182 NORTH ST - BUILDING INSPECTION (3) -tLf 30
� The Commonwealth of Massachusetts
<,a Board of Building Regulations and Standards R-E 'V E, CITY OF
tV)$ Massachusetts State Building Code, 780 CMR"PECTIO AL SERV.ftUEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate x bi pe a
One-or Two-Family Dwelling b '3
This Section For Official Use Only
Building Permit Number: Date Applied:
In
.4 Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
— 182 North Street
Lla Is this an accepted street?yeses_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
IZoning District Proposed Use Lot Area(sq R) Frontage(11)
1.5 Building Setbacks(it)
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 M On site disposal system ❑
Check if yes®
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Michael Becker Salem, MA 01970 -
Name(Print) City,State,ZIP
22 Hawthorne Blvd 978-590-4181 mike@atlanticcoasthome.com
No.and Street Telephone Email Address f
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building M Owner-Occupied ❑ Rep:a: s(s) ® Alteration(s) ❑ 1 Addition ❑
Demolition M Accessory Bldg. ❑ Number of Units 1 1 Other ❑ Specify:
Brief Description of Proposed Work':Create an open floor plan on first floor with a new kitchen and new bathroom.
New Bathroom with 3 bedrooms on the second floor. New roof and new siding
Partially finish basement(right half). No bedrooms in basement!
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 40,000 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
7,000 ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 8,000 2. Other Fees: $
4. Mechanical (HVAC) $ 6,500 List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 61,500 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES "
5.1 Construction Supervisor License(CSL)
CS-109368 09/10/2019
Nelson Silva License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) <J
32 Munroe Street
No.and Street 'TYPe. Description.
U Unrestricted(Buildings up to 35,000 cu.ft.
Haverhill, MA 01830 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
978-729-6601 ncsqeneralcontractinq@qmaii.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
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 ..........12 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 Brian S. Ortins of Ortins Construction, Inc.
to act on my behalf,in all matters relative to work authorized by this building permit application.
Michael Becker 6/10/16
Print Owner's Name(Electronic Signature) Date
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
contained in this application is true and accurate to the best of my knowledge and understanding.
Brian S. Ortins 6/11/16
Print Owner's or Authorized 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(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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) 1300 (including garage,finished basementlattics,decks or porch)
Gross living area(sq. ft.)1300 Habitable room count 7
Number of fireplaces 0 Number of bedrooms 4
Number of bathrooms 2 Number of half/baths 0
Type of heating system Gas Number of decks/porches 1
Type of cooling system Central A/C Enclosed Open 1
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
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Construction Debris Disposa/Affidavit
(required for all demolition and,.renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debts,
and the provisions of MGL e40,S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
lV rC` �Q r. Ll-n1'
(name of hauler)
The debris will be disposed of in:
C� NOrVILa.N II-
(name of facility)
l�Pi e-f+ MA O 211-(13
(address of facility)
Signature of applicant
Date
6/21/2016 Unofficial Property Record Card
Unofficial Property Record Card - Salem, MA
General Property Data
Parcel ID 27-0147-0 Account Number 0
Prior Parcel ID 61 --
Property Owner BERSANI LAURIE Property Location 182 NORTH STREET
Property Use One Family
Mailing Address 184 NORTH ST Most Recent Sale Date 11/28/2005
Legal Reference 25119-577
City SALEM Grantor MCPHAIL KIMBERLY A,
Mailing State MA Zip 01970 Sale Price 210,000
ParcelZoning R2 land Area 0.068 acres
Current Property Assessment
Card 1 Value Building Value 90,700 Xtra Features 2 600 Land Value 72,900 Total Value 166,200
Value
Building Description
Building Style Colonial Foundation Type Brick/Stone Flooring Type Hardwood
#of Living Units 1 Frame Type Wood Basement Floor Concrete
Year Built 1880 Roof Structure Gable Heating Type Forced H/Air
Building Grade Average Roof Cover Asphalt Shgl Heating Fuel Oil
Building Condition Poor Siding Asphalt Air Conditioning OY
Finished Area(SF)1116 Interior Walls Plaster #of Bsmt Garages 0
Number Rooms 5 #of Bedrooms 2 #of Full Baths 1
#of 314 Baths 0 #of 112 Baths 0 #of Other Fixtures 0
Legal Description
Narrative Description of Property
This property contains 0.068 acres of land mainly classified as One Family with a(n)Colonial style building,built about 1880,having Asphalt exterior
and Asphalt Shcl roof cover,with 1 unit(s),5 room(s),2 bedroom(s).1 bath(s),0 half bath(:).
Property Images
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Disclaimer:This information is believed to be correct but is subject to change and is not warranteed.
http://salem.patriotproperties.com/RecordCard.asp 1/1
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: Ortins Construction, Inc.
Address: 22 Hawthorne Blvd
City/State/Zip: Salem, MA 01970 Phone #: 978-979-5007
Are you an employer?Check the appropriate box: Business Type(required):
1.® I am a employer with 1 employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp.insurance required]** 11.❑ Health Care4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.0 Other Construction
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Associated Employers Insurance Company
Insurer's Address: 54 Third Avenue
City/State/Zip: Burlington, MA 01803-0970
Policy#or Self-ins.Lic.# WCC-500-5015916-2016A Expiration Date: 04/22/2017
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�ains and penalties ofperjury that the information provided above is true and correct.
Sign atwe Date 6/21/16
Phone#: 978-979-5007
Official use only. Do not write in this area,to be 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.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. if an LLC or LLP does have employees, a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. I WCC-500-5015916-2016A
PRIOR NO. I NEW
ITEM
1. The Insured: Ortins Construction Inc
DBA:
Mailing address: 22 Hawthorne Blvd FEIN:""'7632
Salem, MA 01970
Legal Entity Type: Corporation
Other workplaces not shown above:
2. The policy period is from 04/22/2016 to 04/22/2017 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTEA 1111
INTER 000001111 SEE CLASS CODE SCHEDLI E
Minimum Premium $470 Total Estimated Annual Premium $1,595
GOV GOV Deposit Premium $417
STATE CLASS
MA 5437 State Assessments/Surcharges
$1,240.00 x 5.7500% $71
This policy, including all endorsements, is hereby countersigned by � 05/05/2016
Authorized Signature Date
Service Office: A J George Insurance Agency Inc
54 Third Avenue 16 Foster Street
Burlington MA 01803 Peabody, MA 01960
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used whh Its permission.