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49 OCEAN AVE - BUILDING INSPECTION e J l i� The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR,7 s edition OF SALEM i Revised January Building Permit Application To Construct,Repair,Renovate Or Demolish a 1,2008 One-or wo-Family Dwellf g' is S lion For Ofii ' Use Only Building Permit Number. Applied: Signature: Building o issi ner/Ins fB gs Date 1 t1 3 1 C N 1:SITE INFORMATION 1.1 P Address: 1.2 Assessors Map&Parcel Numbers 6Cr gti AVi l.la Is this an accepted street?yes no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(R) 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? Public❑ Private❑ — Check ifyes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP` � " �qwoert of Record• /hEA/AlETI� STF_zAt,JrEELla 99 OCEPAn J OVE, 5/9LEM , Z?Iq Name(Print) AVaess for Service: 979 ) ass- 6 97 2 Signature Telepbove SECTION 3:DESCRIPTION OF PROPOSED WORK'(check B that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition-❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': AJ E ZP F 1= TO FN _ T ii/l YYY laC.. 1= �5x V ES SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only abor and Ma`t�eri`als 1 Building $ �W 1. Building Permit Fee:$ Indicate how fee is determined: 2 Electrical $ OQ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ressiom Total All Fees:$ U /^�` Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ /�/�OV ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION/SERVICES 5.1 Licensed Construction Supervisor(CSL) C5 2!69h Rohe 3�n caM)17 License Number Expiration Date Name of CSL,Holder U - — -- -- - - - _ l l C c List CSL Type(see below) Address Type Description / I.-.. U Unrestricted(up to 35,000 Cu.FC R Restricted 1&2 Family Dwelling Si M Mum Only Telephone RC Residential Roofing Covering P WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5. Registered Hoqre I�4pr�vemeut Contractor(HIC). �ll i mnCKr)Y / Kn3F�zT f�c tJTamt �J J Y HIC Comp�ny Name or C Reg t Name Registration f umber S Ne sr r °� m/ Ad -�ff�-a Expiration Date S' ature Telephone SECTION 6:WORICERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152.§ 25C(6)) t Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide i this affidavit will resuh in the denial of the Issuance of the building permit Signed Affidavit Attached? Yes ..........❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WIZEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, dniNeI4J girl as Owner of the subject property hereby authorize -/h. /�q /t'Gr c. G7Uu� to act on my behalf,in all matters relative to work authorized by tlu—'s b i�t application. Si of Owner Dater SE ON 7b:OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare t that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Sigailture of Owner or Autho ' gent Date Si ed under the pains and pMhfties of 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 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.R6 and I t0.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 halFbaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street r----- Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /y� �r� /v� / / �1� Please Print Le ibh, Name (Business Organizationlndiciduap: , J ' 1 r 1 ' 1ncKr 1- C,P,In,UV Address:_S P-nie ST. �e�/ �/� City/State/Zip: /Y/�S�IUA,� O�?� Phone #: �2j — S)si o� 77/ Are y an employer?Check the appropriate box: Type of project(required): I I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New constriction employees (full and or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7 ji-Iremodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' ❑ Building addition 9. (No workers comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions 3.[ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I-) ❑ Roof repairs insurance-equired.] ` c. 152, §1(4).and we have no employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that checks box=1 must also fill out the section below shoring their workers compensation policy information. Homeowners wwho submit this atlidacit indicating the,are doing all work and then hire outside contractors must submit anew aflidacit indicative such. Contractors that check this box must anached an additional sheet showing the name of the sub-contractors and state t,hether or not those entities hace emplo%ces. If the sub-conincmrs hare employees-the%must provide their workers comp.police number. 1 am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: � /rg TNS Police=or Self-ins. Lie.=: W C)V 1B'2 St]SOULI Expiration Date: '7 Job Site Address: 39 GUEST <J_ City State2ip: kjESTrOR(J�m 9 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure zoveraee as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 S250.00 a day against the violator. Be advised that a cope of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification 1 do hereby certij},under thee pains l penalties of perjury that the information provided above is true and correct. Signature: A o I IlK/�/7 Date /O)�/s— g �'"�99 _ Phone=: 663- aO / Official use only. Do not write in this area,to be completed by cin•or town offtciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: DATE ACORD. CERTIFICATE OF LIABILITY INSURANCE 1/4/2009 11 4 2009 YY) PRODUCER Phone: 603-625-1100 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION USI Insurance Svcs of NE, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO Box 6360 HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Manchester NH 03108-6360 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE _ -- -_--_ NAIC# INSURED INSURER A:Hanover Insurance ComT)any 22292 P M Mackay and Sons, Inc. INSURERS:Massachusetts Bay Insurance C 22306 - 5 Pine St Extension #6 Mill Annex Nashua NH 03060 INSURERC: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. OTWITHSTANDING 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 NDUL POLICYNUMBER POLICYEFFECTNE POLICYEXPIRATION LIMITS DAM(MIWDXYYI A IS ERALUABILRY ZHV670069808 4/22/2009 4/22/2010 EACH OCCURRENCE $1 000 000 COMMERCIALGENERALLIABILITY PREMS aES EEoc m.m $100 000 CLAIMS MADE IX I OCCUR MED SKIP(My one Person) $5 000 PERSONALSADVINJURY $1 00Q 000 GENERALAGGREGATE $2 000 QQQ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 000 000 POLICY PRO- LOC $ AUTOMOBILELWBILRY ADV668158811 4/22/2009 4/22/2010 COMBINED SINGLE LIMIT $ ANY AUTO (Ea a dd M) $1, 000, 000 ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (P Pelson) E ar X HIREDAUTOS BODILY INJURY X NON-OWNEDAUTOS (Per acdtlenl) $ PROPERTYDAMAGE $ (Per acdtlen) GARAGELIABILHY AUTO ONLY-EAACCIDENT $ ANY AUTO OTHERTHAN EA ACC $ AUTOONLV: AGG $ A EXCESSIUMBRELLALUIBILT' UHV757373306 4/22/2009 4/22/2010 EACH OCCURRENCE $2 000 000 $I OCCUR CLAIMS MADE AGGREGATE $2 00O 000-. DEDUCTIBLE $ RETENTION $ $ $ WORKERS COMPENSATION AND WDV874575004 4/22/2009 4/22/2010 X WRY`MR CTR EMPLOYERS'LUIBILT' E.L.EACH ACCIDENT $1 00Q 000 ANY PROPRIETORIPARTNEWEXECUTIVE OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EAEMPLOYEE $1 000 000 Ryes. a antler SPECIAL FAIL PROVISIONS below E.L.DISEASE-POLICY LIMIT I$ OTHER DESCRIPTION OF OPERATIONS LOCATIONS VEHICLESI EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS C-no excluded officers. reject: WORK AS NECESSARY TO COMPLETE JOB AT 49 OCEAN AVE., SALEM, MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER TOWN OF SALEM, MA WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE BUILDING DEPARTMENT CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO 120 WASHINGTON STREET SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON SALEM MA 01970 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108) ©ACORD CORPORATION 1988 Nlassachusetts- Department of Public Safetc Board of Building Regulations and Standards Construction Supervisor License License: CS 91696 Restricted to: 00 - - - ROBERT A BENJAMIN 11 FERN COURT MILFORD, NH 03055 Expiration: 6120/2011 (l,mmiseionrr Tr#: 16705 J,�. �o�waeoxwnoalu o�,�1� �, 9Board of Building Regulatlosa and Staodarda HOME IMPfWVEMENTCONTRACTOR Reglstr ih, 151909 EkkiwWip"1312010 Trill 271450 iate Corporation i P.M.MACKAY&ISONS�IN � ROBERT B�NJAIdIfy5 PINE ST #6 MINASHUA, 3060 ' Adodslatrater, CITY OF SALEM is PUBLIC PROPRERTY YW1 DEPARTMENT I20W.NiI11M.! 1NSINLET6S.V I'�t,S1.\iiAr I II 'I Iii:1`>• T'Ln:978-74 939$ ♦ 1::Nx:978.7449846 Construction Debris Disposal Affidavit (r«luired 11or all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 ClV1R section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit It -._ is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c t 11. S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in /�CNS�ItJv _._ r� »4517Z ' (name of raci ily) (address of facility) _ gnature of I)ermit pl'cant �clnl„ii dk