1 OCEAN AVE - BUILDING INSPECTION The Coin mouwealth of Massachusetts
Board of Building Regulations and Standards CITY OFSALEM
Massachusetts State Building Code, 730 CLNIR 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 Number=s Date Applie
Building Official(Print Name) . 'Si Lure Date
SECTION 1: SITE I FORT
1.1 Property Address: 1.2 Asses ap Sc Parcel Numbers
I.1 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: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2 PROPERTY OWNERSHIP'.' '
2.1/yOwner'of Reco�jd:
' �c-t:•'.c' 51 ALL cc" -5A L e 1 q• /� C7 / / 70
Name(Print) City,State,ZIP 5n-1LLc0n6
Oc6AJ 4V 617S'/03z75 POO Gov
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that,apply)
New Construction❑ Existing Building El Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)•11 Addition 11
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIiVIATED CONSTRUCTION COSTS
[tern Estimated Costs: Official Use
Labor and Materials Only
1. BuildingS (fj 1. BuikHhg Permit Fee. S Indicate how fee is determined:
Electrical 3 z2w ❑ Standard City/fotvn Application Fee
2. ❑ fatal Fie e ' Cost'',(11tem 6)x mu[tiplier' xx
3. Plumbing S 260 • ? Other Fees.: $
1. Mechanical (IIV:AC) S List.
5. it[echanical (Fire S
Su ression) Total All Fees: S
Check No. Check Amount: Cash Amount:.
6. 'Total Project Cost: S tib 1696- ❑ Paid in Full ❑ Outstanding Balance Duc: _
SECTIONS: CONSTRUCTION SERVICES
5.1 Conshuction Supervisor License (CSL) /_2 e ?) 2.q (3 ,
I(CC�A _ License Number Expiration Date
Name of CSL holder
List CSL Type(see below)
WWF_✓I �,"' 'L Description
No. and Street
/r-U-7 Unrestricted2 Fau(Buildings u el ing cu. R.)
` Restricted ISc3 Tamil Dwelling
Cny/Town, State, " IP - NI Masonry
RC Roofing Covering
WS Window and Siding
SF I Solid Fuel Burning Appliances
Insulation
"Cele hone Email address D FDemolition
5.2 Registered Home Improveme t Contractor(HIC) ' 1 12��'� 1�;Ifq
uI A t
�� �.�� HIC Registration Number Expiration Date
HIC Coin
"I (66a i-yI . -1 C •�istran Neste J,t t, , ,1 L_'0���„l,/�
No an eet Va-(.� //&'I,/ �jA-166q Z0(o /W�" L Email address v'J/
City/Town, State, ZIP M I l TLele hone/
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L, c. 152. § 25C(6))
Workers Compensation Insurance affidavit mast 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
I, as Owner of the subject property, hereby authorize�� ✓/��r//1
to act on my behalf, in all matters relative to work authorized by this u Iding 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 tr d accurst the best of my knowledge and understanding.
,",f/ N[ 12- 13
Print Owner's or Authorizes:\-ent's Name(ElectronicSignature) 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.mass.gov%oca Information on the Construction Supervisor License can be found at ycww.m:ss.�ovidL
2. When substantial work is planned, provide the information below:
Total floor area(sq. 2) _(including garage, finished basement/attics, decks or porch)
Gross living area(sq. ft.)_ _ Flabitable room count
Number of fireplaces- Numberofbedrooms _
Number of bathrooms Number ofhalt/baths _
Tvpe of heating system ---------- Number Number of decks/ porches ___._-
F)pe of cooling sy;iem_,—_--_ Enclosed----.. .-------_Open _
3. ''Cotal ['rojeCt Squnrc finny be sub;tituted for'Tol,il Project Cost" __
CITY OF S.U.EM, INLUSACHUSETrs
i. Bl:iLONG DEPAR-I1l&NT
1 ' ' '^ N• 120 WASHNGTON STREET, 3"°FLOOR
TEL (978) 745-9595
F.jLx(978) 740-9846
KIJiBERLHY DRISCOLL
i+LMR TH10.%W ST.PIERRS
DIRECTOR OF PL13LIC PROPERTY/HCILDDIG CONWISSIONER
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 MGL c 40, S 54;
Building Permit 9 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:
sV(/kNLjr-q CoNsi -
(numc of hauler)
The debris will be disposed of in :
wo
_-- (name of facility)
_— --(address of facility)
signature of permit applicant
date
dcbn.aiF dux
i CITY OF S:u Em, NL1SS ICHUS=S
v BI:ILDING DEP.IRTm&NT
• '= 5 130 WASI ILNGTON STREET, 3'o FLOOR
TSL (978)745-9595
Rax(978) 740.9846
KIJBERI.HY DRISCOLL
INfAYOR T Homs ST.Pium
DIRECTOR OF PCBLIC PROPERTY/BUILDLNG CONZIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractor9/Electrlcians/Plumbers
A t ilicant Information Please Print Legibly
C0
Vtlmt:(Uusiixs>.OrganiratioNlndividual): ^
Address: `'^ "`ry M7
City/State/Zip: ✓''w Phone
Are nu an employer?Check the appropriate box: Type of projeet(required):
1. am a employer with 3. 0 I am a general contractor and 1 6. 0 New construction
Pmnployees(ILII and/or part-time).* have hired the sub�conlractonl
2.0 l am a sot*proprietor or partner- listed on the attached shout t 7. 0 Remodeling
ship and have no employees These subcontractors have 11. 0 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.) otYicets have exercised their lo.[] Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGG 11.0 Plumbing repuirs or additions
myself.(No workers'comp. C. 152, $1(4),and we have no 12.0 Roof mpains
insurance required.)t cmployees.LNG workers, 13.D Other
comp.insurance required.)
-Any appdcam nut chucks box el must also fill urs the rection below showing their workers'compensation policy inturmadon.
'1 hwnoowm"who sulmdl this alfldavit indicating they ata doing ail work and thea biro ounida contmcton mtut submit a new amdavil indinting such.
:Cumrwtors thus cheek this box most attached an addidunul short showing the nomo of the subremradan and their wurkms'comp.policy infomuation.
I am an employer that Ir prov(dlnA workers'coinpensadon Insurance for my employees Below Is the policy and Job s(tv
irrfortnatlon. A A J
Insurance Company Name: �l�/v4 . ( eo -
Policy a or Self-ins.Lic. 6: Y'W C 7 M 1-�?I`7 ooj L-e�(LExpiration Date: ��
Job Site Address: I �G�AN d12—, City/Stawaip: '�t /��� .
"/ l
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to sucunr coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51,500.00 and/or one-year imprisonment,as Well as civil penalties in the form of a STOP WORK ORDER and a line
of up to 5230.00 a day against the violator. Ile advised that copy of this statemunl may be forwarded to the OI'lice of
Investigations ufthe DIA for insurance coverage vurilicatiom
Ido hereby rrr atdde the It tdue/t(ds o r1 Usy r/lar the h1format/011 provided above is true mrd correct
Data:
P o ,Y
O/jicial use only, Oa not,wtlte in t/rfs ureth to be completed by city as,town ajIuad
City nr Town: PermittlAcenee N
Issuing A W hority(circle one):
L Board of Ileillh Z.Building Department J.Cilyfrown Clerk J. Clectrfcal inspector 5. Plumbing Inspector
6.Other
Contact Persons ._. . . _ _ _ Phone 4:
PROPOSAL
PROPOSAL NO
CONSTRUCTION'
17 Worcester rd '.SHEET NO. .'
Peabody
wvvvvMANLEY-CONSTRUCTION.comDATE
PROPOSAL SUBMITTED TO:
T
WORK TO BE PERFORMED A
NAME„� " II'CDg ` '.. ADDRESS
ADdORE� y�V•i/,�+( ar *0V /
r'
DATE OF PLANS.:' ^^
l
w r� -:., " ARCHITECT s e
PHONE NO � � . . -
We hereby propose to furnish the materials and perform the labor necessary forthe'completion'of
P eC c 6 s Fr'
6 CDL4'' g
«i-
c p
I r UAc /,A-f6 C-C lCs-f tt E ��-u ( l�r7 �► —
"may ?I DhJI� ;�C�/vaVu'�
All a n is guaranteed To a as spegfied, an the above work to be performed In accordance with the drawings and specifications
submitted for above work, and;completed in a substantial workmanlike manner for the sum of
Dollars ($ = G
with payments to be made as follows:
(oft700. D • Soo �a.�cPl� cr+ •,
y r CCC bF R- �� Respectfully submitted
Any alteration or deviation from above specifications involving extra costs
will be executed only upon written order, and will become an extra charge Per
over and above the estimate. All agreements'.contingent upon strikes, ac-
cidents,or delays beyond our control. ;
Note - This proposal maybe withdrawn
by us if not accepted within days.
ACCEPTANCE OF PROPOSAL
The above prices; specifications and conditions are satisfactory and are hereby accepted. You,are authorized to do the work
as specified. Payments wilt be made as outlined above.
Slgnatu4/1
Date—/2 =Z = 2 01 Z . Signature
�, naiia rsn�'Nn�-%r• ♦ I .
Massachusetts- Department of Public Silrei
1 Board of Building Regulations and Standards
Con sttuctiorrSupervisor License
'License: CS 85208 'e'
. . a
NICHOLASA�MANLEY "
17 WORCESTER RDt� ,. ��
PEABODY;;MA 01908 t"r T
�—
�"'�' Expiration: 3/24/2013
(' mmi..vionrr" a�i Tr#: 12514
pp�� ✓�e '[ioow�xanurea� yp✓�•ado�u'�u/Je� `' f
aaa office of Consumer Affairs&Business Regulation '
HOME IMPROVEMENT CONTRACTOR Type. ,
Registration 142467
ff Expiration 4l5@014bBA
E �q
MA LEY CONSTRUCT ( �
IO
NICHOLAS MANLEYy �
17 WORCESTER ROAD +- f'y,
PEABODY.MA 01960 -"�J% Undersecretary
i
01/02/2013 11: 19 978-777-9804 JOHN J DOYLE INS PAGE 01/01
AC Q" NICHO.2 OP ID: KAG
��. CERTIFICATE 4F LIABILITY INSURANCE DATE(MM/DO/WYY/
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 INSURERISj AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cIII ficate holder ig an ADDITIONAL INSURED,the PollcyI'll I must be andorsed. If SUBROGATION I5 WAIVED,subject[a
rs
the terms and conditions of the policy, certain policies may require an andorsement. A statement on this Dart not confer fights to the
certificate Folder in Ifeu of such endoements). ifiDate does
PRODUCER 976.T. ATACT
John J Doyle Insurance Agency E: Kim Giambrone
85 Constitution Lane Ste zH 976- NE 97Danvers,MA 01923 lac,Exll. 8-777.6384 `Ac978..777-9John J Doyle EesI kim@doylelnsurance.com
INSURRS AI FFORDING COVERAGE NAIC9
INSURED Nloholas MenleyERA:AIMManley Construction RER Is:17 Worcester Rd. ER C:Peabody,MA 01960 ER D:ER E fCOVERAGES ER F: `
CERTIFICATE NUMBER: REVISION NUMEIER-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED 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 POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS.
I R
TYPE OF INSURANCE POLICY NUMBER POLICY PO pp
GENERAL LIABILITY MWDIVYY MMIC Y OMITS
COMMERCIAL CENERAL LIABILITYEACHOCCRREE 8
CLAIMS-MADE O OCCUR PREM1kE9_fEe o¢umnceJ $
MED EXP(`A one para") S
PERSONALE ADVMJURY 8
OWL AGGREGATEGENERAL AGGREGATE S LIMIT APPLIES PER: _
POLICY RR - LOC PRODUCTS•COMPI AGO 9
AUTOMOBILE LIABILITY S
ANY AUTO UMBfI�Na m$IN LE LIMIT
Ea eo
ALL OWNED SCHEDULED 8001LY INJURY(Per Demon) 8
AUTOS AUTOS Per BODILY INJURY accidanl $
HIRED AUTOS NON-OWNED ( )
AUTOS PR -RTYDA�WI,,: -
_LPeraecidon0 $
UMBRELLA LIAR 8
GccuR
EXCESS LIAR EACH DCWRRENCE g
CIAIM$•MADE -
OED RETENTION$ AGGREGATE S .,
AND EMRS COMPENSATION 8
ANDE OPRIETRS'LMBNERI WCSTATU- OTW-
ANYPftOPRIETORIPARTNERlEXECUTIVE YIN AMC7027319012012 06/06112 OB/06!70 T-gym¢$__ _
OFFICERN,EMBER EXCLUDED? ❑ NIA E.L,EACHACCIDENT 5 10(),00
(MaIA-RI In NN)
0.8 RIPTIPNOFO E,LDISEASE-EAEMpLOYE S 100,00
DESCRIPTION OF DPEMTIGN$helDw
E.L.DISEASE-POLICY LIMIT S 500,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AIGeh ACORD 101,AddMI Remarks Sch,I II PI Is mqulmd)
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
93 Washington St ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, MA 01970
AUTHORISED REAR TIVE
John J Doyle
7 R- 10 A RD RPO I . All rights reserved.
ACORD 25(2070105) The ACORD name and logo are registered r of ACO