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13 PARADISE RD - BUILDING INSPECTION a 1 The Commonwealth of Massachusetts V I, Department of Public Safety �`...,,,.` ..\Iaesechusctts State Building Code(780 CAIR)Seer lh Edition City of Salem o Building Permit Application foran Building other tha a -F i Dwellin (This Section For Official Use Only) ulding Permit Number: Date Applied: Building lnsP2! r: SECTION l: LOCATION (Please indicate Block N and Lof M for locations for which a Ytreit address is not available) I3 FRRh01SF- RA�b `3fLI5M TO Ofq-70 VLn)Iyltj S(uAFF— Nu.and Street Citv /Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building Repair❑ Alteration Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑ ' Is an Independent Structural Engineering Peer Review required? Yes ❑ NO Brief Description of Proposed Work: IIli fEfZID(C hF—MODFL dF �XIS�iy/ Sri( TS 776Z1= SOME f1h -Y VVID 6:414-AjiC E E ? n/ u � LOO/Z IIV X+DD On)� GOc 02t/dfl S�rJK Rc4RTF-b PxuM&Nq + 1F ILL MOUE a 5TR,0G(e-gk- HFA- SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): r Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-t❑ R-2❑ R-3❑ R-4❑ S: Storage SI ❑ S-2 O U: Utility ❑ 1 Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) FIA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) ter Su I Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: PP YPublic❑ Check ifoutside•Flood Zone❑ Indicate municipal ❑ A trench will nut be Licensed Disposal Site❑ required ❑or trench orspecifv: 'ri Bate ❑ or indenli(c Zune:_ or un site scstrm ❑ permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: \I:\ I liM uric Cnnmi>sim Itecir„ Pn n,s: \ol :\pplicahle ❑ Is St nicnoe erilhui air,urt a ••rnadi area' In their recie,c completed?i l l i leted? I ( �mscnt to Rudd enclosed ❑ Yes❑ or No❑ Yes❑ \o ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Ldnion of C„de: Lsr Gruuphl: rope of ConslnicGon: Occupant Load per Flour 1)oes the•building contain an Sprinkler Svslem.': Special Stipulations: Z y a• SECTION 9: PROPERTY OWNER AUTHORIZATION q ti Name and Address of Pm pert\,Owner Q 16 7� MA VNP)ifl �� '�5 Q DIS R� `519 � V1 Name(Print) Nu.and Street City/Town Lip Property Owner Contact Information: Title Telephone:No. (business) Telephone Nu. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address Citv/Town State Zip to act on the pro pert\owner's behalf, in all matters relative to work authorized by this buildinl;l2ermitapplication. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If building is less than 35,t)(V cu. ft.of ends d s ace and/ur nut under Construction Control then check here C and skie Section 10 1) 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company ame: i4 �CiOL111 Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip La�4� 9T 60 -M 523� f)IIDD� 20 mx1 1�t134 �_ Telephone No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c.152. 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application7 Yes O No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor Total Construction Cost(from Item 6) =S 3>1,1'5�800 t ( 0 and Materials) 1. Building $ 'Iry Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ 6-62 appropriate municipal factor)=$ 3. Plumbing $ 000 Note: Minimum fee (contact municipality) 4. Mechanical (HVAC) $ 5. Mechanical (Other) $ / 0 Endow check payable to _ 6.Total Cost $ '3 Q Q (contact munici alit )and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT BV entering my name below, I hereby attest a er the pal and penalties of.perjury that all of the information contained in this application is true and accurate to the best y nowt �ea nd understaning. mA�cv�,vl SM/ (,1(7 2�S l 7 r0 Please print and sign name Title Telephone No. Date j©6 l a lT Mldy /,�A ieo ,NA- ©a 3 }tree( Address Cih/Town e Zip .Municipal Inspector to fill out this section upon application approval: ame Date e 32 z�2 .3�r zt 5 r "r CITY OF S.U.EM, , LkSSACHi;SETTS 91.QDiNG DEP.\RT1EAiT 1r 120 WASHINGTON STRERT. r MOOR TEL (978) 74S.9595 FAX(978) 740.98" KJ.,BEMEY DRISCOLL THo&w ST.REam MAYOR DIRECroR or static PRovtiRTY/ecliDLSIG coaansslo.%Elt Workers' Compensation Insurance AMdavit: guilders/Contractor/Electr(clansiPlumbers annlleant Information Please Print lee ibis Vatne leeaineaa.Organdran*n frwhv,d"): MA L L 8 L M S M 1''al Address. hD h OAK S't City/State/Zip: MID() L £J&Qfi ) MA t9g Phone Al. to( -) Are you as employs!Check the appropriate boar 1A. I am a employer with a 6. 0 1 am a gencrsl conbaewe and 1 Type of project(rdequlred) employs"(full andfs pact-time).• have hired the sub.cstbactor 6. ❑New construction 2.0 1 am a sole proprietor or Pontiac- listed on the attached sheet : 7.ARemodeling +hip and have no cmployca Then subcontractors have V. 0 Demolition working for me in any capacity, workers'comp.insurance. 9. 0 Building addition (No workers'comp. insurance S. 0 We ate a corporation and is required.] of keno have exorcised their 10.0 Electrical repairs or additions J.0 1 am a homeowner doing all work right of exemption per MGL I I-❑Plumbing repairs or additions myself.(No worker'comp. C. 152.410).and we have no 12.0 Roof remain insurance required.)t employe".(No workers' 1).0 Other comp.insurance required. •Any apputaa ttr dww boa•t mum air rill wr tM acres.bsiste rbretq ttdr woiMs',.wp and pokey idrat..Mies. ' I hwwuwdane who submit this afilMis indicating they as Joints all work ado than him etusids cennattorr mug A lj a new aMjsvil indioaiq rids <'.wtraelrn than Cheek thin box mudanaettad as aJddlawl Am showing dAr eras of tiro wtk.euaacwn and thb wakes'tong,pdtey inem"don, I oar as earp/oyer that b provid/nr workers'romparaden lesarenerjor my earphryees, adorn/s the pd/q eadlel star irrjorrdrteda Insurance Company Name: t4 e�� S Policy ts or Sclr--in .Lie. p c' S 3 T 1a p2 3 Expiration Dater: 12 a-3ha lub Site Address: 1.3 VAFA )1SF, RD City/State/2ip: J�}l��iL� /1� i�(q�Q .\tierce a copy of the workers'compensation polity declaration pap(showing the policy number and explrsdon date)6 Failure to secure coveralls as required under Section 25A of MGL a I52 can lad to the imposition of criminal penalties of 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 S230.00 i day against the violator. lie advised that a copy of this aatemant may be forwarded to the Office of Inccaugmiuru ul'tha DIA for insurance coverage vcn.fwation. /de hereby certify wrrdir the peiw e�xaftles ery the#the injormetloa provided above is rue and rorrrd:t Uam: 1 I t7 O/Jlcirl oat da/y. De nor write in this ureer to be ruop/rtd by riy or town"I/kid City or ruwa: Yrrmie/Llccnse ts issuing Authority(circle one): i 1. Ituard u(Ilealth 2. Ruilding Mpirtment ]. City/town Clerk ♦, flectriul lospcctor 3. Plumbing Impactor 6. Otheir t_„nracl Person:__ _ __ _.. Phone 0: 1 rr. CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT 51'N@rT 0$.tl I'N, fit.\+S.N fFt: VV4 9i95 • 1'.%X:978.743-9846 Construction Debris Disposal Affidavit (required 1'ur all demolition and renovation work) In accordance with the sixth edition of du Slate Building Code, 730 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit H _ . _ 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 I11. S 150A. The debris will be transported by: 1 name of hauler) 'I'lie debris will be disposed of in C T (narne of facility) (address of facility) signature of Ixnntt applicant 1 /7 /PO late 01-07-' 10 16: 19 FEOM- T-576 F0001/0002 F-632 • �V VCR I Irmom i C Ur LIHDILI I T IIVaUK/UVIFt OP ID DT MSCON-1 01 07 10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Anderson Cushing Ins Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Div. of Farrell Backlund LLC HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Sox 549 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Middleboro MA 02346 Phone: 508-947-3036 Fax:508-947-6182 INSURERS AFFORDING COVERAGE NAIC 0 INSURED INSURER A: American International Co INSURER B: bcotcednle xnavranm company M 3 Construction Malcolm F Smith dba INSURERC: Safety Insurance Company39454 106 Oak St INSURER D: Middleboro MA 02346 INSURER E; COVERAGES 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 W ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED SYTHE 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, MSKAbbla- LTft INSREI TYPE OF INSURANCE POLICY NUMBER DATE(MM/ppryYYY DATE MM DD/YYYY LIMITS GENERALLIABILITY EACH OCCURRENCE b1,000,000 B X COMMERCIALGENERALLIABILITY CLS1566951 01/17/09 01/17/10 KI, I U PREMISES Nw E100,000 CLAIMS MADE FRIOCCUR MED EXP IAny Cne person) S5,000 X Hlkt Addrl In* PERSONAL SAOVINJURY $ 1 000 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $2,000,000 X POLICY JEST LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $S,OOO,ODO C ANYAUTO 6203221 05/06/09 05/06/10 (Ea"dd nt) ALL OWNED AUTOS $ Ix SCHEDULED AUTOS BODILY INJURY IPer pereen) HIREO AUTOS NON-OWNEDAUTOS M.'amYdN�Jt) $ PROPERTY DAMAGE $ (Per eCoidant) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO EAACC E OTHER THAN AUTO ONLY. AGO $ EXCESS/UMBRELLALIASILITY EACH OCCURRENCE S3 000,000 EI X OCCUR CLAIMS XBSODQ1633 Q1/17/Q9 Q1/17/1Q AGGREGATE $3,000,000 DEDUCTIBLE b X RETENTION 30 $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY YIN X TORYLIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVB� WC006921659 12/23/08 12/23/09 E.L.EACH ACCIDENT bi 000,000 OFFICERJMEMBER EXCLUDED? U (Mandatory in NH) HA, PH PEHLMALecA5959923 12/23/09 12/23/10 EL,DISEASE-EA EMPLOYEE S I,Q Q Q,OOQ IIy s,descHne uMer SPECUA PROVISIONS be. E.L.DISEASE-POLICY LIMIT 1 $ 1,000 Q00 OTHER DESCRIPTION OF OPERATIONS/LOCATK)NS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS The Workers Compensation policy does not provide coverage for Malcolm F. Smith- CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION rSALEmTo DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of Salem IMPOSE NO OBLIGATION OR LLABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Building Dept REPRESENTATIVES. 120 Washington ST 3rd floor AUTH ED REPRESENTATIVE Salem MA 01970 • ACORD 25(2009/Ot) 0 C JORP T reserved. The ACORD name and I090 dre r marks O R 01-07-' 10 16:19 FROM- T-576 P0002/0002 F-632 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the polioy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s)- 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009101)