3 MILK ST - BUILDING INSPECTION Commonwealth of Massachusetts CI "1'OF
Board of Building Regulations and Standards SALEM1I
Massachusetts State Building Code. 780 CMR Reri.sed.11ur?011
Building Permit Application To Construct Repair, Renovate Or Demolis
One-or Two-Family Dwelling
This Section For Ot I Use Onl
Building Permit Number: D to Applied:
Building 011icial(Print N;une) Signature Id
SECTION I:SITE INFORM1IAT10
1.1 Property Address:3 S.- 1.2 Assessors Nlap& Parcel Numbers N1 ; I �
I.la Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) I Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
L6 Water Supply: (M.G.L c.40.§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record: o
CS 4'rL3PllntC, A5—t�accZ S�4��Ivl� Wli� 0l9 7
N;mie(Print) City.State,ZIP
3 M,'*, S+ '7 ?F7YI/ -2$Y1l 2251041no do'Al
No.and Street 'relephone Entail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ .Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Bri�escriptionofProposedWork': —t- Wit, I*.J+CNC=.MCOSTS
1-Y14 e-
SECTION a: ESTIM1IATED CONSTRUCIt`ittEstimated Costs:
(Labor and Materials)
1. Building S `yp ,Od 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4-Mechanical 0WAC) S List: _
5. ,Mechanical (Fire S rotal All Fees: S
Suppression)
Check No. Check Amount: _C';uh ,\nuxun:----
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
=,-W '
ECTION 5: CONSTRUCTION SERVICES
Construction Supervisor License(CSL)
1' ) zG� nl _ License Number If.cpiruion DaterList CSL'f)pc(.See below) (J
'1 1 vpe Description
\AAA ���, �Z (I I Inrestricicd(Buildin,s ti to 35,000 cu. IT)
_ rW1 [� O 19 tt Pamil Dwelling
t'll�/1 own.Slate.ZIP R Restricted IX2 M Masunr
RC Roolin•C......n
W'S Window and Sidin
7 ffJ ,3—f S'S L ei F�C�vv� SF Solid Fuel Burning Appliances
Q P )vICYH , ive I Institution
T I
5.2 R hone Ismail address U Demolition
egistered Home Improvement Contractor(HIC)
$etuce �✓��v�t ��s' ca� vtC ( 2Jt��2o)
I II C ontP� )tit y Name or I IIC Regist ant Name I IIC' Registration NumM:r li.gtir:rtiun Late
3 trees < S �' �f cI h c4a f6 hnreh5�No.and Street W e-
h v\ w1 w a r 4� 7SSl—> 3—� >—s Z Finail address
it /Town,StaLte,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... 19' 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 Gg2I C e 14ACk, e
to act on my behalf,in all matters relative to work authorized Ty this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b: 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
contai d in this appliccaatiti n is true and accurate to the best of my knowledge and understanding.
v � -
c
Print Own s or AuthorizeJ Agent's Name(Electronic Signauvo) , Co /
Dole
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 M.G.L. c. 1 42A.Other important information on the HIC Program can be found at
t�)s%t- ova Information on the Construction Supervisor License can be found at t%)�+q.in;)is.y+n
2. When substantial work is planned,provide the information below:
Total fluor area(sq. R.) (including garage, finished basement'attics,decks or porch)
Gross living area(sq. 11.) _ Habitable room count
Number of fireplaces-- -- Number of bedrooms
Number of bathrooms --------------
-----_----_------- Number of half
1')pe of heating system _-------------.-- Number of decks, porches ------------
1 s pe or cooling ss stem .. rnelosed peen
3. .:total Project Square r�,olage"may be substituted for"rotal Project Cost-
6 I
Proposal
SERVICE PAINTING COMIC.
93 COLLINS ST.
LYNN,MA 01902
781-593-1552
LIC. NO. DC000017
LIC.NO. H.I.0 111402
LIC.NO. CS067300 Date: 1 0/1 412 0 1 1
Job Number. 3milk
Carl Salmons-Perez
Milk st.
Salem,MA 019704412
We are pleased to submit the following cost estimate:
Job Description: INSTALL KITCHEN WINDOW
QUANnn DESCRIPTION PRICE TOTAL
1 INSTALL OWNER SUPPLIED PELLA WINDOW, KITCHEN INSTALL INTERIOR AND 1,280.00 1,280.00
0 EXTERIOR TRIM,SIDING AND WALL REPAIRS, 0.00
0 ADJUST EXISTING FRAMING,INSTALL WINDOW HEADER
REPAIR SIDING LEFT SIDE
1 MISC MATERIALS FRAMING,EXTERIOR TRIM,FLASHING,SEALANT, 235.00 235.00
1 PERMIT 125.00 125.00
1,640.00
DESCRIPTION PRICE TOTAL
Total proposal 1,640.00
ACORIZ CERTIFICATE OF LIABILITY INSURANCE 011
1o/1a/2o11
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 ft 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 teems and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
canibicate holder in lieu of such endorsement(s).
PRODUCER CONTAUT
NAME:
Duffy Insurance Agency, Inc. P N ._. 781.S93.1200 Juc,ndX781.593.7260
3,r�1,�7.,.,B�roadway
Wyoma A�pRESS:.
Square wSURER(Sl AFFORDING COVERAGE NAIci
Lynn, NA 01904-2602 wsuRERA: Safety Insurance Company 1394S4
WsuRm Service Painting Co Inc wsunERa: Safety Indemnity Company 133618
93 Collins Street muR c: Associated Employers Insurance
Lynn, NA 01902-2247 wsuRERn:
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER:81 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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 TYPEOrmtMANCE INSR yyyp PGLICYNUMBER DWYYVY) IMU/OD/YYYY) LBdeiS ',
GENERAL t1ABLL$FY BP000109 10123P2010 1012312011 EACH OCCURRENCE $ 1>000,000
X COMMERCIALGENERA UABILRY PREMISES(EattcvneAce) 1$ 100,0
CCAIMS-MADE OCCUR MED EXP QArryO�P{'Z S 10,000
A PERSONAL.SADYIPUURY is 1,000,000
GENERALAGGREGATE $ 2,000,00
GEMLAGGRETG�ATELMATAPPLESPER; PRODUCTS-COMROPAGO E 1,000,00
7X POLICY I I PECTRO- $
LOC
AUTDMOSILE uABUJTY 621219 02O6121111 021'0612012 .. . ;,I' $
ANY AIfeD
BODILY INJURY(Per RCrsdOi $ 250,000
ALL OWNED SCHEDULED I
B AUTO$ X ALTOS BooarlNnmr(ve,a¢reerA) $ S00,000
X HIREDAUOS X AUTO SED Pera¢ideek $ 2S0,00
E
UMBRELLA UAS OCCUR EACH OCCURRENCE $
EXCESS UIB CLAIMStAIAOE AGGREGATE $
DED RETENTION$ jS
0 woRR COMPENsAroN WCC500601801201 10/0312011 1010312012 X
�ANDEMPLOYERS'LUMBAITY. TORY LNdIIS ER
ANYPROPRIEfOR ARTNERIEXECUTNFa MIA E.L.EACH AGCIOENT (S 100,0
OFRCERR1Et5ER EXCLUDED?
(Maddem>Y id Nell EL DlsEase..EA EMPLOYEE$ 100,00
000
¢yes,dexAeddwer
DESCRIPTION OF OPERATIONStrefar I EL DISEASE POLICY LaUT'S SOO.00
OESCWPTION OFOPERATIpNS I LOCATIONSf VENCLES(AN ACORDIOLAdddlOnsl RCmANCn SeOdddlc,nmAnsewoe is,e@dm@
V_CERTIFICATE-HOLDER CAMELLATION
SHOULD ANY OF TH ABOVE DESCIUMD r4nJC1EE RE CANCELLED BEFORE
THE EXPIRATOJN E W���E111R�EOF,NOTICE WILL BE DELIVERED IN
ACCORDANCEm WE.rydUCYmovrsi0NS.
Carl Salmons-Perez AUTROR R //AfJ
3 Salem,
Street �w 6�
Saleem, NA
//
- 014VACOR CORPORATION. All rights reserved.
ACORD 26(2010NS) The ACORD name and logo are regist4d marks of ACORD 1
t ,1\ CITY OF SALENt
t: ,1/ PUBLIC PROPRERTY
DEPARTMENT
vlulrl
I!C 1VA,rnAr,ht.\iIACYI' • i.11FM..\t.hr.11.I tt rl I n,i l'/7,',
\\'urkera' Cumpenaa(lon Insuruncr\ 1 illc•rn UOdaviC llullders/Cdntracturs/Ele trlclanyplumb@re
In unnaUo
Pf .� In Le 'hi
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Phone il; 5-�3-
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Linys4lf
u)ceY(cull.nd/ur pvrt•tint-).• huvu hirvJ Ih-vuh•cunnacwn �' ❑New'unatructivn
a tale proprietorar pu/lner• limed . eeRoil have no cln lu cva • ❑Remodolins
ng fin me rn y i3paclty. -vats n bonp.�munn.ctors vo
orkers'cutup, insuranceQ We are a cnlpontion and its q' ❑Ouddind adaniun
It) 'Orcers haw-uveminud theirhulrleuerJuing all work riyhlureieln tiara 10'Q Eleerried«pain uradditions
.(t\'O workers'comp• c. I31, ¢I(�),lnd%vs. vlooI LQ Plumbing rcpuirs ur aJditiuryco rcyuired.l t I I.Q Ruul'mpuin
ampleyeva. INC workers'
cnmp< invurancn myuired I]'Q Other
"f.rpphcua Ihm.•hcb la•�I mum JW till,nrr I
im-he r,ymrir Ibis arlldmvit ilwlruin , w#join,,
halal- Wrt as IMir mi,ilim rwnpumrmrluw
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Ird 01-la,liu,rJ J vw,Ihmiov the 0,3410 or tho rub,&vt rasa mWl it%, a raw rinJava in,llayl,n
1 tun un enryloy-/that lr p/uv/r//nr Ivurk-q'curnprnmNoe lm.ranrnce/L-rny rrn .��IYer ru,y,rra a•wa.
ra'mI•laJ,cy,nlbr,mollua
in/�rnrurAna A� p/J ra.R Bduty/i rAe pu/ley ens//ol.tir�Invuranvu Cunopaty Nmnt/-r�S 6C�q.-�.e�
1111"'y if Of SvlGina. Lie.rh WC�(opI !f-jj 2(:�>/ i
r EApimltan O,Ue:
)vb Site \Iltlrcia:��1 f S `f" �Le � Ki o4-
.flick if cu I'-- ('Ily'slateiZlp: C9/ go;,
VY arlhe workers'cumpenlilift"policy Juclarallun puye (thowlnq the Polley numb--and ecplrarlu■ dote).
I;,tlury to ,'cure cur ervye as required under Sculivn?J/\ ul'SIGL e. 152
eau lead to the iropasition o/'criminal ltonolrip oh
^'e lyr In 1'I JnO,lln inalur uu-•yea impri.vlm,nunt, .rr wvll4.v civil(letlulllus in the runt aria STOP WURK ORDER and a riot
of up rn i?iQ/M a Ju I
Ln;.m• Y Iluitul di♦ r6tl.uor. II'aJn.a'd Ihw a copy oflhla.dales the may be ST arJ'J to the RDE of
�utnlnr v(;liu 1)1,\ :qr m.nr.-'cc cuvcrd •u ,cnlic.lion.
/,/u/h•rrey r. i/y rurJ.v dry/r,ri t,rrrJp/nu/lie--
rprr/try/her,drip irr/-/nIY/IOO yNYir/-1/YO-r'-%! co//t cR
rf//lriu/rnr mdy. pu.rnl rvrir-in dlir drru, lu d
-ru'•ry/end ty dry u/brute o//lrivl
( ilv or Town;
I„uin —_— ---- Fermi//License o
y .\ulhanty (eircfa vne1;
I IL•.IrJ "(IIr.Joh t. Iludrbny U,p.unllent I. Cil,.'1'o,r❑C'Icrk J. C•'Icetriall In, tccNr :,
G. ILhe♦
I (`lumbiny Inrycrtor
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information and Instructions
h ter 1 iI 1Cywres all c every
`°+on In the fary tee at anothercwi let instruction,,,,,
:untnct f hire tilt thcir s
�Lu�.nhu.:eusucnarrlLiws: uy evar) P
an em /urge is JetineJ as
{h,rou.utl r rlrl '14cj. j d. P i _ two Of Indfe
Prowl or tmphCJ, oral or wniterL" urauon ter nlhcr Icgal cnnry, n Illy
Iu
�n Cmplupdr li JctinCJ as"an mJrviJual, Pur,nenhip, diiiii auoe,nor➢ ees. however the
nee, and mcluJtng the legal rcpreseutativcs of a deceased employer,or I t
,�J to a lulnt cntcrp auuo or other legal.noty.cmpluytn{employ
„I the laregolng c,g L' +tmershlp,asses
'"diver fthe
or dwells uF.ut se having p to be an employer.'•
to a rions to do nAinidnunce.cunstructioloo�nent be Jaemod to b dwelling house
owner of a I(Ublc dwelling having not more than three aparfl^anu and who reaiJeti theraln or the occupant d °
.IwClhn i huusd of aaolhd( who emp Y• Pa
the grounds or building appuR+^ant therero shall not because of such emp Y
net shag withhold the Issuuea or
�SC(6) also sous that"wary slate or local Il0jesing 1 .-,Y
�IGL ally
chapter 132, �_ ulrad:'
/tense or D ce of CumPgrea wltY the Insurance c li cd{iubJ)visions shill
ren+ivrl otr I +rnslt to uyerare a Auslnits or to coestruct bullelln{s 1e the eomsn,trage re for 44-
raducsd uccdpoable evldee ol'iu po
who has not p �N',w r the commonwealth not anY • ,um liautee with the insurance
Ileum , s anus anCa ut� V
�rDP _�C171 c cable evlJ
•L vhu ter I S , i •. work until act 1
\JJiltonully, �lCa D ca ut ublw
enter into any Co^tract for the P+rfamran P
requiromenls ui this Chapter haw bean presented ro the contructin{authority,'•
A llcsnls l to our situation cold,if
VD etel ,by checkin{the bones that upp Y Y
cusauon affidavit completely. nibs ,y Mang with chair ednificutolA than the
' comb one nu r( es other
workers* and h em to u
ll out the ,1rt +s) P with no P Y
u aJ W P
Please tructompanies(L Psrwutance. i L ) have
nacv►sttry, supply sub•eon
w carry wohdrs' compensation subotilstd to the Dep uotrnam Of Industrial
insw:rnce, Esmond Liability Companies(LLC)or Limited Liabilityins
rnembdrf or p utn+n, an nut required
employees,a Policy is required 9e advised that chit a►lldsvit Inay united. not the O,tPastmcnt of
\cciJanu for contlrma►iun of instsrsneo covdroge. Alse be sure to sl{e teed Jute the ufllJevl4 The affidavit should
t the Permit Of Ifcdfu is being rcq
You have any 4uest Obtain is worker$'
ioru regarding the law ter if you tee required ton°see should enter their
he rculmeJ w the city or town that the apD :t stoiha nu nber listed below. Sdf insurvd comp
I ndustriul ,\cuidanu. Shouldcall the Oep
Compensation policy. Please
sulf•insurrnce license number OR the a ro riute line.
