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144 NORTH ST - BUILDING INSPECTION (2) / The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY y 0 Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM Revised January Building Permit Application To Construct, Repair, Renovate Or Demolish a 2008 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Nu Date Applied: ry Signature: �' ✓'t ( 10 Building Commissioner/In r Of Buildings Date M' SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers I q Y kJ5Ve-T-H Sr- 21tlt 1 , nitfi 1.1 a 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 11) Frontage(tl) 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❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownerl of Record: Name(Print) Address for Service: - - -781-(931 - ots Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical ❑Standard City/Town Application Fee $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S / T� 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire $ Suppression) Total All Fees: S q Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: S a,,s/v ❑Paid in Full ❑Outstanding Balance Due: - -�1/d�q SECTIONS: CONSTRUCTION SERVICES �- � 5.1 Licensed Construction Supervisor(CSL) pv g(vifq 4 9KK FYZ rr- License Number Expiration Date Name ul'CSS,L--I lulder List CSL Type(see below) rypeDescri Lion Adddrreess,,, /^ U Unrestricted u to35,000Cu.Ft. R Restricted 1&2 FamilyDwellin it Signature pq M Mason Only �T9�� -�3!/ RC Residential RootingCovering relephone WS Residential Window and Sidin SF Residential Solid Fuel Burring A liance Installation D Residential Demolition 5.2eg�ter2H�melm�Svemeut Contractor(HIC) RS� �3 Ii IC Company Name or HIC Re utrant Name Registration Number APW Add 9co-S)l j3S Esp— i nDate Sign Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 , 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. Sianature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I, k icr( L V06f-Vj ,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 3f31 ) !O Signature of er oirAuthorized Agent Date (Signed u the pains and 2enalties ofperjury) 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 Mol have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,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' 'S CITY OF SALEM �i PUBLIC PROPRERTY DEPARTMENT .I'.11. Mlhl - AN'111 �I ., µ Ise 9I'.,+nl.�o;.w5rserr �S.tu�t.�1n+;.0 nl a 1.,:r/•_ 141:971-743.9599 •1:19:971•740.'h146 Construction Debris Disposal Affidavit (required I'ur 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 be disposed of in a properly licensed waste disposal racility as defined by MGL c I1I. S 150A. The debris will be transported by: Pocr W P—ECVCLI A/L (name of hauler) The debris will be disposed or in : (Game ul aci Ity . (address of 'acilily) rue ig t of Ixrn it pplicant sJ3i ht) date ^ U/amm0 !/6 rs• (�.nsv:t�uafeE" - ,yt,• . Board offff Building Regulations And Standards .. _ �.. Construction Supervisor License License: CS 96194 Birthdate:-7/1411967 Expiration:7f142010 Trill 96194 Restriction: 00 Y - S d MARK FREEMAN ro. 11 DAYLILY DRIVE NASHUA,NH 03062 ` ''`"•%�"' Commissioner 1. J Bo i`1'ufU'uii' ing g/F�io.1(kantTe7d"s"- HOMEIMPROVEMENT CONTRACTOR , Registration: 153131 Expiration: 10/3012010 Tr# 275360 Type: Ltd Liability Corpor AJC PROPERTIES DR" .�-., MARK FREEMAN _ 11.DAYLILY DR . . NASHUA„NH 03,062 ldmiiiistrator " . / i The Commonwealth of Massachusetts , Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass,gov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers APPlicant Information Please Print Legibly Name (Business/Drganization/lndividual): AUC QROP'flUT Address: -76 NdYlwtyryZk4J bL,\, q City/State/Zip: NAnA9 lif QWi�;� Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.ETI am a employer with 4 _ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp, insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4),and we have no 12.[v]Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp, insurance required.] Any applicant that checks box Nl 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, tContractors that check this box mast attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name: L03642til V-U`� W% Policy#or Self-ins, Lic. #: .wC 13 I S 31e� N 2®{1 Expiration Date: -7 I It Job Site Address:_19Y A/t31t-TO S7, City/State/Zip: SMVM � tVYlq 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 impnsomnent, 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, f do hereby certify under the pains and penalties of perjury that the information provided above is true and correct r Si nature: �/"� _ Date: 3bl /to Phone, / ' 139`) F[Offficialse only. Do nor write in this area, to be completed by city or town officialown: Permit/Licenseuthority (circle one): of Health 2. Building Department 3. Cityrrown Clerk 4. Electricai Inspector 5. Plumbing Inspector C'ontnet Person: . Phone 4: Clien*.29385 AJ PR ACORD- CERTIFICATE OF LIABILITY INSURANCE 10/2009""Y' 09/10/2009 PRODUCER THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION Eaton&Berube Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 11 Concord St HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O.BOX 1089 Nashua,NH 03061 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURERA Western World AJC Properties LLC INSURER B: Liberty Mutual Ins.Co. c/o Mark&Shirley Freeman INsuRER c: Berkley Risk Administrators 11 Daylliy Drive INSURER D: MBine Mutual Group Insurance Co Nashua,NH 03062 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANV 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ L EFFECTIVEPOUCYNUMBERICY `UWiS A GENERAL LIABILITY NPP1211103 04113/09 04113110 EACH OCCURRENCE a1 OOO OOO X COMMERCIAL GENERAL LMUTY DAMAGE T RENTESG I. D $50,000 CLAIMS MADE ©OCCUR MED EXP(M one Ma1aa) $5 OOO X BI1PD Ded:500 PERSONAL&ADV INJURY $1 OOO 000 GENERAL AGGREGATE $2 000 000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $1000000 POLICY PRO- LOC D AUTOMOBILE LIABILITY KA0113773 W24109 06/24/10 COMBINED SINGLE LIMIT $300,000 ANY AUTO (Ea weBenl) ALL OWNED AUTOS BODILY INJURY E X SCHEDULED AUTOS (Pef oe,aaa) X HIREDAUTOS BODILYY E X NONOWNED AUTO$ (�B�ddw!)ai) PROPERTY DAMAGE $ (Par aoO ) GARAGE UABILRY AUTO ONLY,FAACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGO E EXCEOMMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ B WORMERS COMPENSATION AND WC131S367442019 07/01/09 07/01/10 X I WCSTArU oYH- EMPLOYEW LIABILITY E.L.EACH ACCIDENT $100,000 ANY PROPRIETORMARTNERIEXECUTNE OyffIICER/MEMBER EXCLUDED? YES E.L.DISEASE-EAEMPLOYEE s100000 9PE6 &"PP WON E.L.DISEASE-POLICY LIMIT I$5011000 C GTI46R Workers WC282800204701 06/27/09 06/27/10 $100,000 Each Accident Compensation NO Excluded $100,000 Each Employee FOR NH Officers $500,000 Policy Limit DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS "Workers Comp Information" Policy#WC131S367442019 for MA: Members Excluded:Mark Freeman Policy#WC282800204701 for NH:Members INCLUDED:Mark Freeman CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION """For Informational Purposes""" DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL _10_ DAYS wRITTEN NOTICE TO THE CERTIFICATE HOLIER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IWOSE NO OBLIGATION OR LIMLITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 of 2 #S391141M39113 CBX o ACORD CORPORATION 1980 `T. * Y - - It MASSACHUSET,TS EXTERIOR SOLUTIONS INSTALLED SALES ROOFING/SIDING CONTRACT t INSTALLED SALES SPECIALIST- 1 t �t NUMBER x CUSTOMER .� �3 .��.r]�S' 77 f ',1��. �.'r.�rf� k^ <� i STORE NO 'STREETA DRESS j A =i S STREET ADDRESS 14 A{/ .� ✓ �� Cf /6rflrA CIT,C-� STATE ZIP { f" CITY TAE ZIP ?" J YY, 1�y- _ C <`1:2._3 -,,.. ¢. r0 TELEPHONErt a ``¢,/ //� `� ;tx, TELEPHONE _ 1.i1 A DATE ( LOWES HOME CENTERS INC S MA HIC NO 148fi88 1 cASH enH6 1 ✓ u` FEIN 56-0]48358 .� ^+�r{'r t CARGpi hLCC .„]J N'ti.V`�!f sl y CHARGE drx utT, This is only a quote for the merchantl 6clude with t 9pnnted below This becomes an agreement upon payment"Upon pzymenq the onM1re;agreement,mclutlmg the apecrficsily completed iiages of lhts s * +document the Terms-'and CondNopsiridudetlwtth th1s document and ar,,r It r atldentla and attachments hereto shall beireferretl to hereto as thts Coniracf. L.. w n ,c tea,,. ,y',,; ft R..PLEASE READ ALL TERMS AND CONDITION RE VERSE SIDE OE PA THIS GE AND FOLLOWING PAGES BEFORE SIGNING *< ;t fix t s. .k ' S ON THE INSTALLATION STREET ADDRESrS I j � CI STATE ZIP Color. Style: cr Accessories- Show drawing where shingles or siding will be installed. Contract T?tal 1„ Are'permits required for this installation?: � ]Yes [ ] No applicable tax included LJ�' C�.f NOTICE TO CUSTOMER:Federal law requires Lowe's to provide you with the pamplet Renovate Right:Important Lead Hazati /ntormation for Famll- ies,Child Care Providers and Schools.By signing.this Contract,Customer acknowledges having received a copy of thispamphlet before work began -informtng,C ,stomer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwellin' ariit. Work is to commence upon reasonable availability"of Contractor and/or availability of any sial order or custom made Goods which is anticipated to be `f� .�,t [fill m date]. Estimated completion date is —i'+S pec [fill in date]. Said estimated,substantial completion date is not of the essence. Contingencies that may materially change said estimated completion date follow. (If applicable,insert a statement of such contingencies). IF THE CONTRACT TOTALIS$1,000.00 OR LESS Customer must pay in full. COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: " [(]Customer to Pay in Full; OR [ ]Customer to use the following payment schedule: (1)Deposit $r to be paid upon siging contract.Deposit should be 1/3 the total contract price;and V - (2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe s to do'one of the following-(check appropriate box below): [ ]Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or '+. < [,]Deposit my/our check for,the amount of the payment indicated above anytime after the date this Contract is signed;and ' --(3)Final payment of$100:oo to be paid upon Completion of the installation and both parties'satisfaction. s NOTICE REGARD kGARBITRATIONAGREEMENT FOR CLAIMS COVERED BY M G L c 142A - ,.n LOWE'S AND OWNER HEREBY MUTUALLYAGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNINGTHIS CONTRACT THAT LOWE S MAY SUBMIT SUGH'DISPUTE-TOAPRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT- IVE OFFICE,OF CONSUMER.AFFAIRS AND BUISNESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS.PROL DED1iN A'f.G.L.a947 �.�....., ..,:.... . ? .�.�_..,..- _ -' l Date: _ ,d .,hjff� ' Lo es L,o,],ti Centerst'c.� y..c^� By. t Date: N )yl• — h ;, � a .. s .... .L", .'.`0 '.:mr, w� . "?.`4:W, ds �, h 'T sF, ''rrR "�h,.:k Y'w = ,�,.=;r.;y syr s. IwTM1rs is oNy aqume:fir Ne merchandise and services printed below This becomes an agreement upon payment Upon payment the entire agreement mclutling Me speafically completed pages it is ..�, dowman Me Terris and Contlt6om included with thls:documentand any other addenda:and aHaohments hereto shall be referred to herein as th Contract a PLEASE(READ ALL TERMS AND CONDITIONS ON THEREVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING ."z�{e g �;F`tea' ka4 s� 'yam c T'r £r' " sQ.3I,.♦1�»=fi t.�4 V,aril« ir. ..,::1/^,Y�`.. ,3+ s'r,'kI €.. !'��+F z^ 2s - � a ,']f <�— L ! ti'sI v INSTALLATION STREET ADY CI STATE ZIP fly!" ] S.z .v Style: I. I r. Accessories: _ I r f *Show drawing where shingles or siding will be installed. ' Contract Total " Are'permits required for this installation.?: Yes [ ] No - "applicable tax included �J r w' 5 NOTICE TO CUSTOMER:°Federal law requires Lowe's to provide you with the pamplet Renovate Right:Important Lead Hazard Information for Famil- ies, Child Care Providers and Schools.By signing this Contract,Customer acknowledges having received a copy of this pamphlet before work began s Informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling.unit. Work Is to commence upon reasonable availability of Contractor and/or availability of any special order or custom made Goods which is anticipated ` ,to tie . '�' '"t, .CS `[fill.in date]. Estimated completion date is '.r°1`.: [fill in date].- - . .._ °',. . . ,. - Said estimated substantial completion date is not of the essence. Contingencies that may materially change said estimated completion date follow, r .. (If applicable,insert a statement of such contingencies): IF THE.CONTRACT TOTAL IS-$1,000.00 OR LESS Customer must pay in full - COMPLETE THIS.SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: - PiQ Customer to Pay in Full; OR. [ ]Customer to use the following payment schedule: . (1)Deposit $ .to be paid upon siging contract.Deposit should be 1/3 the total contract price;and (2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation, I/We authorize Lowe's to do one of the following(check appropriate box below):' [ ].Charge'my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or:.- [ ]'Deposit my/our check for the amountof the payment indicated above anytime after the date this Con`ract is signed;and - - --- 3).Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M G 1- c 142A LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT.SUGH-01SPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT- IVE OFFICE OF CONS,AER,AFBAIRS AND BUISNESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION .w,.0 AS:PP 1^ED-'IFP-A71.P.L-C� a;- ......:,.....:.e,..r....d..;t.,._.. By: D Lo a s e,C cters l6cilv By:: �.. --•' ` - Date: e.Zl.s:1J,I(J rOwner Sig at rial ` J T E SIGNATURES I THE—PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED -BY LOWE'S PURSUANT TO M.G.L.c.142A.THE OWNER MAYBE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES. - DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. , BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE.. WITNESS OUR.HAND(S)AND SEAL(S)BELOW THIS ,f 0 DAY OF f//0--l-r h .�P;rJ.✓.� - Lowe's Home Centers, Inc. ( t Special t'tir i? ve - Uwner Spouse Customer acknowledges receipt of a true copy of this coneract which was completely_fjll�d in prior to Customer's execution hereof.You,the buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation form for an explanation of this right. C 2004 by Lowe's.@ Lowe'a and the gable design FXTFRIf1R Cr1111T1(1N Rr1r1FINlf/RIfIINIr;/Rcv 19/not FILE COPY are regtsstered traderrars of LF Corporation.