87 ORD ST - BUILDING INSPECTION Z, The Commonwealth of Massachusetts
tA� Board of Building Regulations and Standards Town of
ky Massachusetts State Building Code, 780 CMR, 7" edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tno-Fmnily Dwelling
This Section For Official Use Only
Building Permit N mber: Date Applied:
Signature: )02/1 /O
Building Commissio er/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
11.
1.1 Property Addres 1.2 Assessors Map At Parcel Numbers
(VI 0aZ D.I a Is this an accepted street?yes ✓ no Map Number Parcel Number
3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(R)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner'of Recor ++ „
?;It2a�Yt1nz SKI n5LJ
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': 1 fl 1 l., C u
4olA: {Ju AlAMJ KIo02 Ihltticry Doa�Z S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building S 151 trc7o 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ O oU ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S ) U�U 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S O' ❑ Paid in Full ❑Outstanding Balance Due:
� �ayon
Re aa,,i Rcr�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �,. s5-76 1 L3 09
+.6 T l Q� et,6 License Number Exp rati Date
Ngmc fCSSLI- Hplde��lr NNN� 1 List CSL Type(see below)
2f'(:1 'Z2t1 P—ld �"���� T Description
Addres U Unrestricted u to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature gsZ��6� M Mason Onl
wq - RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 10 w l S
3fic bo ChA0 Registration Number
HIC Company Name or HIC Registrant Name
10
Addres O E epirat on Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... ❑ 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.
Si nature of Owner Date
SECTION 7.,b: OWNERr OR AUTHORIZED AGENT DECLARATION
60 C, —(is ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of r u
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 I l0.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 half/baths
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"
. , CITY OF SALEM
3
s
PUBLIC PROPRERTY
`, DEPARTMENT
r
:,I1I P;;._KiliT JR15Cm�LL
\Ltrt to 12^WASHl.NG 10N S t'ttecl' • SAt.rs+,Maiincl n ail:'l.r s 0197-
rhi.:978-743-9595 0 Pax: 978-7410-1846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ry7� Please Print Leeibiv
Name (13usiixss/Organizatiorvindividuup: C� V)
Address:
Cityslatc /..ip:�MkAl� /1VI (1il15
Phone ;:: (�-'l IS
.,re you rn employer'? Check the appropriate box: Type of project(required):
1.t, I am a employer with �-. 4. ❑ I am a general cotractor and In 6. ❑ New construction
enlylo yces full and'ur art-tints).• have hired the sub-contractors
1 > ( P 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. :
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'coat insurance 5. ❑ We are a corporation and its
1 P•
required.] otlicers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing-repairs or additions
myself. LNo workers' comp. c. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.] r employees. LNo workers' 13.❑ Other
comp. insurance required.]
-.Any.nplicaut that chucks box it[ must also rill out the section below showing their wurkus'eumpenvtion policy ioformutiom
'l lumcuwmrs who submit this a ffilavir indicating they are doing all work and then hits outside contractors must submit a new affdavir indicating.much.
�C,,rrrnton that check this box must attached an additional sheet hawing the namo of the sub-contractors and their workers'comp.policy information.
l am un enrpluyer drat is providing workers'cot»pcnsntion insurauee for trty employees. Below is the policy and job site
inforumtion.
Policy k or Sclf ins. Lne *: . _ Expiration Date:—
IVJ U1
Job 5im :\ddress: � -1 (3Cd -- City"Stateizip: )W`�/�i� rJA
Attach it copy of the workers'compensation policy declaration page(showing the policy nurnber and expiration date).
Failure to secure coverage as required under Section 25.A of}IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 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 copy of this stulemcnt may be forwarded to the Office of
hnvrsrigarions ol'Lhe DIA for insurance covcrugc verification.
l do hereby certify under the pains wrd penuldex of perjury that the infurinution provided above is truce and correct.
Sie:lulmc, _. --.- Date( O
Phr�r;c is
Offieiul use only. no not write in this urea, to be completed by city or town official.
City or Town: Permit/License#_-.--_
Issuing Aulhorkv (circle one):
t. Board of health 2. Building Department 3.Cily7fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. O I her —.._.
Conlrcl Penton: Phone
.Information and Instructions
Massachusetts 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 hire,
express or implied, oral or written."
An 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."
`1GL 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, 'vIGL chapter 152, s§'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 fill 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 nutnber(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 dale 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 tlae 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 ;md 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.
111case be sure to fill in the permitilicense 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 bur leaves etc.)said person is NOT required to complete this affidavit.
I he Office ice 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-NlASSAFE
Fax # 617-727-7749
Revised 5-36-05
www.mass.gov/dia
°^�'M"°"m ACHIli.i1. CERTIFICATE OF INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
GERALD T MCCARTHY INS HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
P.0 BDX-E'3ff ALTER THE COVERAGE AFFORDED BY THE POLICIESL BELOW.
92 NORTH STREET COMPANIES AFFORDING COVERAGE
SALEM MA 019700839 COMPANY
28WXD A THE TRAVELERS INDEMNITY COMPANY
INSURED COMPANY
BOCHES, BRIAN DBA B
COASTLINE CONSTRUCTION - COMPANY
19 REZZA ROAD C
BEVERLY MA 01916
COMPANY
D
COVERAGES '
THIS IS TOCERTIFY 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.
CO POLICYEFFECTIVE POUCYEXPIRATION
L7A TYPE OF INSURANCE PODGY NUMBER DATE(MM\DD\YY) DATE(MMV)D\YY) UNITS
GENERAL LIABILITY GENERAL AGGREGATE S
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. S
CLAIMS MADE El OCCUR, PERSONAL 8 ADV.INJURY §
OWNER'S S CONTRACTORS PROT. EACH OCCURRENCE §
FIRE DAMAGE(Any one fire) S
MEO.EXPENSE(Any one person) S
AUTOMOBILE LIABILITY
COMBINED SINGLE $
ANY AUTO LIMIT
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per Person) S
HIRED AUTOS
BODILY INJURY S
NON-OWNED AUTOS (Per Accident)
PRUPEHTY DAMAGE S
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY
EACH ACCIDENT §
AGGREGATE S
EXCESS LIABILITY EACH OCCURRENCE S
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
A WORKER'S COMPENSATION AND STATUTORY LIMITS ': NIA '.
EMPLOYER'S LIABILITY (1.113-26OX479-2-07) 03-14-07 03-14-08
EACH ACCIDENT S inn nnn
THE PROPRIETOR/ INCL
PAFFNERS/EXECUTIVE DISEASE-POLICY LIMB $
OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE § 1
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
CITY OF SALEM, BUILDING 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
INSPECTOR LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
ONE SALEM GREEN LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
SALEM MA 01970
AUTHORIZED REPRESENTATIVE
I.? n
ACORD 25-S(3/93) ® ORD CORPORATION+1993
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR'I"?NIENT
1<111 ' Will i':I
12QAA%I1H.M..,INS I!11:1 r • s.ki i It.
11:1. 1,074-'4;.9;95 ♦ I'.\c 978J4 -9d4ii
Construction Debris Disposal Allidavit
(Itquired li\r all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # - _ 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
111, S 150A.
The debris will be transported by:
Qw � S01 , d u0A
ame of hauler)
'I he debris will be disposed of in
(name of facility)
� 1d P3ok6-d rd
(address offacili(y) �n
signature of permit applicant
�ec 1 4g ---
,late