29 NURSERY ST - BUILDING INSPECTION ",' X �" tl�e The Commonwealth of Massachusetts CITY
° Board is Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM
Revised January
Building Permit Application To Construct, epair,Renovate Or Demolish a 1, 2008
ne- r Two-Famil Dwelling
Tlis Section Vr Official Use Only
uilding Permit Number: Date Applied.
Signature:
Building Commissia r/In pe in mgs Date
CTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
ZC)
1.1 a Is this an accepted st O yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
T,),dl K0z) 6wSk1 Z9 Idurgeir-W Sf
�(I Name(Print) Address for Service:
9-7 7y1/- 8 19
Signatu Telephone
SECTI N 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specity:
Brief Description of Proposed Work2: u r cQ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1. Building $ Cicl 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost' (item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ C) q 100 , ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) Q )-�
)
License Number Expiration Date
Name of CSL-Holder � List CSL Type(see below)
_ r Gt.rr� _ ler�1
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.
Signa R Restricted 1&2 Family Dwelling
-7 _ 7 y M Mason Onl
tf-f r)Q
Telephone I RC Residential Roofing Covering
WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registere\d�H6mle Impr�me nt Contractor(HIC)
HIC Company Name or HIC Registrant Nam Registration Number
Addre�J
c2J rC a� rcf SW SCE C1-27- j 3
/ /d:26 l�/ _� s- f�/y- Expiration Date
Sig ure 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 .........4 No ...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, ,Z1 0 O Z Ir w S , as Owner of the subject property hereby
authorize `rh e C'In0-Y+r, P c.i to act on my behalf,in all matters
O ry,�r n i ,
relative to work authorized by this building permit application.
Signature of Owner VDate
SECTION 7b: OWNEWOR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foretEling application are true and accurate,to the best of my knowledge and
behalf. —f
/A_I-1 n P. `_o 0A n
Print N
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
1. An Owner who obtains a building permit to do his/her owm 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.R5, 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"maybe substituted for"Total Project Cost"
/-MON OP ID:SS
/4II`�/20° o6/14112 CERTIFICATE OF LIABILITY INSURANCE °"'�" "'
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CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CRERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESF,NTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 endorseme a.
PRODUCER 978_88-7000 CONTACT
NONE:
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AME,
1tRi Massachusetts Avenue Arc Ne:
North Andover,MA 01845 Ed AIL
Durso&Jankowski Ina.Alley. ADDRESS:
sTo ID .CHIMN-1
MSU S)AFFORDING COVERAGE NAIC I
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DBA Charlene Tobey
62 Orchard Street INSURERS:Liberty Mutual Ins.Co.
Salem,MA 01970 INSURERC:
INSURER D:
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INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
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EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
`SR TYPE OF INSURANCE POLICY NUMBER POLICY ffF POLICY FXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE f 1,000,00
A X COMMERMALGENERALLIABILITY 16802773RS56ACJ12 0~2 06I M3 PREMISES eooamence s 300,000
CLAIMS-MADE I I OCCUR MEDEXP(Anyonepecec) S
PERSONAL S ACV INJURY S 1,000,00
GENERAL AGGREGATE $ 2,000,00
GEN'LAGGREGATE DMIT APPLIES PER: PRODUCTS-COMP,OP AGG S 2,000,00
POUCV PRO- L0 $
ECT
AUTOMDMLEUABIUTY I COMBINED SINGLE LIMIT $
(Ea ecdden)
ANY AUTO BODILY INJURY(Per pemon) S
ALL OWNED AUTOS
BODILY INJURY(Pareaitlerd) S
SCHEDULEDAUTOS PROPERTY DAMAGE
HIREDAUTOS (PW aaaded) f
NON-OWNEDAUTOS $
S
UMBRELLA UAB OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE I f
RETENTION f
WORKERS COMPENSATION WCSTATLr TRW
AND EMPLOYERV LIABILITY
B My PROPRIETORIPARTNER,FJ(ECUTIVEYIN C131S378103011 06106M2 06106M3 E.LEACHACCIDENT $ 1,000,00
OFFICERIMEMBER EXCLUDED'! � NIA
(Mandatory In NNl E.L.DISEASE-EA EMPLOYEE $ 1r000,0()
D SECRIPNONOFOPERATIONSbtlaN I I E.LDISEASE-POLICY LIMIT $ 1,000,80
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(AINeI ACORD IN,AddM.1 Remarb Schedule,Mmorespeceis reetlnun
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
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