_ aty or rawe OMcLU P ar.d ut tho bottom
rioted Icgtbly. The De artmant has provided u sD' � the applicant.
MCaae he wro that the affidavit is complete and p applicant
of the affidavit for you w /ill out in the avert/ the 0111ea of Investigations has to contact your In addition'
Mbar which
c any be
year, need only submit and all davit indicating current
1'I:asd be auto 0 till in the Pdrtni l lidluda nambar which will iv used ah`j ueho IJcO lwrits"Al lucuuununin n ap 1' Y or
that must submit multiple yennie'INJ`s±�J.P,lab site Address"the ur marked it rh+city or town nay bu proviJuJ to the
Policy'.informatioe lif necessary)
wwnl, ,\copy o1'tlte utyldavit Ihat hat bdon ofneiully sump' business of comntereial venture
applicant as proof that a valid aiflJuvit is on ftld t'or Ntust Patmits or licenses. Anew aR sines must m tilled nut eat
year. �o'here a hwne owner or cifizcn is ubtainin{a license or pennU not relate)to any
,lug lica>ia or Permit W burn Idaves ate.) said persun is NOT required ro completc This atfl is a haw my yuuudne.
I h. t)uicC „t lnve,ligutiuns ,could Idle w flank You in aJvanCc Fur your coupuaua❑ auJ should y
hlCa,e Jo nut hesiratd to gtvd us a call.
fhC U:p•uuncnt s xldraie, tulcphuns and fax Wombat. t AuSetft
The Commonweolth of Masco
Dep Ocoe denta
e'of svesdig dons
600 Wasimntlton Street
iloston, MA 02111
fat• M 617.727E 4
900 ext 02 of 1-817•MASSAFE
.vw,,v.may.Gov/din
1
CITY OF S,V-&Ni, AUASSACHUSETTS
Ram(; 0EP.1A-mvir
120 WASHNGTON STREET, 3iO FLOOR
TIM (978) 74&9595
FAX(978) 7�984d
K1J�ERIJaY DRLSCOLL
,MAYOR T HO.."ST.P111"
DIRECTOR OPPLeLtcPROPERTY/9t: DL%IGCOUNUSSIONER
Construction Debcls' Disposal Atfldavit
(required for all demolition and renovation work)
In accordance with the sixth edition ortha State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p is issued with the condition that the debris resulting from
This work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S I50A.
The debris will be transported by:
(name
A-I—
(name of hauler)
The debris will be disposed of in
I�D COh'tWle..Y14LSt�r/Y�ge� S14I✓t4lC '
q (name of r"111,y) , . -
I
(addre!! of PoCi6ty)
G�
4sign re ofpermlt jppliClnt
Id(C
�lassachn.cetts- Department of Public SafetA
Board of Building Reumlationc and Standards
Construction Supervisor License
License: CS 67300
GEORGE W.MCKIE
48 GREGORY ST A.
MARBLEHEAD, MA 01945
Expiration: 7212013
(."ommisxinner Trp: 17645
Office-C'TkfCons — s nminess ega a
- HOME IMPROVEMENT CONTRACTOR
Registration 4011111402 Type:
d
e - : Expiration ]2/1'72012 Private Corporatio n
S CE PAINTING CO Nt C
ij GEORGE MCKIE
i 93 COLLINS ST
LYNN, MA 01902 �r\ �i! q — ii
Undersecretary 'f
Y;
i