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44 PERKINS ST - BUILDING INSPECTION 9 The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of kj Massachusetts State Building Code, 780 CMR, 7ih edition Building Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Tiro-Family Duelling 1 — This Section For Official Use Only Building Permit Number• Date Applied: ,2- Signature: eZ `2, t� Building ommissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 14 Pr erty Address: 1.2 Assessors Map& Parcel Numbers 4lren ,�ree 5+ ✓ no Ma I.la Is this an accepted street?yes _ P Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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? Municipal❑ On site disposal system ❑ Check if yes❑ rt� ' SECTION 2: PROPERTY OWNERSHIP' 2.11oQlYlerI�L�F}.!/`Y�gtAd Ll q '17f,VI 2 el } Name(Print) Address for Se ce: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building A Owner-Occupied ❑ 1 Repairs(s) ® 1 Alteration(s) ❑ Addition ❑ Demolition jL Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': 14Z SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Officlal Use Only Labor and Materials 1. Building $ 560,o I. Building Permit Fee: $ Indicate how fee is determined: Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ Soo'ob aid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) q�q" License Number Ex/pi,atio Datc Nome of CSL-Helder (`S. �1 n List CSL Type(see below) Vl • }"C/��.'T !�/L �'�r"i T Description A(/d,�4^d'ress qq�� 4 U Unrestricted u to 35,000 Cu. FL) `-1� r•l � R Restricted 1&2 FamilyDwelling Si n toe M Nlascinry Only RC Residential Roofing Covering Telephone WS Residential Window and Sidin 01 7is �� I/ SF Residential Solid Fuel Burning Appliance Installation Q 4 D Residential Demolition 5`� Regi tered Home Im rovement Contractor(HIC) //7, 71 llA1 � i2 ( :�M Registration Number HI C ,�try,amhot�I�ChRggtstrant N�atn�e - Ad res Y�L �I""JJ1Ul��KK'� 2L-��J� Q 1b f L !t� Expiration D to Signatur !7 U Telephone S CTION 6: WO OMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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. Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1 ,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 edu 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 I I 0.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 halfibaths 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 PUBLIC PROPRERTY DEPARTMENT L'; A.I,( INtifcrr l �f. \h.;\I III V'X.'ai ') :); • I-%X: 978-'4J_ )84,1 Construction Debris Disposal Affidavit (iciluired li)r all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 1 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit N is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c I 11, S 150A. The debris will be transported by: ILLPL �� 541 d-K)(rr)'5 (name othauler) I he debris will be disposed of*in : ( ,Lr.a _.PIS Po5A- — (nafne ut facility) (addros ur facility) NLnature ')t pernllt .. is ) I^ ,tale CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ._moo .I1I1', w t\' 1MIml.11 1 vl\\,wt _ I1� Wnsru�l:lstn SGILI I' � 5•\lPll,M.\».\. ul w Its Jl`il� fhl. ve8-7 tiv5'r5 • 1:\x 9711-NC'I346 Workers' Compensation Insurunce Afffdu.it: Builders/Contractors/Electriciuns/Plumben imucant lnfurmation Please Print Leeihly Nil net u)rgam nai�nulnJls�duall: i KNI �� /IJ`�" ` I"' "� ,Address: 11 <h tvf 41 (,( 20"X I/ J CilyStal ,zip CIrnn Wl.A ©1 ` �7(9 Phoney •':q7� �o�� 7 Cll I . . Are y m an employer?Check the appropriate box: 'T)pe orpntjecl (required): 1.❑ 1 ant a employer with 4. ❑ I :un a general contractor and 1 6. ❑ new construction cntploy'cc%(full and/ur part-time).• have hired the suh-contracturs 7. ❑ Remodeling 2. 1 am a sole proprietor or partner- listed on the anachcd sheet. t These sub-contracton have tl. ❑ Demolition ship and have no ctnpluyces working litr me In any capacity. \Yorkers' comp. Insurance. 9. ❑ Building addition No workers'cum insurance 5. ❑ We area cni-potation and its I P 10.❑ Electrical repairs or additions I required.) officers have exercueJ their . ri ht ofcxcntPon per er MGL I I.❑ Plumbing repairs or additions 3.❑ I 11111 hnmcuwner doing all suck 8 ' I, myself. lKo workers' comp, c. 152. q 1(4), and we have no 12.0 Roof repairs insurance required.j t employees. (Ko workers' 11.® Other (7eJhVAlfsj comp. insurance required.] •%11% y1tba all that chvcka box trl must alw lilt out the wcl Ion Iwtuw diowmg Minor w,akos'cumpensWion policy ndi trmation. 'I lomeawnrn who,,J1o141 this affidavit indicating they art Joint'all work aswl Own hire w1ulde contracton most.uhruil a new al rdavil indi"Ing muck -('.,mrxu.ry that OvA this box must attxhYd.m adJuional nlwal•hawing Ilw nano of the sub-conlext.xs and their workeri comp rrohcy mfurmamm /aw tor.employer that/s pro,idhkg Ivurkers'c•urnpenvadon in.surance jar my eurpluyees. Below is dye pu/ity and Job.mite reformation. Imorancu C'untpany Vame: co 11oli;:v a or Self-inss,.(lLic. h: I _... .. . .. -_ Expirauun Date: n� Job Silt: Address: Yq 1ti-ki✓IS �_._. City;StaluZlp: Atf—M i jg�TT .\tech is copy of the workers' cumpensatlon policy declaration page (showlnK the policy number and expiration date). Failure to secure cu\erage as required under Section 25A ul'.>IGL c. 152 can lead to the imposition of criminal penalties of a tine op to JI.5oo.00 amL'ur one-pear imprisonment, as \cell as cis II penalties in the funn of STOP WORK ORDER and a fine Of up to 5250.00 a Jay .lguinsl the violator. He advised that a copy of this tiatcanctil may be turwarded to the Office of Ins,>h,aumis ul ,tic DIA :or o,mmicc covcragv \ci itmaUon. /du hereby r ertifv under t/re nine and/en lticv of perjn that the infunnarlon provided above is true our/correct r t1/Jiciu/use mdy. /Jd not n'rile its this area. to be cunrp/rttd by l ity up town..//iris/. ( iiv or I'nw•it: _... __ PermitA.ieamse 0_ Issuing; Aulhurily (circle noe): I. Board of llc.dlll Z. Ihulding 141): rmical .1. Cit),-funn Clerk 4. Electrical luspertor 5. Plumbing Impeclor b. Outer _ Phone it: Information and Instructions >la�sac Is u:ctts General Laws chapter 1 i2 requires all :wplo)crs to provide workers' coinpenxauon tiff their employees. Pureu.ml to t'nis ,ratute, an emyluree is defined is- es cry pcison in the service of another under any contract of hue, e vprees or implied. oral or wvrrtten." An employer is dctined as"an individual, partnership, associauou, corporation or tither legal entity, or any two or more ..t the G,reeou,g engaged in a joint enterprise, and ineIuding the legal representatives of a deceased cmplu)cr, or the receiver or trustee of us individual, parnurship,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 dwehhing house of another who employs persons to do maintenance,cunstruc'tion or repair work on such dwelling house or or. the.rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152. §25C(6) also states that"every slate 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 re wired." \dditiunally, hIGL chapter 152, §25C(71 srates"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ufpuhlic work until acceptable evidence ofconipliance with the insurance - requirements of this chapter have been presented to the contracting authority." Applicants Please rill 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 number(s)along with their certiftcatc(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 ghoul be rewnicd 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 the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant. 111-::uc be sure to till in the pennitilicense nuniber which will be used as a reference number. In addition,an applicant iliac mum submit multiple permitlicense applications in any given year, need only submit one affidavit indicating current policy int'mmution(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 is proof that a valid affidavit is on file for future permits or licenses. A new affidavit niust be tilled 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he i)ifiec of In Vcsti.atWna 1Wul lice so think )flu in advlmc'c fur your cooperation and should you hate any questions, please do nor hesitate to give us a call. the MparnnciiCs address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Offlee of Invesdgadona 600 Washington Street Boston, MA 02111 Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE Fax q 617-727-7749 www.mass.gov/dia 12/01/2008 09'24 FAX 978 957 GG12 COUGHLIN INSURANCE 001/001 A_CVRD CERTIFICATE OF LIABILITY INSURANCE DATEjMM4)Ryy`Y' ov l (,p PAODU a F'RWpa0 12,10 08 CNAs1&eS J COVOHI.ZN THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION IN9URAIWK AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 D1HL8Y ST. p.O BOE 10 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. DRACUT MA 01826-0010 --- — EhRonne_ 978-957-3588 FA%:978-957-661.2 INSURERS.AFFORDING COVERAGE i NAIC M INsuR,=R A' Nataenal Granpa Iaa Co __, 1_4788 PYoparty Solutipng I--..—_.`•-• _ V1 Rdp* $u gaea NIsuRFac: "- 11 ucest r, Road INSURER D: Gloucester, MI 01930 � INStAiFA E: cuvERace's THE PCLICFS Op INSURANLC USTEO AELOw I,AVE MR"ISSUED TO THE INSURED NAMED ASCVE FOR THg pIICY PERIOD INUX:ATEO�NOTWIIMBTANDING ANY RCOUIREMENF_TEAM OR CONDITION OF ANY CONTRACT ON OTHER DOCUMENT WO,g6&PGCT TO Wli1fM THIS CERTIFICATE MAY SG ISSUED OR MAY PERTAIN.THE INSURANCE RECORDED 9Y THE POLICIES 096CREED HEREIN 18 SUBJECT TO ALL THE TERMS,EIILL U61ONS AND rOMQR10N8 OF 8VOf1 POLICIES..AOUREDATC LIMITS 51-OWN MAY HAYG BE el 111111C—ED BY PAID CLIUMI& � LTR7��ENI DF IMS POLICYNU w —i_ I pgTi DATG T L�� EACNOCCURRENCEWIN�f 1,DDD OOO. UL GENERAL LASiIRY -- ,S MADE I a occua army500 000. ' s48086803 10i000.a/oz/De a/Da/o9 PER80NA SAOVMURY fl 000,000.ITE LIM T APPLIES PER: ^PRODUCTS-COMPIOP A00 f71 vEGT �LOfi AUTOISOSAE LAMILRY GOMSINeD SINGLE LIMB' a i R ANY AUTO (6A RxISeN) _- III--7f ALL OWNED AUTOS DILY SCHEDULED AUTOS� P MgOUAY S I NON NIT08 I 1 HDN{)tNlEO ALDOS (P.BOD=4) f .. IPW emtlAlx PROPSRtT ONMGE f (Pm at'CDMI) OARAOG LURILRV �ANY AUTO AUTOONLY-EAACCIDENT OTHER THAN EAAC— r� — AUTO ONLY: A00 E EA4IS9&11MIRELLIA—W,Mtm EACH OCCURRENCE_ f OCCUR MA.MAD6 Ac�,RE0.ATE _ S DEDUCTIBLE —�f a ft6TENTH)r! f WORAGR!COUP NSA ANO i B EMPLOYeRO'LIAGIITY d382027 X TO YUUNTO E -- ANYFROPRIETORA'ARTNERIEXECUTN6 11/04/08 11/04/091E.LGACNACCIDGNF f100,000. OFFI00"EMBER EXCLUDED? 119,E — I GL.DISEASE-BA EMPLOTF' a100,000. uL PR"OvisroNS mb., OTH ILA I E.L DBEASE.POLICY LIMIT s 500 000. DES PTI(NI OF OPF3fgTON81 LDCATDNS/VGNN:LEE/SXCLYSIONS ADDED AT£NDORSEM6NT/BPLHJAI.PRO ONR I -- Carpentry CERTIFIC.AFE HOLDER _ CANCELLATION PEREOCKF. aia ANY OP TN&AR UVG OERCAIgSO FOUCIES RE CANCGLLEO AFPOAC I'M EXPIRATION BREDF,TNc ISBu1NG INSURER WILL ENOFAYOR TO. A lO_ DAYS WRITTEN DI THE GERTIRCA7........AMED IO THE LEA,DUT,.VI.URF.TO DO SO SHALI. C U®LIGATgN OR LIABILITY Ol'ANY AAR UPON THE iNSUAP.A.ITS ADENIa ON iNTAT S___.._. P Marchi .iCGRD 25(TODT.rOW! ---_�_ - - -_- `- COIif1 CORPORATION t988