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1 MOUNT VERNON ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF SALEM Massachusetts State Building Code, 780 CMR Revised Mar 1011 Building Permit Application To Construct, Repair,Renovate Or Demolish a One-or Two-Family Dwelling - - - This Section For Official Use Only Building Permit Number: D Applied: - Building Official(Print Name) ,Signature - .. ate SECTION 1: SITE INFORMATI 1.1 Propewrt�y Address•'/ 1.2 Assessors ap&Parcel Numbers / /�D vN>r dLR.N DN ST' Lla Is this an accepted street?yes✓ no Map Number Parcel Number - 1.3 Zoning Information: a"" 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq In 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: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner o[Record: /2at��� > .r� �Inyloer=cc f'rai 0/97a Name(Print) City,State,ZIP dl(ouNr j/t�4o. 57—. 47E. Sft. Iryo paviow CnMrnt at oek mL-0AJ No.and Street Telephone Email Address ""SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition 0 Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify: Brief Description of Proposed Work2: /c.iic..= ( z) P iv c x Ca 8,w Er- --• Sf�Ecy�s fAn,o T�..,rw r�-ov/4, XrT� rcn, �c.�.Grxr i.rL SECTION.4i ESTIMATED-CONSTRUCTION COSTS ��: .. Estimated Costs: ' x.. Item Official Use Only Labor and Materials .,: 1.Building S 57 00, p-p I. Building Permit Fee $ _ Indicate how-fee is determined. $ ❑Standard CityrFown Application Fee 2.Electrical p 00 0- ov ❑Total'Project Costa(Item 6)z multiplier � ` x 3.Plumbing $ I Other Fees: 4.Mechanical (HVAC) $ List 5.Mechanical (Fire $ Suppression) Total All Fees:$� Check.No."' Check Amount: Cash Amount 6.Total Project Cost: $ f Z o o- o•o ❑Paid in Full 0 Outstanding Balance Due: cQ vU p G��j SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CA2" (�J p h/k kb License Number Expiration Date Name of CSL Holder _ List CSL Type(see below) V ag No.and Street Type. Description J �J &,J C71 4�7 U Unrestricted(Buildings u to 35,000 cu. ft. R Restricted I&2 Famil Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1p Fq(Zis// C*PcaNsr c, CvMc4;T. NE'- I Insulation Telephone / Email address I D Demolition 5.2 ^/R1eg�is�tered Home Improvement Contractor(HIC) 1/-2/ ' 5'9 1.441 x)6" t.or fI7, c floesz H[C Registration Number Expiration Date HIC Co any Name or HIC Registrant Name In rJvn/— rf-- CAPcolvi AGvmrA/r- NE'T- N .and Street 3 S/r Email address Ci /Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.Lc. 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 ...........0� No........... ❑ SECTION 7ac'OWNER AUTHORIZATION TOBE,COMPLETEDWHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize C42--v (244 M IA-,;, to act on my behalf,in all matters relative to work authorized by this building permit application. A11,0 (� to 3�c/'3 Print Owner's Name(EI ctronic Signature) Date 4itoSECTION 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 contained in this application is true and accurate to the best of my knowledge and understanding. %C1 r1 rA1 C•t0'►nw l r n.o � G /3 Print Owner's or Auth ized Agent's Name(Electronic Signature) Date NOTES. 1. An Owner who o_ . . u �u 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. 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.eov/dns 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 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" f f: 71. �a „r„off/ oow� l t+�� Massachusetts- Department of Public Safety Office of Consumer Affairs&Btfsiness Regulation &nU'tlorBuilding Rellulatlnn5 and Standards HOME IMPROVEMENT CONTRACTOR Con structi'on Su pervisor License Registration: ,,4�1999 Type: - 1 Expiration 7&9 QU DBA License: CS 61061 C NIGROCOt6T$ `:E? OW CARLO 3 i CARLO E CAPONIGRO CARLO CAPONICy � s 1598URRILLST 159 BURRILL STs ; a SWAMPSCOTT, MA 01907 SWAMPSCOTT, MAA01;9�OAy ' Undemccretary . Expiration: 7/25/2013' Commissioner Tdt: 17390 ' OP ID: LR CERTIFICATE OF LIABILITY INSURANCE DAT 111151`12 ' 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 781-935-8480 CONTACT DeSanctis Insurance Agcy, Inc. 781-933-5645 PHONNc Ext: FAX Na: 100 Unicorn Park Drive EMAIL Woburn, MA 01801 PRODUCER CUSTOMER ID 0:CAPON-2 INSURERS AFFORDING COVERAGE NAIL 0 INSURED Caponigro Construction