69 ORCHARD ST - BUILDING INSPECTION (4) �Ov
fhe Commonwealth of Mossachusells
lloard ot'lluilding Regulations and Standards Cl 11, OF
Slassaehusetis State Building Code. 780 C'NIR SALE'M
Building 11cnnit Application To Construct, Repair. Renovate Or Demolish a
Ohre-ur ruo-Fonrdr Dive/Up k
This Section For Official Use Only
Building Permit Number: Date App cd:
Building 011icial(Print Mane) Signature Dote
SECTION 1:SITE INFORMATION
ILP�ro�rtylA 2 sss,,4 1,2 Assessors Nlap& Parcel Numbers
I.la Is this an occe ted street? -es no Map Number Parcel Numher
I..1 Zoning Information: 1.4 Property Dlmenslons:
Zoning District Proposed(lse Lot Amd(sq 11) Fronlage(11)
1.5 Building Setbacks(it)
Front Yard Side Yards Rcar Yard
Required l'mvidcd Required Provided Required Provided
1.6 1Water Supply:(M.G.I.c.40.§74) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Ihiblic Private O Zone: _ Outside Flood Zone?Check if csl>!. I MunicipalOn site disposal system ❑
SECTION 2: PROPERTV OWNERSHIP'
2.1 Ownerl of R ord:
Kati ply? Qom
Mang(Print) (-iq. State !. P
rag o ,-eA 54 C. Av-7, - 7e
36
Nu.and Street c ephone Email Address
SECTION!: DESCRIPTION OF PROPOSED WORKs(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alterattan(f) Addition ❑
Demolition ❑ accessory Bldg.❑ 1 Number of Units Other ❑ .Spevily:
Brit f0escriptionofPro�o;e rk°: T�
P in u 8 o c ih t -i- e K Lo g ¢c{
2yrlvuQ . ,2 rY, w;h :.0 and rim new 2sn arsvi, Casma"
$ i2
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
(Labor and .' Y
I. Building S /610C)0, r c� I. Building Permit Fee: S Indicate how lae is determined:
❑Standard CityiTussn Application Fee
'. lileeuical S 3 SU U,UO ❑Total Project C-ostt I Item 6)n multiplier
I'lunihing S "'S(2U. 4X� ,• Other Fees: S_ -
J. %W1.utical ill\ \(•I S List:
\Iechanical it trc
rural \II Fecs: S
---- --------. -- --- . . .
S — — — — -
vc,swni —..-------
('hcd Vo. __Check .\manure: ('aeh \manors:
n 1'uWl Project Cu,t: S� r (�� � 0. ❑ P,,id in Full 13 Outstanding BaLuice Due:
SECHONS: CONSI-RITTIONSERVI('FS
S.I Cbnstructiun Supenisor License IC'SL) 3��(0_
I't+ lian D;IIe Icensc Nuulhcr Iiru
N.unc ol'CSl. llnldcr - ..-. . IIst 01. 1\pc(see hclowl.__.L't
Poe
'f)PC Dcicriplion
No. .utJ ti(rcel (I I htreitricleJ I litiildin s tin in 14,1111n eo Il.l
u r1
L. 7V)h —�__. R Hc,IricicJ Ll2 f.unil Du cllin
Cit)i fawn.SLIIe.LII' %I Shisun
RC Rollin Oni:rin
R'S Wndow.wd Siding
.— SF .solid Fuel lhrmins,\pplialices
I Institution
l'eie bona Pnnlil adil ss D Demolition
S.2 Registered Home Improvement Cuntrnctor(HIC) 2r`P_954�iii
IIIC I(egistration Number Evpirutiun Daly
IIIC'Cumpan) Name nr I IIC Itegisnu Na ne
No. and Street / Finail address
rl ego, Cot?-S'F��'a'�'3
City/Town, State ZIP relc hone
SECTION 6t WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52. j 25C(6))
Worker 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 ..........0( No...........O
SECTION let OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorizC�a, r0
to act on my(/b�\,eehtalf.in all matt relative to work autho zed by this building permit application.
ap
I�nt wnei s Nwtle(E cctrunic.'iignature) � �Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penal ' s of ?I that all of the information
contained in this application is true and accurate to the best of my k wed d understanding.
