6 MONROE ST - BUILDING INSPECTION (2)r
so ( lot 3(,0°-b
ILI The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
(o (rlOno!ea l Sn{
1.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 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 a 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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
St4�4/►t� /hA
Name int) City,State,ZIP
6 10 -7-309-79(0( AM&7H(e2<N#Mc 60IRR,'um . e�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building A Owner-Occupied ❑ Repairs(s) X I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': T U
ef4im-claa der, Z N w
U6 rN .
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials '
1.Building $ 3 50 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS—08P'fr8'7 -1/aW/t.
tTP-(fiF2 N /\p(Gk License Number Expiration Date
Name of CSL Ilolder -List CSL Type(see below) V
l R C142 k tf+
No.and Street Type Description
�f4NV E Unrestricted Buildin s u to 35,000 cu.ft.
R RRestricted 1&2 Famil Dwellin
City/rows,State,.ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
78/—°1r3-3oa9�i ✓.X"AQ hbfmoix. cckh I [ I Insulation
Tele hone Email address D Demolition
5.2 Registered Rome Improvement Contractor(HIQ lbS�2y211 IZOIG
kt tt-enodet and (onf-Fxtrc,4 dh HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address .
Pt4Nd22f,MV dr923 ��'►-q13-3oo)
-City/Town,State,ZIP 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 ..........)4, No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/J
1,as Owner of the subject property,hereby authorize { d I-eA T4 f tk
to act on my behalf,in all matters relative to work buildingauthoriz permit application.
Print O er's Namb(Electronic Signature) ate
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
con 'ned in this application is true and accurate to the best of my knowledge and understanding.
Pr' 's or thorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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(FUC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dam.
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"maybe substituted for"Total Project Cost"
A CERTIFICATE OF LIABILITY INSURANCE 77E(;�;8i18r)14
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:
Circle Business Ins. Agcy, Inc PHONE FAx (978) 777-4888
41 (978) 777-5619 A/ No:
247 Newbury Street ADIraEss. PaulaHalas@CircleInsurance.net
Danvers, MA 01923 INSURERS)AFFORDING COVERAGE NAIC#
INSURER A:Travelers Insurance
INSURED INSURERS:Safety PrOpertV 6 Casualt
KLA Remodeling Construction INSURERC:AIM Mutual
Jeffrey Rich INSURERD:
19 Clark St
INSURER E:
Danvers, MA 01923 INSURER 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 REDUCED BY PAID CLAIMS,
ILTR TYPEOFINSURANCE ADDL SUBR POLICY EFF PIXJ CY FXP
POUCYNUMB ER MOON MMODIYYYY LIMITS
A GENERAL LIABILITY 6BOOE62352A 2/8/14 2/8/15 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERALLIABILITY DAMAGE TO RENTEDPREMISES Ea o,urrence) $ 300 00
0
CLAIMS-MADE LKI OCCUR MEDEXP(Ar,ore pmsm) $ 5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE L IMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2 000 000
X POLICY PRO_
RO LOC $
B AUTOMOBILELIABIUTY 6222545 5/18/14 5/18/15 EONBINED SINGLE LIMIT a arcroe,t) $
ANYAUTO BODILY INJURY(Per person) $ 100.000
ALL OWNED SCHEDULED
AUTOS X AUTOS BODILY INJURY(Per accident) $ 300,000
HIREDAUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS eraccident 100,000
8
UMSRELLALIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
LIED RETENTION$
$ t
L. WORKERS COMPENSATION AWC4007028707 4/1/14 4/1/15 X WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y/N
ANY PROPR IETORtPARTNER/E XECUTNE E.L.EACH ACCIDENT $ 100,000
OFFICERMIEMBER EXCLUDED? NIA
(Ma dabry in NH) E.L.DISEASE EAEMPLOYEE $ 100,000
Ifves describeunder
DESCRIPTION OFOPERATIONSbelow _7 E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION F O 0 OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 707,Additional Rerrerks SchetlWe,if more slate is requ red)
CERTIFICATE HOLDER CANCELLATION
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.
Building Dept.
120 Washington St AUTHORIZED RE PRESENTATIVE—
Salem, MA 01970
Janet Nichols -
-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail:
License or registration valid for indrwdul use only I.
tratioa date.If found return toulation
before the,exp'
Mice of Consumer Affairs&Business Regulation office of Consumer Affairs and Busin Reg.,
ME IMPROVEMENT CONTRACTOR. Type. 10 Park Plaza-Suite 5170
gistra0on t 5324 , DBA- 06ston>MA02116
xpira0on r2MM-
D '
K.L.A.REMODEL
19 CLAR ST , ' /�,[0
f
JEFFREY RICH (f= _ 3 f�, g
j K �:� —� _• of vali without signature
MA;01923 Undersecretary - . -., _--C4
_.. J
Massachusetts -Department of public Safety
and Standards
Board of Building Regulations
Construction Supervisor -
License: CS 088883
J ZFMY N R1CW
19 CLARK ST `
Danvers MA 0193.3
11
Expiration
02124/2016
Commissioner .
K.L.A. Remodel & Construction
19 Clark St, Danvers, Ma 01923
781-913-3009 Jn.rich6Dhotmail.com
CSL # 088883 HIC # 165324
Contract:
Homeowner: 1 Z' � T-
Address: s
Contractor: Jef6Rev xt"c �
Address: (�[4 vy2�/ Ica d Rz
Date: Slm ll L/
Contract price $3,350
Deposit $1,500
Payment $1,850 after completion
Permit will be acquired by contractor.
***All materials are guaranteed to be as specified.
** *All materials,labor, and taxes are included in price.
***All Labor is to be done in a professional standard of workmanship.
Thank you for your business.
Jeff Rich
K.L.A.Remodel and Construction