Co.,Inc INSURER A:Selective Insurance Co of SC 12572 159 Burrill Street INSURER 8:Technology Insurance Company 42376 Swampscott, MA 01907 INSURER C: INSURER 0: INSURER E: 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. INSR TYPE OF INSURANCE ADDL B LTR EFF POLICY NUMBER POLICYMMID FOLIC EXPYYY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIALGENERALLIABILITY S19164830 11/21/12 11/21113 D E TO RENTED PREMISES $ 100,00 Ee occurrence CIAIMS�E OCCUR MED EXP(Any one person) $ 10,00 PERSONAL 8 ADV INJURY S 1,000,00 GENERAL AGGREGATE $ 3,000,00 GENL AGGREGATE LIMIT APPLIES PER. PRODUCTS.COMP/OP AGG $ 3,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ A X SCHEDULED AUTOS A9092896 06/06/12 06/06/13 1ROPERTYDAh1AGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,00 EXCESS LIAB CLAIMS-MADE - AGGREGATE $ 2,000,00 A 51916483 11/21112 11121113 DEDUCTIBLE $ /�• RETENTION $ NONE - $ WORKERS COMPENSATION X WCSTATU- OTR- AND EMPLOYERS'UABILITY B ANY PROPRIETORPARTNEREXECUTIVE YIN TWC3326129 09/15/12 09115/13 E.L.EACH ACCIDENT $ 1,000,00 OFFICERNEMBER EXCLUDED' �N N I A (Mandatory in NH) MA E.L.DISEASE-EA EMPLOYEES 1.000,00 If ryes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE POLICY LIMIT $ 1,000,00 A Misc Tools 519164830 11/21/12 11/21/13 Limit 15,00 Deduct 50 DESCRIPTION OF OPERATIONS LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more apace is required) Illustration of Coverage CERTIFICATE HOLDER CANCELLATION ILLUS-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ILLUSTRATION OF COVERAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Departrnent of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.Masss,goV144,a Workers' Compensation insurance Afldavit: BuRders/Contractors/L+lectridms/Plumbers A.pplicant Information / Pleas_e Print Lezibly Name nn (Business/organizationdividual): (/ UAAIW C-�,• e Tion c _ . Address: Yl��tit w JT_ 3 f City/Stat,/Zip: 7v R D l o Phone Are you an employer? Check the appropriate box:. Type of project(required): - 1.® I am a employer with 4. 0 1 am a general contractor and I 6. 0 New construction have hired the sub-contractors employees(full and/or part-time).T 7. Remode Listed on the attached sheet �+ 1� 2.❑ I am a sole proprietor or partner- These sub-contractors have 8. ❑Demolition ship and have no employees employees and have workers' working for mein any capacity. 9. ❑Buil1 ng addition. as comp. inslnance.t [No workers' comp. msuian= 10.0 Electrical repairs or additions required_] 5. 0 We are a corporation audits 3.0 I am a homeowner doing all work officers have exercised the r 11.0 Plumbing repairs or additions right of exemption per MGL 12.0 goof repairs myself [No workers' comp. c. 152, §I(4),and we have no . insurance required.]t 13.0 Other employees. [No workers' comp.insurance required.] *Any applicant that checks box 9I must also fill out the section below showing their workers'compensation policy information. t Homeowncrs who submit this affidavit mdieating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached as additional sheet showing the name of the sub-mntraot3n and state whether or not those entities have employ,,,. if the sub-contractors have employees,they most provide their workers'comp.policy number. I inn an employer that is providing workers'compensation insurance for my ernpIoyem Below is the policy and job site information. Insurance Company Name: C, 32-(o f y9 Expiration Date: ni • IS 3 -Policy#or Self-ins.Lic.#: I Wit/ ,3/ Job Site Address: / M�va � (/ L+tiflN ST • City/State/zip: /H J r 1 1�R 01470 Attach a copy of the workers' compensation po&cy declaration page(sbowmg the policy number and expiration date). - Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a - fine up to$1,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up.to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification_ I do hereb erd under naldes of perjury that the information provided above is true and correct Si afire: Date: 3 6:4 3 - PhrrCf11t'Y'Uor' #' use only. Do notwrite in this area, to be completedby city or town officiaLTown: Permit/Licease# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3. City/lown Clerk 4.ElectriInspector S.Plumbing Inspector 6. Other Contact Person: Phone#: