185 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts
� Board of Building Regulations and Standards CITY OF
W 117 Massachusetts State Building Code, 780 CNIR SALEM
W Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Sectio'FOr Official Use Only
Building Permit Number: Date Appl
f r3.
Building Official(Print Name) Signature Date.
SECTION 1: SITE INFORMATION
1.1 f-
1.3ddress: 1.2 Assessors Map & Par 1 Numbers
/ /Vo r�', S+
1.1 a ccepted street?yes_ no Map Number Parcel Number
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 Private❑ Zone: _ Outside Flood Zone? Municipal Won site disposal system ❑
Check if yes❑
SECTI6N2 PROPERTY'OWNERSHIP,-
2.1 Ow a tafRecord
_ o k t-�C.
Name(Print) 0&,t, ,pp City,State,ZIP �j o
A
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(cheek all that apply) .
New Construction ❑ Existing Building I Owner-Occupied ❑ Repairs(s) ❑ .Alteration(s) ❑ Addition ❑
Demolition El Bldg. ❑ Number of Units oZ Other ❑ Specify:
Brief Deescr'pti n of Propose Work c �-%, f>. .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item ,
Estimated Costs:
Official Use Only,
Labor and Materials)
I. Building 1. Building Permit.Fee S Indicate how fee is determined:
2. Electrical S 11
❑ Standard City/Town Application Fee
v O ❑Total Project Cost',(Item.6)x multiplier x
3. Plumbing S c9U p 2 Other Fees: S
{, Mechanical (HVAC) S O List:
5. Mechanical (Fire $
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6, Total Project Cost: S a Co 0v 0 ❑paid in Full ❑Autstanding B:dance Dua:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C S _ 03 a err/ 3"
LE, License Number Expiration Date
Name of CSL Iloldcr Y (�
a 3 L, 3 I c- d) List CSL Type(sae below)
No. and Street Type _ Description
./ O �Q U Unrestricted Buildin s u to 35,000 cu. ft.)
9� ,� kA4 -G (9-n R Restricted 1&2 Family Dwelling
Ci /Town, State, ZIP Nl Nlasonr
RC Roofing Covering
WS Window and Siding
/ T r G/Z.4 ovG 't .9.w Sr Solid Fuel Burning Appliances
(2��(o1'S a�� 4e) L_ C .0 ✓` 1 Insulation
'rele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number Expiration Date
HIC Company Name or IIIC 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 .......... ❑ 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
to 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: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contai m u • @I'cation is and accurate to the best of my knowledge and understanding.
2- Y- / 3
Print Owner's or Aut ized 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 M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.ncus.'•ov/oea Information on the Construction Supervisor License can be found at www.ntass.•o�dM
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 oftireplaces__- Nuntberol'bedrooms _ --
Number of bathrooms Number of halt/baths _
I'ypa of heating system -- _ _.-- Number of decks/ porches- -
fypeofcoolingsystem_ --
..). `'Fotal I'loject Squure Footage" cony be Substituted foi-"'roml Project Cost"
A
f
Vr,
-� CITY OF &U1 EM3 —uSACHUSETTS
BL'ILONGDEPARTJLEIiT
la,t 130 %V-ASNLNGTON STREET, 'FLOOR
T FL (978) 745-9595
KI.NMERLEY DRISCOLL F.kX(978) 740-984d
tiL1YOR TItOSLLS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG COMMISSIONER
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,NfOL c 40, S 54;
Building Permit 1# is issued with the
ng from
this work shall be disposed of in a properly licensed waste disposal facility as defined bt the debris 1ttMGL c
111, S 150A. y
The debris will be transported by;
o T✓z�,�,/-z
(name of hauler)
The debris will be disposed of in
rz
(name of facility) _
(address of acility)
azure of permit applicant
date
.tcbris,IY,Lw
i� CITY OF sauEm, jNL s&kcHusETTS
BUILDING DEPARTMENT
•� j ' '_ �a I20 WASHLNGTON STREET, 3a'FLOOR
TEL(978) 745-9595
FAA(978) 740-9846
KINIBEtIZY DRISCOLL
THO
MAYOROMAYOR MAs Sr.PIE.aRrf
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO3LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r ilicant Informatlnn Please Print Legibly
Name(Busitx's. OrgtnimtiaNlndivitival):
ir—
Add �4a Fr- Pe—.!2 A A, ( & t
City/State)Zip: tyTJ ll C)CFUPhone M:__
Are you an employer?Check the appropriate sr Type of project(required):
I.0 1 am a employer with 4. I am a general contractor and 1 6. ❑New construction
employees(ibil and/or part-time).* have hired the subcontractors
2.0 1 oars a sole proprietor or partner- listed on the attached.sheet t y remodeling
.ship and have no employees These sub-Contractors have S. Demolition
working fur me in any capacity. workers'comp.Insurance. 9. 0 Building addition
(No workers'comp.insurance S. 0 We are a corporation and its
required.)
officers have exercised their l0.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,01(4),and we have no 12.0 Roof repairs
insurance required.)t employees.LNo workers'
comp.insurance required.j l3.❑Other
•Any appllcam that chuck,bar rl must also all out the seclioe below showing their wakws'compeomdon Policy inl'urmaton.
'I btmeowncm who submit this azadavis indicating they am doing all work and than hire outside contractors main submit a new a(1(davit indicating such
:Cunuautors that chick this box mtnt aeached an additiundsheet showing the onme or the NbSenlnciprs and shalt worksn'comp.policy intoma lion.
I are an employer that Is providing workers'compensadon Insurst jot lay employees: Below Is the polley and fob site
injaroradon.
Insurance Company Nome:
Policy 4 or Sclf--ins. Lic. N: Expiration Date: '
Job Site Address: -/tJ- GC/c7 �1� City/Statr/Zip: 5r' ( 42 —�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dato). _
Failure to sccuru coverage as required under Suction25A of MGL c. 152 can lead to the imposition of criminal penalties of it
tine up to S 1,500.00 and/or one-year imprisonment-as well as civil penalties in the Corm of a STOP WORK ORDER and a line
of up to S230.00 a Jay against the violator. Ile advised that a copy of this statement may be rurwarded to the Office of
Investigations of ilia DIA for insurance covcrago verification
I da hereb I the pain and penalties u/per/uryT�al the infurmutlmr provided ubave is true cord correct.
Kara: a
I0/Jicial use ady. Do nal wtile in this urety to he cauple/ed by city ut lawn u/Jlelat
City nr Tuwn: Permiul.1cense 9 _
1Nsuing Aulhorily(circle one): --_—__—
I. Rourd of llealth 2.Building Uepartinunt J.Citylfmvn Clerk 4: Electrical inspector 5. Plumbing Inspector
6.Other
Contact Person: _. phone lt'
i
John R. Olson Columbia Insurance Agency, Inc.
President 31 Central Square
Lynn, Massachusetts 01901
(781) 598-5000
(800) 559-5553
(781) 598-4440 (FAX)
www.columbi ainsurancea gency.ne t
February 7, 2013
City of Salem
Inspectional Services Department
120 Washington St.
Salem, MA 01970
To whom it may concern,
Accompanying this letter please find a Notice of Assignment for Fiducial Properties, Inc. effective
February 2, 2013 with AIM Mutual Insurance Co. I will request a certificate of insurance for the City of
Salem immediately but the insurance company is allowed a number of days to produce the certificate.
Please accept this Notice as proof of Fiducial's satisfying the workers compensation requirement in
order to secure a permit.
Please feel free to call me with any questions.
u rs
truly,
hn R. Olson
NOTICE OF ASSIGNMENT
EMPLOYER: COMBO I.D. STATUS OF EMPLOYER
FIDUCIAL PROPERTIES INC 000969929 Corporation
961 BROADWAY
SAUGUS, MA 01906 _ COVERAGE GROUP
1021742
Coverage under this assignment
The Waiver of Our Right to applies to Massachusetts
Recover from Others Endorsement operations only. For coverage
is available on Pool policies. outside of Massachusetts, contact
Contact your agent for details. the appropriate Pool or Plan for
that state.
INSURANCE COMPANY:
J
AGENT O INSURANCE AGENCY INC AIM MUTUAL INS CO
OR OHN HN OLS OLSON Judith Barr
PRODUCER: 31 CENTRAL SQUARE 54 THIRD AVENUE
LYNN, MA 01901 P O BOX 4070
BURLINGTON, MA 01803-0970
AGENCY FEIN:042456114 (800) 876-2765, Ext: 8704
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
REMUNERATION
-------------------------------------------- ----- -------------- ---------- ----------
CARPENTRY NOC 5403 $10,400 9.61 $999
ROOFING NOC & YARD EMP, DRIVERS 5545 $0 30.99 $0
CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 5645 $0 8. 68 $0
CARPENTRY-DWELLINGS - THREE STORIES OR LESS 5651 $0 8.68 $0
EMPLOYERS LIABILITY 100/100/500 9845
STANDARD PREMIUM $999
EXPENSE CONSTANT 0900 $250
TERRORISM CHARGE 9740 $3
TOTAL POLICY MINIMUM PREMIUM $500
TOTAL ESTIMATED PREMIUM $1 252
DIA ASSESS. 4 .2% $42
TOTAL EST. PREMIUM PLUS ASSESSMENT $1,294
INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $1,294
IS NOT-A BILL _
COMMENTS
Coverage effective 12:01 AM on 02/02/13 .
Coverage under this Notice of Assignment applies to the captioned entity only. If
coverage is required for an additional entity, the employer must submit an application,
check, and an ERM to the Pool for the additional entity.
DATEOFNOTICE: 02/07/13 PREPARED BY: Evelyn Cobb
EXT 522
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street • Boston, MA 02110
(617)439-9030 • FAX(617)439-6055 www.wcribma.org
NOTICE OF ASSIGNMENT
LETTERID: * * VOLUNTARY DIRECT ASSIGNMENT
3916412
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street• Boston, MA 02110
(617)439-9030 • FAX(617)439-6055 • www.wcribma.org
!'lassachusetts - Departmeet of Public Safety
Board of Building Reguiat!ons and Standards
f l,t!tul n i,. i
'cens< CS-032181 ,
MICHAEL E ROSEN
23 LEBLANC DR-' +`
WEST PEABODY MA 019601
J.2...
umm.usion 03/17/2014
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