4 NURSERY ST - BUILDING INSPECTION (2) � o
A
The Commonwealth of Massachusetts Town of
Board of Budding Regulations and Standards
OW
[VV Massachusetts State Budding Code, 780 CMR, 7'"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One. or Tiro-Fuindw Dsrrlling
This ecnon For Ofliicial Use Only
Building Permit um c Date Applied: 3 d
Flais
: \ 3j
Budding Commissioner/ n" for of Buildings Date
SECTION 1:SITE INFORMATION
Property Address: S+ 1.2 Assessors Map dt Parcel Numbers
orCeY�
. s an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(it)
Front Yard Provided
Yards Rev Yud
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici I O On site disposal system ❑
Public❑ Private❑ Check if 60 W Po Y
SECTION 2: PROPERTY OWNERSHIP'
2 Owner of Record: It (U v r S-e.r N
lt?trla- T k a t r d i P
Na (print Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construclion❑ Existing Building Owner-Occupied Repairs(s).G� Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': r e — cs
a/ i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011klal Use Only
Labor and Materials
1. Budding f '7 17& 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical f 0 Total Project Cost'f Item 6)x multiplier x
3 Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) S List:
5 Nechantcal (Fire S Total All Fees: f
Su ression
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S ( gC) 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5..s1 Licensed Construction Supers isor ICSL) �7 C / Q d q
`.�� MojJ K �t'C� U, ULicennsefeNum7ber Espuat
N,*ne—ul.(SL H 1der I-
aL, (i f C U-(�/fl 'f0 y� Lot CSL Type Ix'e Ifeluwl
AJJ s RSF
Unresirica Restricted JSiynatur %lason RcsidcnnalCoTelephone ResidentialWResidential Solid Fuel Bumm Ann
liance Installation
D Residential Demolition
S,3 Regis
'1 erect HQr�e provemeotC Co,ntracto((HIC) I $
riSa rU
d �a TPiU
HIC Cotn7 Nagse,or)IIC t(y{istJ�rz� �v(�,, ri,�� Regtstrauon Number
1
Address Y'C�h. C( (: l 12491 l b
7 it l --)$a•- �d`�'Z Expiration Date
Signature Telephone
SECTION 6:WORKE COM ENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ARdavit Attached? Yes .......,,. r No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT
I. CT`P� r-Cl V s /�o b e_ , as Owner of the subject property hereby
authorize� t T2 or.S vuc_4 t yn�S • S n C_ to act on my behalf,in all matters
relative to work authorized by this building permit application.
,Y—, $l31109
St nature of Owner Date
SECTION 7-b�OWNEW OR�AUTHORIZED AGENT DECLARATION
►, 1 yflo rl A �s• 'T '�-?L7-'rf�, l� , as Owner or Authorized Agent hereby declare
that the statements and inforrrl tion on the foregoing application are true and accurate,to the best of my knowledge and
behalf. I
r` v'Z
Prin
O
ci
Signature ner or Authorized Agent Dal
Si tied under the sins and nalties of rb r
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 W 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 I MRS. respectively.
2. When substantial work is planned, provide the information below:
Total floors area ISq. FL) (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 halfbaths
Type o(heatmg system Number of decks/ porches
Type of cooling system Enclosed Open
1 "Tool Pro)ect Square Footage' may he suhslitutcd for"Total Project Cost'
CITY OF S.U_E.`I, ,Lkss.kcHusETI-S
_ BL'ILDIING DEPARTNMNT
1,20VASHLNGTON STREET, 3"FLOOR
TEL (978) 74S-9S9S
FAx(978) 740-9846
KImSEALEY DRISCOLL
MAYOR �I?tOhW ST.P[F11tlg
DIRECTOR OF PLBLIC PROPERTY/BL'IiDLNG CMDUSSIONER
Workers' Compensation Insurance Alildavit: Builders/Contractors/Electriclans/Plumben
-kispifeant Information 1 Please Print Legibly
Valne (Busiro �Ort.Vuratiom InLbvedeuwl): Fi lei�ct. UA Cons-T%rocAi !)✓i � U
Address: rc f. Ci rUrt
�a
City/State/Zip: `�U ' n!j�✓ 1rA R- of
1� (` � Phone #:
,%re you to employer!Cheek the appropriate boa: Type of project(required):
1.1�rl am a employer with 4. 0 I am a general contractor and t
—�-- 6. ❑New construction
employees(full and/or part-time)."' have hired the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet: 7. Remodeling
:hip and have no cmployew These sub-contractors have B. i0 Demolition
workin for me in an capacity.
a act worker'comp.insurance
g y p ry• 9. �building addition
[No workers comp. insurance S Pe are a corporation and its
required.( a.Mcer have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repaint or addition
myself(,No worker'comp. C. 152.41(4),and we have no 12,,0 Roof repairs
insurance required.)t employees. (No workers'
I3.❑Other
comp. inwnrlcerequired.j
-Any applicant thus sihoefa ties II MUM aW fill WA the seehios betas showing their Wortm QnVwtvdhe pinky infwmadae
'1 bvrwsswtrea who submw this aNldrvt indicating they ant doing all work and then hint aNide Caeogoors t c A suhmis a new,antthvil indisasinit suck
<',maaYan rhsd thank this boa mud anaehsd an adchlhwcel ah01 showing the rune attthe au►•spdntelont and their wwkar'canny.policy inf anntniee.
I am an employer that Is providing woriters'compirmadom insurance for my employees. Selow/s Air pelley and/as sldt,
information. ��/^ _ �
Insurance Company Name: KA-se, Wo{�S am P_ ��Ih� RU M-e U
Pal icy M or Self-ins. Li`c.�M: W C"V"L`a.b0 9 99�y� ` 3�S�, Expiration Dart:: 1 1-0 O
Job Site Address: N y1�5 I-1 City/State/zip.: J�_�-
Attack a copy of the workers'eon ensatloa policy declarslloe pap(showing the policy cumber and esplradoet date}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil Maltics in the form of a STOP WORK ORDER and a taw
Of up to S250.00 a day against the violator. Ile advmed that a copy of this statement may be forwarded to the Office of
Ina,:angmiona afthe DIA for insurance coverage varitication.
1,10 hereby Terrif undo in n/ a /ties afperyury that the beformadow pro
vided about is trat and correct.
01recial oat atdy. Da not write in this area. to be.ompleted by city or town o/f&iai( -
City or fuwn:
I.suing.ituthonly (circle one): — --- I
I. Ituard of Ilralth 2. Ruildlnu Department J. City/town Clerk a. Electrical Inspector 5. Plumbing Inspector
6. 01 her _
CITY OF SALEM
PUBLIC: PROPRERTY
DEPARTMENT
Construction Debris Disposal Aftida% it
(IVtluiIW Ii,r all demolit ion :wd reno%Aion work)
In accurdance 111th the sixth edition of[Ile State Building Code, 7SO C'AIR wcIion 1 1 1 5
Debris, and the pro%isiuns of SIGL c 40. S 54;
Building Permit If is issued with the condition that the dchris resulting from
this work shall he disposed of in a properly licensed waste disposal I'acility as defined by mGL c
I1I. S 151IA.
The debris will he transported by:
cn ) S �o52L
t name of haul&)
1 he debris will be disposed of in
(name of lau 11y)
LiJJrc.. urtn Jnvl
.��!1141 ltl 31 p.unit .ipphun
,ICI:
ffACORDERTIFICATE OF LIABILITY INSURANCE 5/20 9ol/zs/2ooeTE MA- ONLY AND CONFERS NO RIGHTS UPON THE CERTIFI ATE
o Jr musszanoa Agency HOLDER. THIS I TE DOES NOT AMEND, EXTEND OR
21 ALTER THE COWS RAGE AFFORDED BY THE POLICIES BELOW
1960OSSURERSA COVERAGE NAICO
wsnslk A, bolls Protection
Pitaperald CnnetrnCtion SQMV' ere amurete Hass Worker Comp Rating Bureau
2 Orchid Circle aaowgc Cemnorca .. _.
Burlington Mass 01803 -
eaumle
COVERAGES
THE POLICE HE S OF INSURANCE USIED BELOW HAVE SEEM ISSUED TO T INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REOI/WE18TT. TERM OR CONOTIION OF ANY CONTRACT OR OTHHR DOCUMENT WRH RESPECT TO %WCN THS CERTIFICATE MAY BE ISSUED OR
WAY PERTAIN. THE INSURANCE
AFFORDED
BY TIMED POLICIES
DESCRIBEID
CLANS
HEREIN IS SUBJECT TO ALL THE TERM. EXCLUSIONS AND CONDITIONS OF SUCH
POLICES-AGGREGATEPAID
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A ceelAttanm 6500027957 06/27/2009 06/27/2010 o 31 000,000
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i aulsawtAAwYaAm s1,000,000 _
oe+slAtAsmEwTE $2,000.000
i � � wascTs.owAoaiao s1,000,000
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C APIOYORAFUABARY RH6830 De/13/2006 08/13/2009 aMgJEt t
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AuawrmwAw $500.000
R sc�nlm ABTw -
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8spsrate Cart Has been ordered for bolder Mass Xo "" CAP Bureau
AUtomablie is roglaterod to Raysond Mtagerald
CERTIFICATE HOLDER GANCElA710IN
American Painting Co emus ANY OF TIE ASOVS DODMI® POLKIls BE MM6IED BsaRe RUE malAraa
eATE ataEDYJ TIE rise wages Yet vwn R l a —ma tABReI
2 StaneOod St
NPTIt£la ll! �R MULFR NAN®10 TIE le`r lYT FIaM2 !0 W Sa aaLL
Eerliagton Maas _ asmB No OBUOA1bN aR U&SKITY of AYT nm vial TIC What m AGENTS Is
781-229-0565 B@IIFSBIOaAat.
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ACORID
Richard eertoiino
25 TAM