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90 MEMORIAL DR - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 C'MR, 74"edition OF SALEM Rrrurd 11YAV • 111� Building Permit Application To Construct. Repair, Renovate Or Demolish a 7• =/�tiY One-ar rwo-Faindy Dwelling This Section For Official Use Only (�A Building Permit or iber• Date Applied: V y\ Signature: Building C 40r'.-0ft'/Inspector of Buildings (Pate SECTION 1: SITE INFORMATION 1.1 Property Address: '/ 1.2 Assessors Map A Parcel Numbers �Q ag- 1)R/�/_ 3ipl y� Lla Is this an acce ted 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(R) From 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 if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2. Owner'of Ree rd: (� y �l �U6,e /AL 7�r!/9- Na (Print) A—`ifdress for Service: q7 866� Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK r(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition JC3 Demolition ❑ Accessory Bldg.❑ Number of Units -t Other ❑ Specify: Brief Description of Proposed W rk': 5• f o , < ', i;� q,v,,. F•:� i= /�� / O_ly/ ' S E E-u I3 aa/ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Omcial Use Only Labor and Materials 1. Building S 9 DigO, — I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cosh(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: S. Mechanical (Fire S Suppression) Total All Fees: S ^ Check No. Check Amount: Cash Amount: 6. Total Project Cost: S /Q� r'� 0 Paid in Full 0 Outstanding Balance Due: i SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Z tion Supervisor(CSL) C�1 9 14 y- l Z Cki I �� �� ) I.icense Number Expinlion Date Name of CSI.• I I.ist CSL Type(sce below) U f I)escri ion :WJrcss r �• U IlnrestricleJ u to 15,000 Cu.Ft. Z� LcIA R Restricted IR2 Familyt)%tllin Signatu - /✓(L _ M Masonry Unl RC Residential Roolin Lbverin felephone WS Residential Window and Siding SF Residential Solid Fuel Ruming Appliance Installation lv dJ D Residential Demolition 5.2 Re )erect H, ffle Improvement Contractor(HIC) pr lGn saO49� I IIC Company Name or 111C Registrant yame Registration Number r AJJres Expiration Date Co1 2-1i 8';e p Siwwtu Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2. J Milli)) 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 ..........X No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ttit/r� � e(/]f}G / &&nl Qom_, as Owner of the subject property hereby e to act on my behalf,in all matters to work authorized b this building permit application. F-as'=/O o OwnerDate SECTION 7b:OWNER OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare tatements and information on the foregoing application arc We and accurate,to the best of my knowledge and e of Owner or Authorized Agent Dale nderthe ainsand 16—f 'u NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor not registered in the Home Improvement Contractor(HIC)Program), will 01 have access to the arbitration program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 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.) flabitabie 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 <)pen 3. 'Total Project Square Footage"may he substituted for"Total Project Cost" CITY OF SALEM =� a PUBLIC PROPRERTY �'` DEPART'.1vIENT Construction Debris Disposal Affidavit (required lirr all demolition and renovation work) In accordance with (lie sixth edition of the State Building Code, 780 CMR section 1 1 1.5 Debris, and the provisions of'YIGL c 40, S 54; Building Permit ft 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: 1 name(it hauler) Aliee�debris will be disposed of in (name ul laclhty) laddress of facility) ,Illlatufe perllmt .1111lllcant date Al...... J CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT .ism:H(1'y:)WCtu i. .\I]Yt)a 12�^WAsnlxct l U.CSIREET • S•41'N,M.VS\CI II it-I 110197^� 978.745-9595 • F.sx. 978.740-9S46 . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A f rlicant Information Please Print Legibly Naineilia<ilnxsOrBaniratioNlndlv,duull: Address:_iiil �iy ra�irr-n ��',x1 'S T _, � CityiS[acc/sip: ©I Phone i:: (a I :\re you an employer'.' Check the appropriate box: "Type of project(required): 1.0 1 am a employer with I 4. ❑ I am a general contractor and 1 6. ❑ new construction employees (full and/or part-unic).' have hired the sub-contractors 7. Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. Ship and have no employees These subcontractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. We are it corporation and its 10.❑ Electrical-repairs or additions required.] officers have exercised their right of er NIGL I I.[] Plumbing repairs or additions 3.El 1 um a homeowner doing all work g exemption Pon P' myself. [1Co workers' camp. c. 152, gl(4),and we have no 12.❑ Roof repairs insurance required.j t employees. IKo workers' 13.❑ Other comp. insurance required.] , -Any yl1l,ca,al that chucks box at muss also till out the iectiull Wow showing their workuY eumpansmion policy inf arrestiurs. ' Ilumea,wnen who submit this illidavit indicating they are doing all work and(lien him outside Cunsrxlon must.uhmil a new al'fdavil indicomg such. -C'omncu,rs that check this box most aaxhed an additional slarol showing the amne of the subaonuitctam and their wurkum'comp.policy infurmntion. I am an employer tlia[is pruviditrx Ivor'kers'cunrpen.cntinn insurance fur lily employees. Belon,is the puhcy and lob.sile information. InsllraileC Company Vame1___-P-&-V-&-6f�p.. - p�j. ._. q..._.._--._...------- Policy g or Sclf•ins. Lic.>t: XNUg r 9aa1-7J —Z r�/ Expiration Date: 90 ' em�r� Sa le/n . flAV, Job $ite :\ehlress: �rtVf?� CitytStnte/"Lip: Attach at copy of the workers' compensation policy declaration page(showing;file policy number and expiration date). Failure to secure coverage as required under Section 23A c. 152 can lead to the imposition of criminal penalties of a line tip 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 it Jay ;igainsl the violator. Ile advised that a copy of this statement may be Ilimirded to the Office of Invcaugauons of the DIA for iniurar.ce coveragu acrilication. 1 7h,,,ervby]cc2r6fTin ter �jndas �penaftics peperjtrry that the infiuroordan provided above is true and correct. 1'hrrrc ri: -Ca r� :Ztat'I O/jlciul ase only. Do not write in this area,to be completed by city or tolvn official. I Cilvor'fown: _ Permit/Licenseq-_-._._ - - - Issuing:\uthurily(circle one):. _ I. Iluard of Ilealth 2. I311ildin'. Department 3.Cilyi fosse Clerk 4. Electrical Inppector 5. Plumbing Inspector 6. Oilier -- - Couuct Persoo: _.. . .__. . Phone 1: Information and Instructions .Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an emplu1vee is defined as"...every person in the service of another under any contract of hire, ekpress Or implied, oral or written." An einpluyer 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.in 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." `IGL chapter 152, §25C(6) also states tha["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, 'vIGL chapter 152, §§'25C(7)stares"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 sub-contractor(s)name(s),address(es)and phone nurnber(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 u 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 Official Please he 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 pennitflicense number which will be used as a reference number. In addition,an applicant Unit must submit multiple pernin'license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and tinder"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 1 i.e. a dog licenser permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he Otlice of Investigations would like to thank you in advance fur your cooperation and should you have:my questions, please do not hesitate to give us a call. - The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE rtoviscd -�r,-ns Fax # 617-727-7749 www.mass.gov/dia AMkk . ° AVELERS J WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (XHUB-988iW93-2-09) 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 01960 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 10-22-09 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 sm o 'Pir e0a"pWjJe I 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 SD TN TX UT VA VT WI D. This policy includes these endorsements and schedules: I, t= SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classificatlons, 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 ozims T. &W. EXCAVATION 09-96 53 19/"3 7217 10 ANDERSON STREET PEABODY,MA 01960 2`7_/O DA E PAY TO THE iM ORDER OF �' 64 $ ..... .» g DOLLARS ®Eastern Bank QQ IBOOfgSTEPN MEMOZD 1:0 1130 1798E 00 00999 iBOm ------- Ap 7 2 1 7 ----- I