50 OCEAN AVE - BPA-13-999 The Commonwealth of Nfassachusetts CITY OF
�<. Board of Building Regulations and Standards SALENI
Massachusetts State Building Code,730 CVIR Revised Mar 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Saction ForOfrtci se 0n1
Building Permit Number: Date pphed".'
Building Official(Print Name) $tgnature;:: Data
SECTION Ic SITE INFORtNIATIOIY
1.1 Propert ,Address: L2 Assessors Map 3c Parcel Number
6 �(42'&.vti OL4_ '
L 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 ft) Frontage(it)
1.5 Building Setbacks(It)
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? Municipal ClOn site disposal system ❑
Public❑ Private❑" Check if es❑ P p
SECTION Z:; PROPERTII'01NNERSFE11"
2.1 Ownert of Record:
LCr v ew , r,L� �1 ss rU x tun IvA A
Name(Print) City,State,ZIP
qD Q' Zt A N
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED MORKr(check all that apply} "
New Construction ❑ Existing Building❑ Owner•Occupied ❑ I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTINLATED CONSTRUCTION COSTS-"
[tem Estimated Costs: Oftidal Use Only
Labor and Nlaterials
! Building S L.Building Perm(tFee'5' `" indicdie how ree is determined:
❑Standard,.CityPPown,Application Fee
2. Electrical $ q Total Pidjei:t Cost r(Item 6)x multiplier x
3. Plumbing S 2. Other Faes: $
1. Ml chanical (IIV.AC) S List:
. \L:chanical (Fira S 'Ibtal All Fees:.S
Sn � rasiun) -
Check Amount. Cash Auwnnt�
p Check No. __ ---
r, Total Project ('ost: S �V I p Paid in Fall ❑Outst:m(linl' Ital.ul" I)no:
SECTION 5: CONs'rRUCTIUN SERVICES
r5.17onstructionSupervisorLicense(CSL)__ _of llolderlulder
List CSL'Type(swe below
) 2
C 19)pljo�\ AX4 7/ TYpC Description
No. and Street -
n U I Unrestricted(Buildings up to 35,000 cu. tt.
Monru
cted 1&2 Family Dwelling
City/rown, State,ZIP r
Cuverinw and Sidu^ ^, ^, Fuel Burning Appliuncos
`L.pp ,(7- — i1K� C (,9. \�"lr 5f `+Jtionrele hone 773Email address lition5.2 Re istered Home Improvement Contractor(HIC) W4
HIC Registration Number r anon Uate
l IIC I' m , I ZI-,K)C ftc,�is�trn�llt Njut� �`pY 'SkOIL
No.and Street 11 1• S I 56S��7 M Email address OZtr
b/�fV�_7t�c MA ol4a�? ,
City/Town, State ZIP 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 ..........e No...........❑
SECTION 7n: 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.
Print Uw is ur r\u0wrired:\gent's Mimic(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will ram have access to the arbitration
progr in or guaranty fiord under M.G.L. c. I42A. Other important information on the HIC Program can be found at
www.nmsi.euv1,x Information on the Construction Supervisor License can be found at ww•w.m;u _'dP_t
2. When substantial work is planned,provide the information below:
Turd fluor area(ml. R.) _(including garage, finished bascmen tattics,decks or purch)
linhi living arcs(sy. ft.) ffabirtble room count _
Number 0f firaplaecs_—__----- Number of bedrooms
Number of bathrooms -- Nuutber of half''baths
1 c1W of ftd.11]❑g iyi(elll _ —"--'—__ Nnlithef Uf, dCk.i/pureltC9
I})+eofeo0lingtyaunt 1{11closcd -- - _ rlpc❑
I. "Goal I'nq,-,:t iyt :tre Pn,H.I}c"IIIaY he it bitin 11",1 t;,r 1'„LII P1 marl Co X,
t`,.:,at�•Y2 "SS „C ,rw�,� �" Syr a��� � ;'rn..r"`x.y�'TM,�,-+..m ,.......� r, .may
"CITY OF SM EiM, 2ANSSACHUSETTS
= Bluabi,M3 DEPARTMENT
120 WASHONGTON STREET, Sae FLOOR
TEI. (978)745=9505
FAx(978)•740.9846
KI.NfBERL.EY DRISCOLL
V.UYOR THOptAs ST.PmRItJi
DIRECTOR OF PUBLIC PROPERTY/BCILDINIG COSMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Eiectricians/Piumbers
Aptslicaitt Information c�+�� Please Print Le ibiv
Name(Busittos iOrpniratiorvindividual): �.Jsi1nnA _Sk fC1— [J il—M
a
Address: PG_DD)C (D 4J (22f�1�('i
City/State/Zip: Phone M-(q 7 7y`{ —726D
,lrc ou an employer?Check the appropriate box: 'type of project(required):
I.E1 am a employer with; r. . 4. Q I am a genial contractor and 1 6• Q New construction
employees(fltil and/or pait time).• have hired the sub•contsactors
� 2.Q l mn a state propticior or pmtnor listed on tfio attached sheet,= 7• Cl R modeling
ship a nd have no employees,,-;:_ These subcontractors have' a. Q Demolition
working for me In my capacity;i workers'comp h6innce r - 9• El Duitdmg addition
[No workers comp.,insurance.:' S. El We ace a.corporation and.its,
required.; exercised thou !0 Q Electrical repairs or additions officers have ex
3.Q 1 am a homeowner doing all work right of exemption per MOL 11.0 Phunbmg repairs or additions
myself.[Noworkcry''comp. c.,152,§I(4):andwe,hav9Ila 12.�[.00.peics:
insurance requiied.j t employees.[No workers'. 13.Q 00ier'
comp insurance mquired.j;
-Any applitrnn that chucks box#1 most also fill out the se 6w below showing their workers,cgtnpenwiun policy infumntlon, -
tl hvneuwners who i"t H this aeidnit indicating they are doing all work and then We outside cantmetor 1 mug submit a new amdnvii indiodng such.
=Cumraotors thol ehcckihis box most attached an aiLliUund shoot show name of the su6ayntrxbta and thebfworkeo"tbrrtp,pulley infomiotioe:.. , -
!um tin unployer f6at fr proVlding workers'ramprisadon hrsuranca jor sty e�irpluyeesc`Belawls the po/fey andtab site
Insurance Company dame: 6
- Policy 4 orScif ins.LIc.p:_t_I r'�I �f�t� Expirbtion Dow—WaR
Aft '
Job Site Address:� UJ ut City/State/Zip:_i ,1�(itG VT X_�
Attach a copy of the workers'compensatlon'polleydeclaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of VIOL c. 152 can lead to tha imposition of criminal pepaltiea of a
Nita up to S 1,500.00 and/or one-year imprisonment,as.weltas civil penalties in the fdnn'of a STOP WORKORDER and a ring
Of up to S250.00 a Jay against the violator. 13e advised.that i copy of this statement tray be forwarded to the Office of
Invrstigatiutts'ul'the DtA for insurance
/do hereby cerd/jr under dut pules and pena/ries ojperJury char the btjarmat/an praviJrJ above i9 truer and correct.
Siennture: W Ti p 11J,Leb.,� Dare- 2 Q
Phoned; G79z-��Cg
O/rcla/use only Du tier write in rbar urra,to br cuntplered by city qr/owdaJJlclaL
i
City or Town: Permit/fJccnse#
Issuing Authority(circle one):
1. l3uard of Health 2.Building Department 3.Cilyrrown Clerk 4. Efectri at Inspector 5.Plumbing Inspector
6.Other
Contact Person: _ - Phone#• ,i
,i
"' CITY OF sturti[ NWS.,�wHusETTs
v
+ Bl'ILDLYG ❑EPAR11 NT
120 CKISHLNGTON STREET 3
•:. .C7,�,�'•.+ , FLOOR
- L(973) 745-9595
I<l.v0&U-BY DRISCOLL Fv((973) 7•W-9344
AMA tt to�613 Sr.PtPluts
012ECTOR OF FCOUC PROF ERTy/9t:MOLVG CO.%UII5SIONER
Construction Debris Disposal AttIdavit
(required tut all dcmclition and renovation work)
In accordance with the sixth edition ofthe State Building Code, 730 Ct%fR section 1
Ocbris, and the provisions of MGL c 40, S 54;
Building permit N is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal racility as defined by tLIGL e
lI1, 3150A.
The debris will be trnnsportcd by:
(n1mc ut'haulur)
Thu�deb�riiss will be duis�poo.,jeedd Grin :
(n,tma of facility) +�U . ..—
15L
tJwres.t of tixility)
;iquantru ufpermit appliu.mt
I itc I
Cllent#: 149839 SALEMSHEET
DATE(MINI.
ACORD. CERTIFICATE OF LIABILITY INSURANCE 5103/201,
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NeVATIVMY.AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(5),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement,A statement an this certificate does not confer rights to the
eanlfloate holder In Ileu of such andorssmenl(s)- [q
GT
PRODUCER NAME.
HUB Int'I New England, LLC AICD"ri Ea :781-792-3333 IAJG Np1. 781.792.340D
600 Longwater Drive FOD
Norwell,MA 02061 INSURERS AFFORDING COVERAGE NAION
781 792-3200 INSURER A;Commerce Insurance Co. 34754
INSURED WsuRER a:Hartford Casualty Ins do.
Salem Sheet Metal Inc. INSURER C:
Roger Petit INSURER O:
8 Waite Street INSURER E:
Salem MA 01970 asuRERc:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR 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.
`"gmp DOL SUB PO D F POLICY EJIF LIMBS
TYPp OP INSUMNCE IN O POLICY NUMBER MMIa MMIDD
A GENERAL LIABILITY _ HHN900 10/29/2012 1012912013 EACH OCCURRENCE $500 000
)(.COMMERCIAL GENERAL LIABILITY DA/dp TO
e oc ENTER
PREM s nee E 100 000
CLAIMS-MADE 7X OCCUR MEDW(PIMYwoPerson) $6000
PERSONAL&ADV INJURY $500 000
GENERALAGGREGATE 0,000,000
GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OP AGE; $1,000,000
POLICY PROT LOC &
A AUTOMOBILE LIA9ILRY 13MMBBLXBV 3/31/2013 03/31/201 COMBINED GE LIMIT 11000A00
BODILY IN JURY(Perpenon) E
ANY AUTO
ALL OWNED X SCHEDULED BODILY INJURY(Per acdtlent) E
AUTO$ ryONOOwNE, PROPERTY DAMAGE s
X HIRED AUTOS X AUTOS - Peraw nI
X NYe Oth CPr 1
um U LIAa OCCUR EALN OCCURRENCE &
EMCES3 AS CLAIMSIdADE AGGREGATE E
S
OEO LTLTJTION E _
B WORKERS COMPENSATION ORWECAA8678 7/07/2012 01/071201 We srAru DTH
AND EMPLOYERS'LIABRM
PR
ANY PROPRIETOR/PARTNERIEXECUTIVEa E.L.EACHACCIOENT t500 000
OFFICeWMEMBER EXCLUDEDa NIA
(Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $500 OOO
itvvaacaaPacobaUnder 1�OISEANE-POLCYUMIT s500nem
❑ES6AXI'ON OE OPERATIONS below
A Contents HHN900 10122/2012 10/29/201 $10,000 RCV-5500 Ded.
A Mobile Equipment HMN900 10/2912012 10/291201 Form C-093—Included
DESCRIPTION OK OPERATIONS I LOCAPONS I VEHICLES(Atl ACORD tel.Mditbnal R_warks SchedUI9,if Mery apace Is"Uleed)
Operations usual to Sheet Meta)Work.
CERTIFICATE HOLDER CANCELLATION
HamlltonAVenham Regional SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION OATS THEREOF, NOTICE WILL SE DELIVERED IN
Dlstrict/Attn:Mr.Richard ACCORDANCE WITH THE POLICY PROVISIONS.
Shruhan
5 School Street AUTHORIZED REPRESENTATIVE
Wenham, MA 01984 .9 1016-1006aA,a
Q71988.2010 ACORD CORPORATION.All nghta reserve,
ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD
"e`.A nOeA IA M.l CA nn CW001