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94 NORTH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts ° Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR,7`h EM edition Revs ed Jan ary Building Permit Application To Construct, Repair, Renovate Or Demolish a /, 2008 1� One-or Two-Family Dwelling This Section For Official Use Only Building Permit Nu er: Date Applied: i Signature: q /— '71t4�tyt,L Building Commission nspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers GI y NO/1TN Sr l.la Is this an accepted street?yes V� 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 9 Private❑ Zone: _ Outside Flood Zone? Municipal M On site disposal system ❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP` 2.1 Ownerr'of Record: T e(Pri Address for Service: �-- - � y > � ) � �- 6a3 � ign t �elephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building M Owner-OccupiedZ Repairs(s) ❑ Alteration(s) t$' Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Z Other ❑ Specify: Brief Description of Proposed Work'-: .A 1 2 red »s'*" —T—�� Cll^� .4 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1. Building $ 6tgoo 1. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ 1 S i ❑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: 7T SECTION 5: CONSTRUCTION SERVICES 5.1�Licensed Construction Supervisor(CSL) 1 0 Z G 0 1 61/2-1Zol Z 5. //I✓t OTN�- zC�//'� License Number Expiration Date Name of CSL-Holder List CSL'Fype(see below) (� 7gT 4f ,? SHortd/7R .,o5- /?/9 O/`/OL Address /J Type Description U Unrestricted(up to 35,000 Cu.FL) Signature Cry R Restricted 1&2 FamilyDwelling M Masonry Only 7E1-5'$/'OYS6 RC Residential Roofing Covering Telephone WS Residential Window and Siding SI' Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor CHIC) - TarrC,,,zW7C T, ortiy Crsirt /6Z89Z HIC Company Name or HIC Registrant Name Registration Number Z gS Lc nJj Slfo/!e Oa, �yOS Ls.. /f7>J o/90 z Address y//,7 A ?KI 5 g/ OY$6 Expiration Date Signature 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 ..........0'� No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,��-�G\ as Owner of the subject property hereby authonze 1 " L e 3 to act on my behalf,in all matters relative to wor uthorized by this building permit application. ©/ - may- 1 /U Si nature "caner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I, / G� �•- 1 N ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury 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(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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 1 I O.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.) 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" l 0BASBIr DESIGN GENERAL NOTESSPEORCATIONS: FIT 15 THE INTENT OF THESE DRAWINGS AND OBLIGATION OF THE CONTRACTOR AND ALL SUBCONTRACTORS TO MEET ALL REQUIREMENTS OF THE MA55AOHUSETT5 STATE 'w BUILDING CODE 780 GMR,SEVENTH EDITION AND ALL OTHER APPLICABLE CODES, STANDARDS AND REGULATIONS WHETHER SPEGIFICALLY STATED IN THESE DOCUMENTS OR NOT. 2.ELECTRICAL CONTRACTOR TO REVIEW LAYOUT IN FIELD WITH G.C.TO VERIFY LOCATIONS OF ALL 5WITCHING AND LIGHTING. OWNER TO PROVIDE ALL LIGHTING FIXTURES FOR CONTRACTOR TO INSTALL.PROVIDE SMOKE 8 CARBON MONOXIDE DETECTORS PER CODE REQUIREMENTS. _ 3. HVAC CONTRACTOR TO PROVIDE DESIGN BUILD SERVICES, PROVIDE EXHAUST FANS IN EACH AND EVERY BATHROOM VENTED DIRECTLY TO OUTSIDE. 4. PLUMBING CONTRACTOR TO PROVIDE DESIGN BUILD SERVICES.VENT ALL FIXTURES INCLUDING ANY BOW VENTS AS NECESSARY BY LAYOUT.FOLLOW CODE GUIDELINES FOR CUTTING AND NOTCHING FRAMING MEMBERS. - STORAGE oho »oritE haz: CITY --------------- ---------- I- -- - -------- ------------ --- --- --- --- S PJr a-APPROVa°cOwcr,cRc _.t l::C.AT:7:..? v WE AND t.Q�-anON OF FL' F:e::_;:n: c :: I0,FIRr PROTECTION.DF%�ICE3--F! CC- "i'TJ �'' DOWN r i ';,.`rT t":o lCIGoEG Y,CaF.CO:riP r.. ...w Ll f.:.o�'NITX THE FIRE CODE— BEDROOM 5'-3 3/4' EGRESS WINDOW 20"X24"CLEAR SHOWER 4oxaQ BATH ------------------------------------------- Z— -------- - -- -- STORAGE 22"X78"SOLID DOOR GUT LINE TO MATCH ROOF SLOPE T-71/2" 7-41/2" �a STORAGE babbitt LEGEND PROJECT: SHEET TITLE: DRAWINGk: e s i g InEXISTING WALL O SMOKE DETECTOR 94 NORTH STREET PROPOSED FLOOR A 1 TAVIS R.BABBITT ""=^"' NEW WALL F BATH EXHAUST FAN SALEM, MA PLAN OPTION � 60 BREED STREET LYNN,MA 01902 GM CARBON MONOXIDE ALARM 761-592-9201 PROJECT 4: 210216 1 SCALE: 1/4"=1'-0" DATE: JANUARY 28,2010 ©BABB,IT DESIGN STORAGE DOWN , I IE , OFFICE , , BEDROOM -- --------------- ---- ------------ F ------------------------------------- STORAGE LEGEND PROJECT: SHEET TITLE: DRAWING#: babbitt EXISTING WALL O SMOKE DETECTOR 94 NORTH STREET EXISTING FLOOR TAVIS R.BABBITT A e s i g n NEW WALL ❑F BATH EXHAUST FAN SALEM, MA PLAN .� 1 60 BREED STREET LYNN,MA01902 CM CARBON MONOXIDE ALARM 781-592-9201 PROJECT#: 210218 SCALE: 1/4,,=1'-0" DATE: JANUARY 28,2010 CITY OF SALEM js,El I, i PUBLIC PROPRERTY DEPARTMENT .I\II:' BI V..) NN,`I1 \1 120 W.%il IIRG:UV SrNLET♦S.0 I'M.ANSi Nt TLt:971-745-1595 • F%X:979-741PS46 Construction Debris Disposal Affidavit (required fur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit N _ 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 I It. S 150A. The debris will be transported by: ZCN/Z t name of hauler) The debris will be disposed of in S�YNn,,QICQTx l/�� S �L�+ taddress of facility) Signature of permit applicant Date .lolin.,li i:u. DATE IIRVDm'1' M A-G-ORD., CERTIFICATE OF LIABILITY INSURANCE 02 03/2010 PRODUCER (505) fi97-S36fi THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SALVADOR 5 COMPANY IN9• AGENCY, INC- ALTERRTH THIS E COVERAGE AFFORDED BV OES THE POLICIES EXTEND OR 111 MATH STREFT BRIDGEWATER MA -02324- INSURERS AFFORDING COVERAGE NAIC4 INSURER A:I.LOYD S LONDON ENGT.ALID INSURED Umbrian$La, Thomas A. INSURER B: 531 Federal ru=aaca Rd. INSURER INSURER 0: 1plvmouth MA 02360- INSURER E• COVERAGES 111E POLlG1E5 OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. SUED R MAY REOUIREMEPfT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED DR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIRED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMfTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. pOUCV EFFECTIVE POLICY EXINUTION LMDTS INSR D'L TypE OF 1NSUWlNCE POLICY NUMBER DATE(NMIDW'Y GATE MMIDOMY L N 500,000 O5/06/2009 05/06/2010 EACH OCCURRENCE $ A GENERAL W&CITY LGLOB17O29 DAMAGE TO RENLED S 1DOI QOO X COMMERCwL DENERAL LIppILRY PREMISES EeawlNeAcal J J J J MEDUP A are I s S,onD CIAIM6MADE ❑OCDUA $ 6OOIOOD PERSONALGADV INJURY GENERALAGGREGATE $ S,000�OOO PRODUCTS-CCMPAIP AGG 5 SOOr DOO GEWLAGGREGA&TELIMp17�APPUES PER: POLICY iECT 7 LEE AUTOMONLE LIABILITY J J J J COMBINED SINGLE LIMB S (ED NWtlAIB) ANY AUTO BODILY INJURY ALL OWNED AUTOS / J J / (PPalePnl er S SCHEDULED AUTOS HIRED AUTOS SParOY w l)RV $ NON•OWNEOAUTOS J J J J PROPERTY DAMAGE S (PM BCCgPrtl) AUTO ONLY-EA ACCIDENT S GAMGEUABILITY J / / / OTHE0.TNPH EAACC $ ANY AUTO AUTO ONLY: AGO S EXCE88NMBRELLA LIABILITY J J / / EACH OCC RR CE S AGGREGATE S OCCUR CLAIMS MADE S DEDUCTIBLE $ RETENTION $ NA:STATIC• DTI+- WORKERSCOMPENSATIONANY / J / / T RV LIMITS ER ENPLOYBW LIABILITY E.L.EACH ACCIDENT $ ANY PROPMETORIPARTNERLEXECUTN6 / J E.L DI5EASE•EA EMPLOYE $ ,FICERWMBER EXCLUDED? J / BYE d�beuBSer E.L.DISEASE-POLICY LIMIT $ SPECIAL PROV161ONS BOIW OTHER J J J J J J J ! 'pEBORIpTION OP OPERA'RING'I.OGATONENENICLEfJEzcLUSIOHB APYEY BY ENOORSEMENTISPECIAL vROwSIONS RESIDENTIAL CApimmY F=USIONSI ROOFINGINEW CONDO/TONNBOUSE CONSTRUCTION CERTIFICATE HOLDER CANCELLATION ( _ (976) 740-9646 SHOULD ANY OF THE RUM DESCRIBES POLICIES BE CANCELLED BEFORE THE Attn;Building/lnap®Cticn Dept EXPIRATQN DATE WMEOP, THS ISSUING INSURER MALL ENDEAVOR TO NAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City/Town of Salem FAILU ET000SOSHALLIMPOSENOOBUGATIORORLIABILITYOFANYWHOUPONWH INS RCR ITS AGENTS OR REPRMENYATIVES. ALT OR2ED REP TATIYE Sa-ezu OACORD CORPORATION IBSR ACORD PS(2DO1108) Page 1 m 2 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain polices may require an endorsement. A statement on this Certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,extend or after the coverage afforded by the policies listed thereon. I A5131)25(2001109) Pspy m z INS025(otoe7.w AM$ The Commonwealth of Massachusetts Department of Industrial Accidents [' �i Office Investigations fI of 600 Washington Street Boston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information --��-- / Please Print Legibly Name (Business/Organization/Individual):�at0r�/f LEtiQ Q�/� m ('oq«p T•f Address: 2_S5 Lynti .S o ze- elzi, re City/State/Zip: L s,n /%f O/yoZ Phone #: 79l-ram/ OY�� Are you an employer?Check the appropriate box: Type of project(required): 1.9 I am a employer with / 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Z Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. o workers' com right of exemption per MGL Y [N P• 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp, insurance required.] *Any applicant that checks box d I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. CC /' Insurance Company Name: 69- fginitY C-AJv-314, J✓R9ata �o�n�ya f Policy#or Self-ins. Lic.#: Z00,7 P? 76 Expiration Date: t 12 /ZO1O Job Site Address: 9 c/ 111CR7 H 5 , City/State/Zip: . 60,yr ww, Attach a copy of the workers' compensation policy declaration page(showing 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 and/or 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 hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: 1127 hat Cl Phone#: Official use only. Do not write in this area,to he completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: