The URL can be used to link to this page

183 NORTH ST - BUILDING INSPECTION (2) -7Sc-� � The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM ��1 ( Massachusetts State Building Code, 780 CMR Revised Slm• 70(( Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Only " Building Permit Number: DateAppli9d Building Official(Print Name). Signature• Da1e-7T SECTION 1:SITE INFORMATION 1.1 Prop"3 M erty AJdress�j , c L2 Assessors blip Sr Parcel Numbers I Sr r 2th 1 Aa 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(I1) 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❑ SECTION2: PROPERTYOWNERSHIPt" 2.1 Ow cr of Recyrd: 47ine(Print) LoNnr-,ia City,Slate,ZIP > �� 7979yo9 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all than:apply) New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of^Proposed \York': Lg't/ I SECTION a: ESTINIATED CONSTRUCTION COSTS Item (Labor Costs: Official Use Only Labor and Materials I. Building S I. Building Permit Fee:S Indicate how fee is determined: �. Electrical S ❑Standard City/Town Application Fee- ❑Total Project Cost'(item x multiplier x 3. Plumbing S 2. Other Fees: S�7 5 /�� 4. Mechanical (FIVAC) S List: �I---r,/(•} 5. Mechanical (Fire Su� ression) "total All Fees:S Check No._Check Amount: Cash Amount: 6. Total Project cost. S /0( 000 ❑ Paid in Full ❑Outstanding Balance Due: GL4 C--� 10 � � V . SECTION S: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 7D /(3`l License Number Expiration Date Nanic of CSL Holder List CSL'fype(see below) No. and Street TYpe.' Description 7 U Unrestricted(Buildings a to 35,000 cu. It.) /C .7 9✓ XD Restricted 1&2 Family Dwelling C uyfrown,State,ZIP Nlasonry Rc Roofing Covering Window and Siding ' Solid Fuel Burning Appliances (p/7c7�0 a.3�`/ �p�FE�'/� Qi�j-.Z?jiQ%� .CbTele hone Email addressDemolition 5.2 Registered Home Improvement Contractor(111C) IIIC Registration Number Expiration Date I IIC Comp:my Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MIG.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 Wtiance 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' 1,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNERl 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. ---V-✓l,, 4�JL . /a- 2? ( 3 Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 not have access to the arbitration program or guaranty fund under tM.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass. ov:'oea Information on the Construction Supervisor License can be found at www.mass.gov/dps 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 balflbaths Type of heating system Number of decks/porches Type ofcooling system Enclosed Open 3. "Total Project Square Footage"may,be substituted for"Total Project Cost,, a Z® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DOVYYY) 10/23/13 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: Christopher Kokoras Insurance PHONE (617) 522-9000 A/X No: 325 Centre Street E.f,(aL Jammaica Plain, MA 02130 ADDRESS: INSURE IRIS)AFFORDING COVERAGE NAIC# INSURER A:Travelers INSURED INSURER B: Jose Fernandes INSURER C: 7 Perkins Road INSURER D Chelsea, MA 02150 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 INSLRED 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AODL SUBR POUCYEFF POUCYEXP LTR TYPEOFINSURANCE POUCY NUMBER MIDDIY MMOD'YYYY LIMITS GENERAL LIABILITY 6D03957846 10/23/13 10/23/14 EACH OCCURRENCE $ 1,000,QQQ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ S,000 C L4IMSMADE OCCUR MED EXP(Ary one person) $ 5,000 PERSONAL B ADV INJURY $ 1 .000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-OOMP/OP AGG $ 2,000,000 POLICY P RO LOC $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT Ea accident $ ANVAUTO BODILY INJURY(Per person) $ ALLOWPED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIREDAUTOB NON-OWNED 70PERrV DAMAGE AUTOS Paramident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION XASDC1254 10/23/13 10/23/14 WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNERIEXECUTNE E.L. ACG OEM S SOD,DDD OFFICE R/MEMSER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,DDO If yyea describe under DE SCRIPTION OF OPERATIONSbotow E.L.DISEASE-POLICY LIMIT I $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Atlach ACORD 101,Additional Remarks Schedule,if more slece is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN Town of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington Street 3rd Flr. Salem, MA 01970 AUTHORIZED REPRESENTATIVE © 1986 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: CITY OF SALEM DEPARTMENTAL INVOICE FOR CASH PAYMENT Please Remit to Treasurer's Office, 2nd Floor, 120 Washington St., Salem i Department: Date: Individual/Company Name: Payment For: S $ S 8 8 8 8 8 Cash Invoice Total: g Other Information: (if needed) Departmental Signature: Treasurer's Office: Date Received: Signature: CITY OF SALEM, NaSSACHUSETTS i . e BUILDING DEPART`,ZNT ' 120 WASHINGTON STREET, 3iD FLOOR TEL (978) 745-9595 Rux(978) 740-9846 K!\IBERLHY DRISCOLL AVL1Y012 THomAs ST.PtERRa DIRECTOR OF PUBLIC PROPERTY/BUILEiNG CO\LWSSIONER Construction Debris Disposal Affidavit (required for 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 # is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by N1GL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) 23 Li 4 .� � —_`--(address of facility) signature of permit applicant date