1'rinl I7w net's ar:\uthminJ,\galt's None(1.1ccironie Signature Date
N ' ES:
I. An O\vner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Inlproventent Contractor I HIC) Program),will no have access to the arbilratiun
program or guarlmy fund under\1.G.L.c. 1 ?.A.Other impunant information on the HIC Program can be found at
w w.t ntn. O+ •'. I Information on the Construction Supervisor License can be found at
2. \\hen substantial work is planned.provide the informmtiun below:
rota) flour area(sy. 11.1 _ ____.._(including garage, finished bascnentarties, dccks or porch)
Gross lis ing area 154. It.) _---. _ - Habicible ruum count
Norther of lircplacei .. _... . _ N'umher of hcdrooms .. . .
Number of'hathroollis . . . . . Nuniherof hall,ho111s
I1 pe othcaling s)stem Nltinhcr of daki• porches
' 11pco1'c++ahngi)slcin I!nclo,cJ ..
))pen
I.d.II Prolvo Square 1'ootJwc 11111\ he %,h,wutvd far I olal Prufecl (anf
<� CITY UN S,UE.%12 NL1SSACHI:SE'ITS
OCILDING DEP.%JLrmENT
120 WASHLNGTON STREET, 30 FLOOR
TEL 978 745-9595
F.k-c(979) 110-9846
j\(BE.AL-EY DRISCOL L THostks ST.PIER"
AMt
DIRECI'CR OF PCELIC P Ito PERTY/BI:RDNC CO\611SSIUNER
Workers' Cumpensation Insurance Affidavit: guilders/ContractorsjElectrlcians/Plumbers
luplirant Infnrm•atinn Please Print Legibly
Vlllne Illueiix.oUrgtmraliam{l11mtiviJual):
Address: 1/ WVM"
City/State/Zip:���I �. 0190� Phone*Ce -7 S qV-L�.-3
Are you in employer!Check the appropriate box: Type of project(required):
I.tkI am a cmployor with_ Z _ 4• ❑ I am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time).* have hired the sub•conlractors
2.❑ 1 am a solo proprietor or partner• listed on the attachcd.rheet. I 7. ❑Remodeling
.hip and have no employees These sudcontractan have V. ❑ Demolition
working for me in any capacity. workers'comp.imtmnee. 9• C3 Building addition
(No workers'.comp,insurance 5. ❑ We are a corporation and iv
required.) oflicen have axercised their 10.❑Electrical repairs or additions
3. 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(No workers'Gump. C. 152,§1(4),and we have no 12.Q Roof r:poirs
insurance required.)t employees.(No workers' 13.0 Other
cutup. insurance required,]
•.�q eppllewe dot du�W bee rt most alsp all uvt the sectiuo below showing their vrmkrn'eemprnwlun pulley marrmano s.
'1 Mnuuwrwrs who,uhniif this rMdavit indleasing they an doing all went and than hire collide conlraeren rani'mhrttlt a new 301davil indlWing such.
t',mrwtun thnt chuck this bus must attached un.ddillurud.hall showing the nwnu Offer abrunlrsa un and'hair woken'sump.pulley Inrurtnado s.
1 are an employer that proof lhig workers'cumpenradun lnsurunce/or my employees Below it the policy and job late
irr�urnrutlnn.
In,llrlttlee Company Nmne: _........
Policy 4 or Sclf-ins. Lie. 4:�./�� Eapirution Date:
IUta Site Address: D� �IIbN'0.�.. t.11y/5'tate/Z'p:���
,Niels a copy of the workers'componsatloe policy declaration page(showing the policy number and expiration dsto).
F.tiluru to,ecuro coverage as required under.Section 25A of,%IGL c. 152 can lead to the imposition of criminal penalties of s
tiro tip to i 1,500.u0 andlur one-year impri.tonment,as well as civil penalties in the form ofo STOP WORK ORDER and d lino
of iyl to 5230.00 a day against flit violator. Ile advised that a copy of this statement may br furwordcd to the Dlliet of
Invc,'igaliunn ni the DIA for insunn cowrngc veriticaliun.
Ida/rereby rnfj rand r repair I a nu/ .r ulrperjury rout the in/urnulluu provided above it rrve wad currrce
1 i
I)//iriul wnt only. lhu nor write in darer area, tut he cumpleted by city ur town,r,jjWai
Gtyor
I,s airs; \wlnsrily (circla arse):
1. Huard of Ifeallh 2. Iloihilnq Vvitm litters' 1, ('ilylanon Clerk d. Electric it Inspector i. I'fumhinq lospeetur
ti, 'her -- - -- _
Conl.Kt I'erw n:
CITY OF S.ILE.tii, AUSACHUSETTS
JLLEDL�(G OEP.+AntLSr
I 0 TAMLVGTON SrX=, )'O FLOCA
K1313FAI Y DRISCOLL Fkx(973) 140.9846
NCAYOA Maxw$r.Ptnus
DIASC'res OP PL 8Ltc PROPQRTY/8l'MnLYC CowlISdIO V Elt
Construction Debris Disposal Affidavit
(required for W demolition and renovation work)
fn accordance with the Sixth edition of the State Building Cade, 780 CMR section 111.1
Debris, and the provisions of MOL a 40, 3 54;
Building Permit At is issued with the condition that the debris resulting from
i If. 3 I JOA.
(his work shell be dispoScd of in a properly licemed wmte disposal facility as defined by NICE c
The debris will be transported by:
--S� A ;� ,
(name ur hauler)
Thee debris will be disposed of in :
!VOr" LL P
(name of faC Ily)
i
rn� roofpermirpph�Jnt
Sa
i
I j
I I
I
1
I
I
F�
i
E.-L
AL
I �
Note Thl¢ an uYlstf U signed / IRH21�
iite]pi clal ion of the gellel d epp 'tram,of 'iNed. /31/a012_�
the d vig It "not nCwn to be m csawt - -
rcndttton_
I DNI4 Conway-kI[ All Dicing H. I
t
FROM CMON)APR 9 MOIM 13: 11/ST. 1S:1OZNo. 7000OOO1G7 P 1
FRENJE2 OP ID: PN
ncoizo° CERTIFICATE OF LIABILITY INSURANCE DAT041091 2YY)
oa9snz
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(les) must be endorsed. N SUBROGATION IS WAIVED,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 endorsem s.
PRODUCER 781-2334855 CONTACT
Peter A.Rossetti Ins.Agcy. Px0xE PAX
436 Lincoln Avenue - 781.231-3752 ae N E : AID No:
Saugus,MA 01906 A�RESS:
Peter A.Rossetti Ins.Agcy.
INSURERISJ AFFORDING COVERAGE NAM:N
INSURER A:COmm@rC@Insurance Company34754
INSURED Jean Frenette DBA INSURER B:The Hartford
Frenette Carpentry INSURERC:
11 Newcomb Avenue
Lynn,MA 01905 INSURER D:
INSURER E:
INSURER 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 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 BY PAID CLAIMS.
INSR I TYPE OF INSURANCE AODL SU POLICY NUMBER MM/DDIYYW POLICY
IWVD,r Y LIMITS
TR
GENERAL LABILITY EACH OCCURRENCE S 500,00
A DAMAIETURENTED—
COMMERCIAL GENERAL LABILITY BDCMLC 12/12/11 12112112 PREMISES JE.oco.mnos & 100,00
GLAIMSMADE ❑OCCUR MED EXP(My one Person) S 5,00
X I Business Owners PERSONAL&ADV INJURY S 1,000,00
GENERAL AGGREGATE S 1,000,00
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 1,000,00
POLICY PRO- LOC S
AUTOMOBILE LABILITY COMBINED SINGLE LIMIT
Ea aeoidem S
ANY AUTO BODILY INJURY(Per Peron) S
ALL OWNED SCHEDULED BODILY INJURY(Per amdenl) S
AUTOS AUTOS
NON-0WNEO PROPERTY DAMAGE S
HIRED AUTOS AUTOS Peraoddim
S
I
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS LAB CLAIM&MADE AGGREGATE S
DED RETENTION S S
WORKERS COMPENSATION X WC STATU- OTH-
AND EMPLOYERS'LABILITY ER
B ANY PROPRIETORMARTNER/EXECUTIVE YIN NIA 6560U64495P90-&12 Ot/O6H2 O1106113 E.L.EACH ACCIDENT & 100,00
OFRCERIMEMBER EXCLUDED?
(Mandem,in NH) E.L.DISEASE-EA EMPLOYEE S 100,00
II as,des-be under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,00
PROPERTY 5,00
DESCRIPTION OF OPERATONS I LOCATIONS I VEHICLES (Admh ACORD 101,AdONlonal Remurlu Soh W ul ,N mom sPaa Is mquimd)
Carpentry
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Salem Building Department ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, MA
AUTHORMED REPRESENTATIVE
®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/D5) The ACORD name and logo are registered marks of ACORD