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33 OUTLOOK AVE - BUILDING INSPECTION 4 ^ The Commonwealth of Massachusetts I W Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 7u'edition OFSALEM Revised January 1 Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008 One- r Two-Family Dwelling nThis Section For Official Use Only 1 Building Permit N ber: Dat Applied: Signature: Buildin Com sioner pe or o u(dings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers ✓+ L l 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 ft) Frontage(ft) 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? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: .emu l,anil t?artN 3.�3 oc,4 J Ie- s4✓C �ct/P...." N.. /9 0 L97t7 Name(Print) `�� Address for Service: 97R- Cola- e6,93 Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ® Specify: Brief Description of Proposed Work':�i1,/a� LiC Lvs �J r A- ✓ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ to, (p .BQ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (14VAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ p ��q Check No. Check Amount: Cash Amount: l51 6.Total Project Cost: $ � ( '90 0 Paid in Full ❑Outstanding Balance Due: I SECTION 5: CONSTRUCTION SERVICES ` 5.1 Licensed Construction Supervisor(CSL) 90?0a //- l ?O/-IL c�A Begcc License Number Expiration Date Name of CSL-Holder List CSL Type(see below) 00 Address —� a Description .� Unrestricted(up to 35,000 Cu.Ft. 9ig�a '---"�ture �n Restricted 1&2 FamilyDwelling M Masonry Only -&/-''/71'30%5 RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Jiome Improvem'e/nt Contractor(HIC) s "04er/ f' y�,•c�4o%AiorJ.t� �/� /(a48R3 HIC Company Name or l-IfM istram Name Registration Number 7X/ „/ls, Ae 4r ', M'd Address ��_� ✓�,,,� 7�j-S/ �rps- Expiration Date Signature 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 .......... No........... ❑ SECTION 7a: 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. Signature of Owner Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION 1, My/Gr.z, d a�erg ,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 beh�lf. , L rny Otz/C C Print Name Signature of Owner or Authorized gent Date (Signed under the pains and penalties of e 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 RIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.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 Cosf' ,�►coiza CERTIFICATE OF LIABILITY INSURANCE DATE(MMID°VY"") `-�'' 3/18/11 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: H the certificate holder is an ADDITIONAL INSURED, the policy(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 on this certificate does not confer rights to the certificate holder in lieu of such endorsement's). PRODUCER CON T NAME: Paul T. Murphy Insurance Agenc PHONE FAX 16 Lebanon St EMaL N ADDRESS: Malden, MA 02148 PRODUCER 7064 INSURERS)AFFORDING COVERAGE NAICd INSURED INSURERA:Scottsdale Ins Advanced Energy Solutions LLC INSURERS: Peerless Ins 75 Greenwood Ave I INSURER C:AIG Wakefield, MA 01880 INSURERD: 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 AML —11 POLICY EFF POLICY UPTYPE OF INSURANCE POLICY NUMBER MIDDYYYY) (MMIDDYYYY11 UNITS GENERALLIABIUTY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPS1014919 5/7/10 5/7/11 DAMAGE TO RENTED $ -lOO OOO CLAIMS-MADE OCCUR MEDEXP(Anyonepason) $ cj 000 PERSONAL B ADV INJURY $ 2,000.000 GENERAL AGGREGATE $ 2 000 000 GEMLAGGREGATELIMITAPPLIESPER PRODUCTS-COMP/OP AGG $ 2.000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY CONS INED SINGLE LIMIT ANvnuTO (Eaaccimre) $ 1,000,000 BODILY INJURY(Per person) $ B ALLOWNEDAUTOS 8633314 3/19/11 3/19/12 BODILY INJURY(Per aecident) $ X SCHEDULEDAUTOS PROPERTY DAMAGE $ X HIREDAUTOS (Per accident) X NONOWNEDAUTOS If $ UMBRELLA LIM OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION 006789459 5/14/10 5/14/11 WC S1 ATU- OTH- AND EMPLOYERS'LIABILITY Y I N C ANY PROPRIETORIPARTNER/EXECUTNE EL.EACHACGDEM $ SOO,000 OFFICE RIME MEER EXCL TOED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPE RATIONS below E.L.DIS EASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Ahach ACORD 101,Additional Remarks Schedule,if more space is requ red) Insulation-GLAC Inc, Community Teamwork Inc, NGRID Corporate Services LLC, DBA National Grid DBA Boston Gas Co DBA Colonial Gas Co DBA Essex Gas Co and Action Inc on GL per form CG20330704 Coveraqe is subiectto policy terms conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Joyce Fax# 978 740 9846 AUTHORIZED REPRESENTATIVE Salem, MA © -2009 A ORATION. All rights reserved. ACORD 25(2009109) The AC ORD name and logo are registered marks of ACID RD i CITY OF S.UX.N4 2UNSSACHUSETTS BUILDING DEPARTMENT p 130 WASHINGTON STREET,3w FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KINIBERLEY DRISCOLL MAYOR TTtoMAs ST.PtEm DIRECTOR OF PUBLIC PROPERTY/BUI DMIG CO%L%fISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Nalne (Busim-&Orgaaization/Individual): xelyo(vt awl (fkl - `OL O f t / / Address: /,4, z" City/State/Zip: ALZZ `nil Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.C9 1 am a employer with-_ 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition workingfor me in an capacity. workers' comp.insurance. Y9. ❑ Building addition required.) workers' comp. insurance S. ❑ We are a corhave exercised and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' I3.®Other S .,,1 e�,on comp. insurance required.] •Any appliamt that checks box#t must also fill out the section below showing their workers'compenaadon policy information. '1 fnmeownen who submit this affidavit indicating they are doing all work and than hire outside contractor most submit a new affidavit indicating such 'Cuntraxon that check this box must attached an additional shot showing the none of the sub-contractor and their worker'camp.policy information. l am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and fob site information. Insurance Company Name: �w UI 7✓r Policy#or Self-ins. Lic. Expiration Date: 6•/c/- lob Site Address: City/State/Zip: ea /o .r (f4,D19--V Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby certify under/the pains and penoldes of perjury that the information provided above is true and correct. Sian pure „/' _ �� -ice Date: i Phone#: OJrcial use only. Do not write in this urea,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Ifealth 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing inspector 6.Other. Contact Person: __ Phone#: