82 MEMORIAL DR - BUILDING INSPECTION gjI
I The Commonwealth of Massachusetts
' Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, Th edition OF SALEM
�✓ Revised Junuury
Building Permit Application To Construct, Repair, lenovate Or Demolish a 1, ?008
One-or Two-FVrxily Dwelli
This Seclio Fo O(T 'al a Only
Building Permit Number: L D10 gWed:
�LSignature:
Building Commissioner/Inspector of Mildings Date
SECTION I:SITE FORMATION
W LI Property Address: 1.2 Assessors Map& Parcel Numbers
8Z A4rAADRTAL 7bRI7/,4'
I.la Is this an accepted street'?yes no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1)0 2.1 wner of Record:
t2V& A L. A4zfr- ,4 1e-7-A1F.1 F-? g&-d eul- 2?&a16
No/1Ji�a(Print) — Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) $ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': :jk f lacemee -�- VAJ JS
SECTION 4: 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:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (11VAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: s 7, 000, 13 Paid in Full 0 Outstanding Balance Due: �J
SECTION 5: CONSTRUCTION SERVICES
5.1/Licensed Construction Supervisor(CSL) Al 9/(,g-
7_•/P� Ikn License Number lirpimtiun Date
NNatmc olCSL-I lulderJJ List CSL Type(see below) U
Of a) ✓E� f Description
Addr5k li Unrestricted(up to 35,000 Cu.Ft.
R Restricted l&2 Family Dwelling
Signature p M Mason Onl
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) ) O )S
rn /E,.(/ Yl C P S od-1 Registration Number
Ii IC Company Name or HIC 'Irani Name
Zo n ow �mll l Z�o9�p�
AJJres 60 2/2A / spi lion 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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behal
,q,.1
Pr' Name
7— /!E/U
Signature of Owner or Authorized Age I Date
(Signed under the pains and n ilties of 'u
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 no.1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and 110.R5,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"
_s t
CITY OF SALEM
3
PUBLIC PROPRERTY
DEPARTMENT
-.J]1L'.`R(lit'D0.15CULl.
NI,�)oR 120.WMHI.\(:10.N sTaEET • SALLEM,M.,ync:li :si,I tiG1970
'1'I:r:978-.'ii9595 0 P:,x: 979-74:-9S46
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
onlicant Information .� .f Please Print Leeibly
Name (Business/OrBaniiationfindividuuq //l: vI jOt r rimIS On
Address: Z 0 Lo b
CityiStatci%ip: T') V-R's YYtnk, Mone i..j—(0
Are you an employer' Check the appropriate box: "Type of project(required):
1.ER 1 am a employer with -Z 4. ❑ 1 am a general contractor and 1 G. ❑ New construction
colplo •ces full and/or an-time).• have hired the sub-contractors
I y ( P' 7. ❑ Remodeling
2.❑ 1 ❑m a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
To workers' cum insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.) officers have exercised their
right of exemption per NIGL I I.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work g P P'
myself. LNo workers' comp. c. 152,j 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13.N Other Qe?IaGB ✓+ty,^o%ul
comp. insurance required.]
-Any opplicanl Ihot checks box RI must also fill out the ucliuu below showing their work<rs'cumpensation policy infurmutiun.
?I lumcuwrxn who submit this affidavit indiutina they are doing all work anal dtcn him outside cotumeton muss submit anew affidavit indicatinsojch.
�C,,ntraetom that check this box mtut allwhod an additional sheet showing the mane of the subcontractors and their workurs'comp.policy information.
1 a)n air employer that is providing workers'compensation insurance for toy employees. Below is the policy and job she
information.
Insura ice Company Vane: Otd __...._n..... . _... _ p_._... ..___--..-.._....-------
Policy iF ur Self-ins. Lic. B:X n ya "/(Qg� u_r p:3_--Z.-.O_./___ Expiration Date: -Z2 -1Q
Job Site Address: lb O Z ,MLmnn� 3)f rV 2.. CityiStateizip:Ukl"
.%ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
I-'ailurc to secure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against lite violator. Ile advised that a copy of this statement may be forwarded to the Office of
Inv'rstigatiuns ul the DIA for insurance coverage verification.
71:'d,oherchyLerd i a er painsandpenalties afperjary that the infarinution provided above is trite awlcorrect.
auu¢ Date: —
417 7X/
official use only. Do not write in this area, to be completed by city or town official.
City or'fow.n; Permit/LicenseA------
Issuing;%tahority (circle one):
1. Board of Ilcalth 2. Building Department 3. Cityffoten Clerk 4. Electrical Inspector Plumbing Inspector
6. Other,
Contact Persom .--- 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, blGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtance 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-contractors) name(s), address(es)and phone nunnber(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 continuation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retunred 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the per ik/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennidlicerse 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 tilled 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.
I he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do nut hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Rcviscd 5-26-05
www.mass.gov/dia
' CITY OF SALEM
r PUBLIC PROPRERTY
DEPART'N/IENT
i
P•'��INt U,��
\I '.�� �I` 1_'Q \C.\,MM ONS1141:1 T • SAI I'M, \1. 11%1 :It 'I I ��_Il _
l rl: 978-74?-7;45 1'As:'P8.74 9541i
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section I l 1.5,
Debris, and the provisions of MGL c 40, S 54;
Building Permit 9 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
111. S 150A.
The debris will
, ��be�transported by:
� l �
en l Dm on
(name of h ler)
The debris will be disposed of in
I ctr,s ' ✓e.R `cans,ar s�atAkon
(name of facility)
Coymmerb'j S`/4-,
J_'Q/Z �,
J Inddress ul facility)
]I_L'11at Ol'e f panuit applicant
TRAVELERS J WORKERS COMPENSATION
AND
j } EMPLOYERS LIABILITY POLICY
tt TYPE V INFORMATION PAGE WC 00 00-0- (-A)--.---
POLICY NUMBER: (XHUB-9881W93-2-09)
• RENEWAL OF (XHUB-9881W93-2-08)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
NCCI CO CODE: 13439
1.
INSURED: PRODUCER:
GLENN THOMPSON PREFERRED INS AGENCY INC
DBA T&W EXCAVATION 10 NEW ENGLAND BUS CTR DR
10 ANDERSON STREET STE 303
PEABODY MA 019GO ANDOVER MA 01810
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 1 0-22-09 to 10-22-10 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
- Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applie wor n �aFZV I' t d in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SO TN TX UT VA VT WI
D. This policy includes these endorsements and schedules:
o�
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o�
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
)
DATE OF ISSUE: 08-25-09 TP
OFFICE: NAT'L PRGM'S-ORL 715 DIRECT BILL
PRODUCER: PREFERRED INS AGENCY INC 00715
021015
�E1 Massachusetts- Department of Public Safetc
AM Board of Buildim- Regulations and Standards
Construction Supervisor License
License: CS 49168 -
Restricted to: 00
GLEN THOMPSON
20 LONGBOW RD
DANVERS, MA 01923
�-�- 3;� Expiration: 3/28/2012
('onnnisiuner Tr#: 17893