6 MESSERVY ST - BUILDING INSPECTION (2) J� r
The Commonwealth of Massachusetts
�. Bbard of Building Regulations and Standards CITY OF
Massachusetts State Building Coe, 780 CMR SALEM
B d
Revised Mar 20
Building Permit Application To Construct, Repair, Renovate Or Dern
One- or Tivo-Family Divelling
This Section For Official Use Only,
Building Permit Number:;.: Date Applied3
Building Official(Print Name) Signature
SECTION f: SITE INFORMATION
` `� 1.1 Pro rty Address: t d Ix—AL2 Assessors Map Br Parcel mbers
/X 1.la Is t is an accepted street?ye _ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SFCT16N 2:;'PROPERTY'OWNERSHIPL.
2.1 Owners of Record:
Name(P 'nt) City,State,ZIP
No.a niff Street Telephone Email Address
SECTION 3: DES IPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ N tuber of Units_ I Other ❑ Specify:
Brief Description of Proposed Works:
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs:
COSTS-
Item Official Use Only, ,
Labor and Materials
1. Building $ I Building Permit Fee S Indicate how fee is determined:
❑ Standard._City/Town Application Fee
2. Electrical ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2- OtherFees: S
I NI-chanical (HVAC) S List: ! 1
Y
5. Mechanical (Fria S
Sn + ressiun) Total All Fees:t5_
Check No. Check Aumunt Cash Amount:
6, I'Mal Project Cost: S 0'fl ,,a S' //OD, ❑ 1 ul m Bull ❑ Outstanding 13aL1ncc pua:_
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
License Number Gepiration Date
/\ Name of CSL I lulder
List CSL Type(see below)
No. and Streit Type _ I . Description -
U Unrestricted Rauldin s on to 35.000 cu. 11.)
__ R Restricted IA? FamilyDwellin
City/Town, State, zip IvI Masonr
RC Rootin Coverin
INS Window rand Sidin
SF Solid Fuel Burning Appliances
I Insulation
I'cle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(11IC)
HIC Registration Number Expiration Date
I IIC Company Name or IIfC Registrant Name
No.and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. t52. § 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
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED 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 ofmy knowledge and understanding.
P_nnt Owner's or Authorized:4gcnt's Name(Electronic 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 find under D.G.L. c. 142A. Other important information on the HIC Program can be found at
www.m;us. 'ov:'oca Information on the Construction Supervisor License can be found at www.ntass.eu�1dL
2. When substantial work is planned,provide the information below:
Total floor 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 _----_.------
Numberotbathrooms _-- ___-- Number ofhalt/baths _
fvpe of he:uing system _-- ---_-- ------.-- Number ot'decks/porches
-----------
peoFcoolin�sy;tcm.__ Fuclosed _
i "1'.,tal P[o)Cct Square Foot:lge _-utay be ,ubstithited fu"Iirtal Ploicct Co;t" --
�r RE h A�
�- �ylN)tO7tI/�P.2ll� � .
OI•Ree of Consumer Affairs&Business Regulation
YUS
HOMEIMPROVEMENT CONTRACTOR
Reglstratlon �151123 Tr8 �293980
Ex iratlon =5/17/2412
P Type:,'-,I Corp lion
.I J.B.KIDNEY
1 KEVIN KIDNyFY
1 ��
410S80RNE STREE••- �` Undersecretary
SALEM,MA 01970 '' y
Massachusetts- Department of PublicSofeth
i 'Board of Building, Regulations and Stantlartls
Construction.Supervisor License
License: CS 4559
Restricted to: 00
KEVIN R KIDNEY
60 PELCZAR i
DRACUT, MA 01826
Y
Expiration: Z2312012
('Dona isairuu.r. - TrN: 15339 -.
COMMONWEALTH OF MASSACHUSETTS
SHEET METAL WORKERS-%
AS A MASTER-UNRESTRICTED
'ISSUES.THE'A80VE LICENSE TO`.
JOSEPH RI KIDNEY •,
,
JB- K_IDNEY `AND CO INC
OSBORNE, ST +'
SALEM MA 0 1970 2524 "
12203 07/28/14 :201617. -
Fold,Than Detach Along All Perlorawoo 1
CITY OF SM EM, ANSSACHLSETTS
1 BUILDING DEPARTMEINT
120 WASHLINGTON STREET, 31D FLOOR
TEL (978) 745-9595
F.tx(979) 740-9846
KI\(BERJ_EY DI ISCOLI
IfAYOR T HoNus ST.PmRRB
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CO.MlISSIONER -
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A : Illcant information Please Print Legibly
Name lOo�itxSyUr�tni:uio ulndividual):
Address:
City/State/Zip: D Phone H:_2 Zea— 741`I/'aU 7j�
Are you an employer?Cheek the appropriate box: Type of project(required):
I.Q 1 am a employer with 4. Q I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sulaconnactors .
2.❑ I am a sole proprietor or partner• listed on the attached wheel t 1. Remodeling
ship and have no employees These subcontractors havo V. ❑ Demolition
working for me in any capacity. workers'camp. insurance. 9, Q Building addition
(No workers'comp.insurance 5. Q We are a corporation and its
required.) officers have exercised their ME]Electrical repairs or additions
).Q 1 am a homeowner doing all work right of exemption per MOIL i I.Q Plumbing repairs or additions
myself. [No workeri cutup. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t cmployces.[No workers'
sump. insurance required.) Il,❑Other
•Any applicarn that dimlis box rl must also fill uut the sectim below showing thair workers'compenudun policy inrurmatlom
'I hwneuwm"who nubmis this air davit indicating ihey ate doing all workand then him oatsids contmctoa mmr submit a tow amdavit indlc3dny such.
:C,,nimlars that chcsk this box moat anachod an addiduratl shins showing Ile puma of the sub.cdntracton and their workers'ramp.policy iniommnon.
/um an employer that Is providing workers'compentodon Lrsuranee for my employers. Below/1 the policy and Job sire
informallon.
Insurance Company Name:
Policy N or Scif-iris. Lie. N:_ L✓G �,J/S'_3�.1.'�/ n�a Expiration Date:_, zzy/i&
Job Site Address: City/State/2ip: C
Attach a copy of the workers' compensation policy declaration page(Showing the policy number and expiration date).
Failure to secure coverage as required under Suction I3A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesligutiuns of the DIA for insurance coverage verification
Ida hereby certify under the pules and penaties of perjury t/rut the,infunnuNon provided above is true turd cornet.
ii�:nature: Dara:
Phoned:
I Official use only. Do not virile in ildy uree4 to be completed by city ar town oJJJrlud
I
City nr,rosvn: _,_... --Perm 10.1cense
Issuing Auiltnrily(circle one):
1. Board of Ileallh 2.Building Deparintent I.Cilyirown Clark 4. Electrical tuspectur 5. Plumbing Inspector
6.Other _..
Contact Person: _ ---- _ Phone B:
r:
i • ,f�FjVr''
<F CITY OF S�UZ%f, NI:1SS.ICHUSETIS
3. BUILDING DEPARnMNT
t + 130 WASHINGTON STREET, 3"*FLOOR
TEL (978) 745-9595
KIINMERIEY DRISCOLL F•LK(978) 740-9846
NLILYOR Ttaou Ls ST.PIERRE
MaECrOR OF PUBLIC PROPERTY/BL:IMDJG COt6IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11
Debris, and the provisions of NiGL c 40, S 54; .5
Building Permit I# is issued with the condition that the debris resulting from
this work shall be disposcd of in a properly licensed waste disposal facility as defined by MGL c
11 I, S 150A.
The debris will bre®transported by:
�(name of hauler))
The debris will be disposed of in
n-me of facility)
_— -- ddress of tutility�
signaturo ufpermit applicant
(late
10"I
j
1
From: GFIFaxMaker To: 9787409846 Page: 2/2 Date: 4/8/2013 2:09:41 PM
►co CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOIVVVV)
9/8/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
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 endorsement(s).
PRODUCER CONTACT NAME: •TOan Street
SOUCY INSURANCE AGENCY arc1 No,_E,cL (978)744-7110 (AIC No: (978)741-2059
P. O. Box 4467 ADDRESS DSoucy@ SOucyinsurance.com
85 Lafayette Street CUSTOMEER ID a00000603
Salem MA 01970 INSURER(S)AFFORDING COVERAGE NAIL#
INSURED INSURERA:Hanover Insurance Co. 22292
INSURER B Allmerlca Financial Ben Ins 41840
J. B. Kidney S Co. , Inc. INSURER C:
41 Osborne Street
INSURER 0
INSURER E
Salem MA 01970 INSURERF:
COVERAGES CERTIFICATE NUMBER-CL121213 011 8 0 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.
INSR ADDLISUBIR POLICY F x
LTR TYPE OF INSURANCE INSR MD POLICY NUMBER MMIDDIYVYV MMIDDrYYYV LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAG
PREMISES Ea occurrence) $ 100,000
A CLAIMS MADEOOCCUR HN 0797293 05 /22/2012 /22/2013 MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 2,000,000
X POLICY PRO LOG $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,000
ANY AUTO
B ALL OWNED AUTOS WN3404859 /18/2012 /18/2013 BODILY INJURY(Pat person) $
BODILY INJURY(Per accident) $
X SCHEDULED AUTOS PROPERTY DAMAGE
X HIRED AUTOS (Per accident) $
X NON-OWNED AUTOS FIRE $
PIP-Basic $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMSMADE AGGREGATE $
DEDUCTIBLE $
RETENTION I:
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY YIN Y LIMI R
ANY PROPRIETORIPARTNERIEXECUTIVE E L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED' NIA
(Mandator,in NH) EL.DISEASE-EA EMPLOYEE $
fyes describe under
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
(978)740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
Public Properties Department
120 Washington St. , 3rd Floor AUTHORIZED REPRESENTATIVE
Salem, MA 01970
Paul Soucy/HAL
ACORD 25(2009/09) O 1988-2009 ACORD CORPORATION. All rights reserved.
INS025(200900) The ACORD name and logo are registered marks of ACORD
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