49 OSGOOD ST - BUILDING INSPECTION (2) r-1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
I Massachusetts State Building Code, 780 CMR, 71"edition OF SALEM
Revised Junuury
Q / Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
Jj One-or Two-Family Dwelling
This Sectignfor Official Use Only
Building Permit Number 4, 1 Date A ie
Signature: VZA- /
Building Commissioner/InsppCtorof Buildings .� Date
SECTION 1. NFORMATION
1.1 Property Address: /�1 .2 Assessors Map& Parcel Numbers
1.[a 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 11) Frontage(11)
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?Public❑ Private[3Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: S.� n� �
Name(Pri Address 5'
for Service:
5ifnZd
a urns Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work'-:
6
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
6. Total Project Cast: S
Check No. Check Amount: Cash Amount:
G` ❑Paid in Full ❑Outstanding Balance Due:
t
S�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.icense Number Expiration Date
Name of CSL-I lolder List CSL fype(see below)
.f Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Famill Dwelling
Signature M Mason Only
RC Residential Roofing Coverin
'I"clephone WS Residential Window and Sidin
SF Residential Sulid Fuel Btunin Appliance Installation
D Residential Demolition
5.2 Registered Home Imp v mt Contractor(HIC)
FIIC Company Name or t11C rant Name Registration Number
Address Expiration 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...........0
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 71b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, M�tS t �wl$1�1+�FG/�1Z13g70°'� Z N C- ,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 C, � } ,_Y_`�l
Print Name � f r "it
Signature of Ot onzed Agent Date
Signed under the pains and penalties of 'u
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 no.1 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 110.115,respectively.
1. 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"
DATE(MMIDDMYY)
l;tK i IFICATE OF LIABILITY INSURANCE 04/0612010
PRODUCER (508)39317744 FAX (508)393-6983 THIS
LYCERTIFICATE
AND CONFERS NO RIGHTS UPON HEOCERTIFOICATEION
ON
Eastern Insurance Group LLC - Comercial HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
155 B Otis St - ,) ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
POBox I125� INSURERS AFFORDING COVERAGE NAIC#
Northborough, MA 01532
INSURED Mass Wear eriZat7on Inc. INSURER A: Co
Western World Insurance ,
3 Ocean Avenue NsuRERB: Charter Oaks Fire 25615
Salem, MA 01970 INSURERC: American International Group
INSURER D:
INSURER E:
COVE GES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO 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 DO' TYPE O_IINSURANCE POUCY'NUMBER POLICYEFFECTIVE POLICYEXPIRATION LIMITS
GENERAL 11ABILlTY NPP11675171 05/28/2009 05/28/20I0 DACH MAGE TO RENTS S 7,000006
DAMAGE TO RENTED S inn-pop
X COMMERCIAL GENERAL LIABILITY
MED EXP(Any Ole De(90n) 5 S,OOp
CLAIMS MADE OCCUR
PERSONAL&ADV INJURY S I nnn-Opp
A GENERAL AGGREGATE S 21000 000
PRODUCTS-COMP/OP AGG S - 21000 000.
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO. LOC
BA469H7036 1010412009 1010412010 COMBINED SINGLE LIMIT $
AUTOMOBILE LIABILITY
(Be eccidenO 1,000,00
ANY AUTO
R
ALL OWNED AUTOS er per O ILYURY $
INJURY
B X SCHEOULEDAUTOS
X HIREDAUTOS BODILY(Par ac�de't)INJU g
enn
X NONAWNEDAUTOS
PROPERTY DAMAGE $
IPer accdanO
AUTO ONLY-EA ACCIDENT S
GARAGE LIABILITY O EA ACC 5
ANY AUTO AUTOUTO ONU ONLY:AN AGG $
EACH OCCURRENCE S
EXCESSNMBRELLA LIABILITY AGGREGATE $
OCCUR OCLAIMS MADE $
4
DEDVCTIBLE S
RETENTION S WC STATU OTH-
BOO,O
WORKERS COMPENSATIONAND WCOO27OSSS3 09/03/2009 09/03/2010 E. .y( c
E.L.EACH ACCIDENT 3
EMPLOYERS'LIABILITY
ANY PROPRIETOPJPARTNEWEXECUTNE E.L.DISEASE EA EMPLOYE S BOO,OO
OFFICE MEMBER EXCLUDED? E.L.DISEASE-POLICY WAIT S 500,00
If yeb.deaOrib,Vndw
SPECIAL PRGdIS10N5 Celow
OTHER
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES I EXCLUSION$ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
FI-National Grid Residential Weather7Zat7on Rebate PrograM is an additional insured with
egards to General Liability where required by written contract.
C N E ON
FICATE 1'01 DFR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EFT'=National Grid Residential Weatherization EXPIRATION DATE THEREOF.THE ISSUING INSURER MALL ENDEAVOR TO MAIL
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Rebate Program
Attn: Rosemary St. George BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
40 Washington Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTA,TIVE•S.
Suite 2000 AUTHORIZED REPRESENTATIVE P ` j/ .liNd�
Westboro, MA 0I581 Francis Kittred a (EO) SED ` {I} �CWNN���P ��_
mACORD CORPORATION 1988
ACORD 25(2001108)
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12�\1 A51 II\I.:,IN SI MA T • SAI I-\I, \i,\ii.\t :I! �i 1 _I
775.174 A841,
Construction Debris Disposal Affidavit
(required fix all demolition and renovation work)
In accordance \with the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of NIGL 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
l 11, S 150A.
The debris will be transported by:
(name of hauler)
'I lie debris will be disposed of in
(name of facility)
(nddrcss of facility)
sienature of permit applicant
date —
.lohiiaa'd,i �> D-4rtS _r/klc1!M W f A. V-2
Bo r o uil mg egulat�Ions*anStan ar s�
One Ashburton Place - Room 1361
F Boston. Massachusetts 02108
Home Improvement=Contractor Registration
Registration: 111617
Type: Private Corporation
Expiration: 1/12/2011 Tr# 260650
MASS WEATHERIZATION, INC --
RICHARD LAMBY
3 OCEAN AVE --
SALEM, MA 01970
Update Address and return card.Mark reason for change.
Address ❑ Renewal Employment ❑ Lost Card
OPS-CA1 G 40M-OSIOB-OBSLIFORMCA108212008
+-= INlassachuscits- Department of public Safel'N
Board of Buildin!" Rc_ulatiuns and Standar(Is
Construction Supervisor Specialty License
License: CS SL 102293
Restricted to: IC
RICHARD LAMBY d
3 OCEAN AVENUE--
SALEM, MA 01970
�,G-- --�--1s Expiration: 5/3/2012
('......=i..urr Tr#: 102293