38 OAKLAND ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
ppe(l' 4 Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR
gUUU Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numbers` Date`Appl'
Building Official(Print t time) .'gnature - - Date -
SECTION 1: SITE IN
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
L l a 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 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 ❑ On site disposal system ❑
Check if yes[]
SECTION 2 PROPERTY'OWNERSHIPi'
2.1 Own rt�"o..ryryf �rrd:/' //rr/ u
Name(Print)
—fti��rr �vi
City,State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check,all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': . , f Y roz• w N>"t— AJ 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs:
Item Official Use Only, ,
Labor and Materials
i. Building S 2Uv 1. Building Permit Fee: S Indicate how fee is determined:
❑ Standard City/town Application Fee
2. Electrical S -
❑Total Project Cost',(Item 6)s multiplier x i
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire
_Suppression) I Total All Fees: .S
Check No. Check Amount: Cash Amount:
6, Total Project Cost: 3 ❑ paid in Full Cl Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Coynsh-uction �Siiliervis/or License(CSL) 2 �� J
J�/7Y/ /� License Number Expiration Dale
wt
Natne of CSL holder
L /� r r j List CSL Type(see below) !I
No. and Streit Type Description
U Unrestricted Buildin.s u to 35,000 cu. ft.)
✓�,�T•� t�7 /� R Restricted 1&2 Family Dwollin r
City/rocvn, State, ZIP - - - bl i`4asonr `
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
[ Insulation
"relz hone Email address D Demolition
5.2 Registe ed Home ImproveniqHt Contractor(fii ) /�
Cob— Y C Usi� e FI[C Registration Number Expiration Da e
I ! Company N ne or FIIC Rst�nt Name
/✓e3 11 y< 2 eoi
No. and Str et Email address
City/ own, State, ZIP rele hone
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 .......... Ea�/' 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
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: 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.
_ � Z
tat Owner's or Authorized Agent's Name(Elecn'onie 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 trot have access to the arbitration
program or guaranty fund[order M.G.L. c. I42A. Other important information on the HIC Program can be found at
www.niass eov/oca Information on the Construction Supervisor License can be found at www.ntass.go�'relL
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 tit oplace.s_ __ Number of bedrooms - --____--
Number of bathrooms Number of halt/baths _
type of heating system _----_—___-- Number of decks/ porches -_-__-- --
1'Ype of cooling system_..------- - Enclosed-- _._---_--_Open- _
3. `dotal Project Squaro Footage" may be suhtitutad for"total Project Cost" ----------___- ----
9PROF02 OP 10:JM
CERTIFICATE OF LIABILITY INSURANCE DAT 12105DIYYYY)
2/05/12
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()es) must be endorsed. If SUBROGATION IS WANED,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 endomeme s.
PRODUCER Phone:973-745-3300 SEA
John J Walsh Ins Agency.Inc P O Box 4407 Fax:978-745-9557 ND Ed], No):
Salem MA 01970-BC07 E
John I Welsh Ins.Agcy.,Inc. ADDRESS:
INSU 8 AFFORDING COVERAGE NAIL S
INSURER A:ZUdCh
INSURED Professional Roofing INSURER a;First Mercury Insurance Co.
Contractors Inc. INauRERc;Commerce Insurance Company 34754
P.O.Box 282
Salem,MA 01970 INSURER o:
INSURER E
IN RER 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 POUCY 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILT TYPE OF INS POLICYNUMSER M MMIDY LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000.00
B X COMMERCIALGENERALLIABILMY NJ-CGL-0000005591-01 OV17112 O2117H3 PREMISES a $ 50,00
CLAIMS-MADE ❑X OCCUR LED EXP JAny one ) $ 6,00
PERSONAL B ADV INJURY $ 1,000,00
GENERAL AGGREGATE S 2,000,00
GEM AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG i 1,000,00
X POLICY PRO LOC S
AUTOMOBILE LIABILITY Ro,,MBswW�E 61NGLE LIMIT 1,000,00
C ANYADTO BDPSGP O5I01)12 05/01/13 BODILY INJURY(Per pendn) S
ALL OWNED X AUTOS
SOULEDAUTOS BODILY INJURY(Per do ioeN) S
I
HIREDAUT03 X NON-OWNED PROPERTY AUTOS DAMAGE S
t
UNIORELLAINB OCCUR EACH OCCURRENCE S
EXCESS UAe CLAIMS-MADE AGGREGATE S
DIED I I REY I IS
WORKERS COMPENSATION WC STATU- - OTH-
AND EMPLOYERS'L1A81U1Y
A ANY PROMIEI�FARTNEEmXECUTIVE Y� NIA US-0450NOB$12 06/01/12 05101113 EL EACH ACCIDENT $ 500,00
OFF(Myeenld.k"In NN) E.L.DISEASE-EA EMPLOYE S 500,00
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMITS 500,00
aesexim N OF oFemTxms I LDCArous I VENK:LEs IA11+ah ACORD 101.Additional Rensns Sahadule,N more spare Is required)
ROOFING—CO14MRCIAL
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING INSPECTOR ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINTON STREET AUTHORRED
SALEM,MA 01970 John
(cHNJ.W
John J.Walsh Ins.Agcy.,Inc.
(D1988-2010 ACORD C PORA '�,Nkohts reserved.
ACORD 25(2010)05) The ACORD name and logo are registered marks of ACORD
CITY OF S�1L.E,,I, NUsSACHUSETTS
s, BUILONG DEPIRTMEINT
120 %V.%sHLNGTON STREET, P FLOOR
TEL (978) 745-9595
FA.K(978) 740-9846
Kj.%IBFRt &Y DRISCOLL
,bLkYOR THO1tAS ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BUILD DJG C0%6I15SIONER
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 l 11.5
Debris, and the provisions of tNIGL 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 MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
6 / 2-
date
Icbn:all',Ix:
CITY OF S.U.E i, %LxSSACHliSETTS
BUILDING DEPARTMENT
O
120 WASHINGTON STREET. 3"FLOOR
TEL. (978) 745-9595
F.+e(978) 740-9846
KIN LBERLEY DRISCOLL
MAYOR THoN.►S t3 ST.PIERR
DIRECTOR OF PUBLIC PROPERTY/BU11,I)MG COJ61fISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t ilicant Information Please Print Legibly
Narrie(BusitxsvOrganizatiorutndividual): /u /Ur F , ,
City/State/Zip: Phone ✓ :
Are you an employer?Check the appropriate box: Type of project(required):
I. I am a employer with e? 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] 10.❑ Electrical repairs or additions
officers have exercised their I
3.❑ 1 ran a homeowner doing all work right of exemption per MOL I LE]Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12. oof repairs
insurance required.]t employees. LNo workers' 13.❑Other,
camp.insurance required.]
;Any applicant Jut chltiks box+1 must also rill out the s lioa blow showing thou worker'mmpensatiun policy infurmation.
I hwneuwrtcma who submil this anidavit indicating They are doing all work and thm hire outside contractors most submit a rrcw affidavit indicating such.
:ConI mien that chcTk this box must aeached on additional sheet showing Ilia name of the subcornraeton and Iheir workor'ramp.put icy infomution.
I am an employer that it providing workers'compensation insurance for my employees. Below/s the policy and fob site
information.
Insurance Company Name: Znd/r(/L/ /.t, r ��
Policy#or Self-ins. Lic. 0: �//,,/3 G k�/�� / Expiration Date: ' /y�
Job Site Address: 3k �1s 1 c' cJ/� City/Statr/Zip:-�s�/•r 7.., /��/
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 23A 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 imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
investigations or the DIA for insurance coverage verification.
I do hereby certify a e//r the pains and penalties of per/jary that the information provided above is true and correct.
S'„ Ire• % / G Y ram/jv ' Date' ✓Zz�z_z_
OJJicial use only. Do not write in this urea,to be coatplered by city ur town oJJicial
City or
Issuing Aulhority(circle one):
I. Board of Health 2. Building Department 3.Cilyirown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other�,— -------_.._
Contact Person: —_............._—'--_- Phone#:
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