . . . . .
Rakes . . . .4J . . . . . . . . . . Ceilings. .if ?� U- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ` . . . . .
5. Window and Door Frames . !?Y1�'. :rr w .C . . . . . . . . . . . .
6.Gutters and spouts U'les ❑No Use heavv gauge seamless. . . . . . . . . . . . . . . . . . Color u . . .
7.Shutters 0 Yes 1wo
8. Windows and Doors c � � cd+i /
. .,'1 . . /,/ . . . . . ..rl�?��. . . . . . . . . . . . . . . '
ROOFING
MaterialType . . . . . . . . . . . . . . . . . . . . . . . . . . .,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Color. . . . . . . . . . . . . . . . . . . . . . .
Areas to be done . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . .
Remove existing shingles i] s ❑No 15 lb.felt. . . . . . . . . . . I . . . . . . . . . . Metal Edging . . . . . . . . . . 6 . . . . . . . . . . . . . .
Chimnev and vents. etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NO 5. . . . � < . . . .. . . . . . . . . . . . .. ...
. . . .
y ..Deposit
Material and labor to cost$. . .46. . .U. . !J. L1. . .. . . . . .payable as follows: $. . . . . . . . . . . . .l st Installment
DO NOT SIGN THIS DOCUMENT IF THERE ARE ANY BLANK SPACES. $. .. . . . . . . . . . .2nd Installment
$ G. q(?i :i .Balance on completion
Contractor will do all said work in a good workmanship manner. You may cancel this agreement if it has been consummated by a parry thereto at a place
other than at address of the seller, which may be his main office or branch thereof.provided you notify the seller in writing at his main office or branch
br ordinan•mail posted, 1;v telegram.sent or by delivery, not later than midnight of the third 6shiess dad•following the signing of this agreement.
IN IVITNES THEREOF, the parties have hereunto signed their names this. . . . . . I. ./. .day of. . . 201S.
Accepted — ,/�//�� Signed( \ {C. 0 Owner_ �.�c� : . . . . . .
�01C W,Ders, 3lttc. f
Y signed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Owner
Per. -ra. .
Repies native Authorized Rep. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Strikes, labor disputes. inclement weather.or material supplier delays rendling in work stoppage are hesond the control of the company.
r �y •
IMPORTANT: if the certl8cate holder is an ADDITIONAL INSURED.me POIICYIN SI mtu De ffl V'WU. .. - .-...
the terms and Conditions of the policy,certain polidss may requite an Endorsement A statement on this Certificate does not confer rights to the
CerOficate holder in Ileu ol such endorserrl s
PRODUCER Phone:978-TT7.9394 KABIL Dan Humor
pNONe
Dan Hurley Insurance Agency Fax:878-777NQ P�q AJ
978-7779394 :ABC No):978-7773306
Chestnut Green.SUIN 24 + dan@hur(eyinsural�.com
Seven Federal Street LIMBS, h eY(nsurar
Danvers.MA 019233e20 INSURERi$)AFFOPD!tK+ NAICa
Daniel J Hurley
.
INaulrEan:AlMMuhuallrts.,Co. .. _
.15024
INSURED Kile. _y Brothers Cons.truction _INSUr�Ne:Pre4aned._ _Mutual __. .. ._ _ _._. .__.
Bartholomew KHey DBA
56 Conant Street
Danvers,MA 01923 INsu�no;_
F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDS�BFY PAIPo CLAIMS.
ffXp
MSR YYPEOFWWMAMM AWLSUeR POLICY NUMBER Mmam Lam
GENERAL LIABILITY EACH OCCURRENCE S O RGNTED __ 3001K
BOPOI00720147 IWIW 014 IW18120•I6 � _ I __.s . . 100100
'S X COMMERCIAL GENERAL LIABILITY - - 1010[
.. __ _ CLAIMSNAOE _X OCCUR NED EXP(Any m PIVWI) S
_... -. PERSONALBADvnIJURY .5 SOO,OE
GENERAL AGGREGATES 60010(
60010(
PRODUCTS-COMPIOP AGG S
GEN'L AGGREGATE LIMIT APPLIES PER.
_ S
POLICY Z'T LOC OM SIRED SINGLE LNIT
AUTOMOBILE UABIUTY _(E6 .UCBnD S
. . - EMILY INJURY IPW Paso^) S
ANY AUTO BODILY INJURY IPa S=da10 S
ALLOWNED �O EDULED _AGE S
- --" -
S PROPERTY
A11T03 NONIMMEO )DALI
HIREDAUTOS AUTOS - -E
UMBRELLA UA6 OCCUR EACHOCCURRENCE-.... ..$
_
...._ -_.-. AGGREGATE 5
PJICE98 UAB CLAa75.fAa0E _ .
DIED RETENTIONS WC STATU- OTN'
WORKERS COMPENSATION X. TORY LN)TS- .. ER._
AND EMPLOY�•LIA&UTY AWC400-7026216-MSA 0612012015 06I2IU2016 EL EACH ACCIDENT s 100,0
A ANY PROPRIETORIPARTNER�IfECUTIYE Yam.) NIA _ 1gg10
OFFICERNENBEREXCLUDED7 I T t SEE NOTES E L.DISEASE-EAEMPLO?;EE S -
IMandelaY in NNI E L DISEASE-POLICY UNIT S 50010
Ifyyes,dasci6e-
DESCRIPTION OF OPERATIONS bob.
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AWPN ACORD 101•AdditlonN Rsaaln Sellemda.Nasiwsere h Mldndl
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE
THE EXPIRATIDN DATE THEREOF, NOTICE WILL BE DELIVERED IP
ACCORDANCE WITH THE POLICY PROVISIONS.
AUnMRREID`RE-PRESENrATIVE
01988-2010 ACORD CORPORATION. All rights reserved
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD