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40 OCEAN AVE - BUILDING INSPECTION S] The Commonwealth of Massachusetts Board of Building Regulations and Standards 111, ! Massachusetts State Building Code. 780CMR. 7'hedition MUNIt'll':V.I'I'1' USE W Building Permit Application To Construct. Repair, Renovate Or Demolish a Revised Junuorc One- or Two-Funti(v Divelling i. 'ix)3 This Section F r Official Use Only Building Permit No r: 11 Date Applied: Signature: 3 Building Commissioncif Inspector of Buildings Date SECTION 1: SITE INFORMATION i 1.1 Property Address: 1.2 Assessors Map & Parcel Numbers �,(p elewr Alle I.la 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 R) Frontage(1l) 1 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: Zone: _ Outside Flood Zone? al Munici ❑ On site disposal system ❑ Public❑ Private❑ Check if yes❑ p ��11 SECTION 2: PROPERTY OWNERSHIP' 2.1 07Sp .of R o�Cs> !is CJi7 h Name(Print) Address for Service: 919 a �77Ga Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Descri [ion of Pro ed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Officlal Use Only (Labor and Materials) I. Building $ t. Building Permit Fee: $ Indicate how fe et mined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier/ x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Suppression) C q Check No. Check Amount. Cash Amount: 6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: 1 \' SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Namc ol'CSL- Holder List CSL Type(see below) Type Description 4ddress U I Unrestricted(up to 35.000 Cu. Ft.) R Restricted 1&2 Family Dwellin Signature �1 Mawr Onl RC Residential Ruotin Covering Telephone WS I Residential Window and Stdin SF Residential Solid Fuel Bumun A chance Installation D Residential Demolition 5.2 er me Imp v ,nt/('o trarcrt-or(HIC) /S 7® 7 HIC orypany Na r HIC Registrant Name RegiAru ion Number CLr G/r., Addre 971l' 9,VTPP Kxp6ation Date Signature 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 .......... B( 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. Signature of Owner Date SECTION 7b:/OWNER3 ORIJOYHORIZED AGENJPECLARATION as Owner of tit orized Agent reby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name ' G Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.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 halt/buths Type of heating system Number of decks/ porches Type of cowling system Enclosed Open 3. 'Total Project Square Footage" may be substituted for*Total Project Cost" CITY OF SALEM 3 PUBLIC PROPRERTY r A DEPARTMENT Ki�IBH<LI-a DRISC19I, MAnm L'v�Y'nstnNc;T��S-far:P:r ♦ SAI[Al, MASsat?It.-Sl 1970 r[l.: 978-795-9595 • Fax: 978-740.9836 Workers' Compensation Insurance .affidavit: Builders/Contractors/Electricians/Plumbers Apnlicant Information Please Print Le ibl V iIIriC (t3u;incsv OrgunizatioNlndividuul): Address: _2 69 rh 674'f7 Au City/State/Zip: 0nhyoewz ,"- W9-12 Phone Are you an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with 7 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).' have hired the sub-contractors 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 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' con insurance 5. ❑ We are a corporation and its [ p 10.❑ Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.0 Plumbing repairs or additions 3.❑ I am a homeowner doing all work g P myself. [No workers' comp. C. 152, $1(4), and we have no 12.Zo Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] `Any applicant that checks box It must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. �Cuntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. /am an employer that is providing workers'compensation insurance for my,employees. Below is the policy and job site information. / JV /f�� Insurance Company Name: /P�/ < n y / Policy #or Self-ins. Liiccc. #: CO Z Z �/�/+J D�/ �L o�l �7 Expiration Date: Job Site Address: —/U OlwN '/ City/State/Zip: �� /44" &2 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 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 penalties in the form of a STOP WORK ORDER and a fine of up to 5250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify der the pains and penalties of perjury that the information provided above tssttr to and correct Si It uure Date: I hone-4 / 9dr 427 3W. Official use only. Do not write in this area, to be completed by city or town official Citv or Mown: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions %lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of Iss o implied, hire, i lied oral r written." \n employer is defined as "an individual, partnership, association, corporation or other legal entity, or any,two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." %IGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, IvIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. -Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation.insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials - Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current - policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia CITY OF SALEM y PUBLIC PROPRERTY `4?4 DEPARTMENT M Iny S:aEET rn:Y78-I45-')5)5 t' C:WS-74v)846 Construction Debris Disposal Affidavit (required for all demolition xid renovation work) In accordance w ith the sixth edition of the State Building Code, 730 CbIR section 111.5 Debris, and the provisions of NIGL c 40, S 54; Building Permit # - _ is issued with the condition that the debris resulting from work shall be disposed of in a properly Licensed waste disposal facility as defined by MGL c I 11, S 150A. The debris will be transported by: Iname o!haular) 1'h,e debris will be disposed of in Warne ul fa ity) ACORD CERTIFICATE OF LIABILITY INSURANCE DATE 12/2I007 10/12/2007 PRODUCER (g7H) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Lauranzano Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Scott Girard INSURER B:MWCARB Girard Construction INSURER C: 7 Eden Glen Avenue INSURER D'. Danvers MA 01923- - INSURER E. COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD POLICY EFFECTIVE POLICY EXPIRATION LTR ADDINSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD DATE MMIDDIYY - LIMnS GENERAL LIABILITY / / EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS MADE ❑OCCUR / / / / MED EXP(Any one persdn $ PERSONAL S ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S PRO- POLICY 17 JECT LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS / / / / BODILY INJURY $ (Per Person) SCHEDULED AUTOS / / / / BODILY INJURY HIRED AUTOS $ (PEr accident) NON-0W NED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO /. / / / OTHER THAN EA ACC $ AUTO ONLY: AGG S E%CESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ _ $ B WORKERS COMPENSATION AND 6ZZUB-071BL21-5-07 07/18/2007 07/18/2008 X RCySMIT TwS °a EMPLOYERS'LIABILITY 100,000 R ANY PROPRIETOPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ 100,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500.000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLEV"CLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE - Salem MA 01970- ACORD 25(2001108) ©ACORD CORPORATION 1988 �_-INS025(0108).05 ELECTRONIC IASER FORMS,INC.-1800)327-0545 Page 1 of 2 pp�� �� �O7IbIH99t(uPf� �� A �V Board of Building Regulatiods and Standards HOME IMPROVEMENT CONTRACTOR Registration:. 157099 Expiration: 9/5/2009 Trill 258889 Type: DBA GIRARD CONSTRUCTION SCOTT GIRARD 7 EDEN GLEN AVE. DANVERS, MA 01923 - Administrator //PRODUCT 118T rr C SIGNSPLDS (978)531.64W ' • S Page No. of - Pages I , _ GIRARD CONSTRICTION I A Company You Can Count Onl i 7 EDEN GLEN AVE. DANVERS, MA 01923 (978) 42X3U2 • Fax (978) 774-1520 PROPOSAL SUBMITTED TO / PHONE DATE l STREET - JOB NAME ! CITY,STATE and ArCOD JOB LOCATIO ,.�o - - - DATE OF PLANS JOB PHONE ARCHITECT 1 1 We hereby submit specifications and estimates for: r !Zi / �l-C--//r�'-Gf��. �!at (`yl�:•l'i ., fC(.Yt�i �' ! (` 4f, lv�.E^-mil Ar / /We Propose hereby to urnish material and labor—complete in accordance with above specifications, for the sum of dollars($ - I Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized manner according to standard practices. Any alteration or deviation from above specifications Signature involving extra costs will be executed only upon written orders, and will,become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or Note:This proposal may be delays beyond our control. Owner to carry fire, terrace and other necessary insurance. Our withdrawn by us if not accepted within days workers are fully covered by WoBman's CompQnsation Insurance. Acceptance of Proposal —The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature p y e f work ass specified.Payment will be made,es outlined above. Date of Acceptance: `/ . Signature -