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10 PICKMAN RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Board of Building Regulations and Standards OFSALEM CITY Massachusetts State Building Cude, 780 CMR, 7 edition Rrvrsrr/Ju.rar.n• I� Building Permit Application To Construct, Repair, Renovate Or Demolish a /. :INAV One-or Two-Family Dwelling A�� This Section For ORcist Use Only A Building Permit Nu ber: Date Applied: Z� Signature: �d✓'2L�f c7 RuildintiVAxnatissioned Inspector of Buildings Date SECTION 1:SITE INFORMATION I.1 O pf N .� ' /,C /1 1.2 Assessors Map A Parcel Numbers t i { 1/7 I.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Foe Area(sq 11) Frontage(11) 1.5 Building Setbacks(B) From 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❑ lone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Reco / Name(Print) Address for hem ice: 7 Z z Signature Telephom� SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.0 Number of Units_ Other ❑ Specify: Brief De cription of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OlRelal Use Only Labor and Materials 1. Building S 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee ?. Electrical I ❑Total Project Cost'(Item 6)x multiplier x ). Plumbing S 2. Other Fees: S l 4. Mechanical (IIVAC) S List: S. Mechanical (Fire S Su ression Total All Feet:S 6. Total Project Cost: 5 a Check No. Check Amount: Cash Amount: (/ 3S 7 v ❑Paid in Full ❑Outstanding Balance Due: cue SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) a✓ro,/ .�� License Number I:vpiri uun 1 ale if Name ol'CSI.-IIoIJer�--r) or, List CSL Type(see below) f Ihscri ion \wmuj 1 _ (. � t./� U llnmlricteJ u to 75,000 Cu.Ft. R Restricted Id]Famil lTvellin Signuwre �� � M M Onl RC Residential Roulin C'overin WS Residential Window and SiJin SF RaiJential Solid Fuel Bumin A IIa1Ne IOYIaII:111Y11 O i D RaiJemial Demolition S.2 Registered Horne Improvement Contractor(HIC) I IIC Company Name ur IIIC Registrant Name Registration Number Address 5�� /\�.a-ydt/1 Expiration Date Signature I/ rT 1 Vi'O" V�'rdephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 1ST.f TSC(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 ..........O No...........O 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 ure of Owner Dote SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I Qq, ,J ,as Owner or Authorized Agent hereby declare that the statements and information on)Ita foregoing application are true and accurate,to the bat of my knowledge and behalf. Print Name !� !� �� 0 Signature of( nee or Auhorized Agetft Date l� ` ' S unJe Ahapains and penalties of '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 Bg have access to the arbitration program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 1 IO.RS,respectively. Lof n substantial work is planned,provide the information below: ors area(Sq. Ft.) (including garage,finished basement/attics,decks or parch) ing area(Sq.Ft.) Habitable room count of fireplaces Number of bedrooms f bathrooms Number of half/baths eating system Number of decks/porches ooling system Enclosed Open al Project Square Footage"maybe substituted for"Total Project Cost'- CITY OF SALEM ' PUBLIC PROPRERTY DEPARTMENT a Uu:Ni FY:)g HCUI.I. %l.\n oa 12C W ASHINQ I'ON 5'I'aEL•l' • SALEM,MASSACul ,hri s O197Z 978-.'43-1595 is FAX: 978-74^-9846 Yorkers' Compensation Insurance :off[davit: Builders/Contractors/Electricians/Plumbers % ) ilicant Information ] Please Print Letihly Marne 111uciucss gr8aniratiaNlndtviduuq: e�� Address: ( /6?�"L,^1 4 e_ (. / /� Ly/y�" Ilyi$[:1CCi�Ip: ��. LV l'[lone i1. �� Q 0/ J ' LI .krc you an employer:'Check the appropriate box: 'Typo or project(required): 1.❑ 1 um a employer with G. ❑ 4. a I m a ocncral contractor and 1 new construction entployces(full and/or part-time).• have hired the sub-contractors - 7. El Remodeling © 1 listed on the attached sheet. : 2. am a sole proprietor or partner- ship and have no employees These sub-contractors have K. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9, [jpudding addition No workers'cum 5. We are a corporation and its � P insurance El have exercised their 10.❑ Electrical repairs or additions 1required.] I I. Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per hIGL ❑ b P' myself. LKo workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. LKo workers' 13.0 Other comp. insurance required,] -Any:yphcaut that cP..ceks box nl must:,,so Lill our the u:clian Wow showing choir wurkexhi cumpensalioir policy ioliunmliurs 'I lomeuwncn who submit this affidavit indicating ihcy are doing all work and then him outside contractors must.uhmit a new affidavit indicating such. -C hors that cheek this box most anaehai on additional sheet showing the nanhe of the sub<ontracwrs anJ their workers'comp.policy information. /am tin employer that is providing workers'c•oinpell atiou insurance for nay euapluyees. Below is the policy and/ob site information. Insurance Company Name:__.._-. - - ._ . ._..------------ Irulicv is or Scif-ins. Lie.it: ..._.__ Expiration Date: Job Site Address: City/State/Zip: Attach It copy of the workers' compensation policy declaration page(showing the policy nu[uber and expiration date). Failure to secure coverage as required under Section 25A 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 \veil as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 it day against the violator. Be advised thut a copy of this slutemenl may be forwarded to the Office of Inceaugaunns ul'the DIA for insurance covcragc verification. /do hereby certify end r the paJn//y�•�an/dLprn Woes of perjury that the inforinalton provider/above is)truue and c•orrec(. tii ,:hanoe _ Ali 1 t/ �� f I I, i r i/ Official use only. Do not write in this area, to be completed by city or town official. CRY or Town: - Permit/l.iccnse4___.._... -. - Issuing Authority (circle one): I. Board of Ilcalill 2. Building Department 3. Cil.s rotsn Clerk 4. Electrical [uspector 5. Plumbing Inspector 6.Other .—- - Contact Verson: _. . .__ Phone Y: - 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 at 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." NIGL 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, NIGL chapter 152, §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 w ith 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-contractors) name(s),address(es)and phone number(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 date the affidavit. The affidavit should he 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 the 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 and 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. Please be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant that most submit multiple pennitflicense applications in any given year,need only submit one affidavit indicating current policy intormation(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 t i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. I lie OtIice of lavestigations would like to thank you in advance fur your cooperation and should you have any questions, please do not hesitate to give us a call. The Departincnt'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-MASSAFE Revised ;-Sri-vs Fax N 617-727-7749 www.mass.gov/dia CITY OF SALEM 5 PUBLIC PROPRERTY - ' DEI'AIZ"I'MENT 1d Re r • 1.\I I \I. \L\ �\I .. I . .I'I II1 'r );4; ♦ 1 'i'%.'i:'r.i 11, Construction Debris Disposal Affidavit (rc\Iuired lix all demolition and renovation work) In accordance \kith the sixth edition ot'the State Building Code, 780 CNIR section 111.5 Dcbris, and the provisions of v1GL c 40, S 54; Building Permit B is issued with the condition that the debris resulting front this work shall he disposed of in a properly licensed waste disposal facility as defined by V1GL c I1I. S 150A. The debris will be transported by: Inome:of aultr) The debris will be disposed of in : 2 (nurnr ul laelhty) t ndJres. ul IxJily) i i alu a nt prnnit appheaul i � IC � I 1 iv 1 SS:ICnUSC(is- mpartmcnt of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 104055 Restricted to: 00 DAVID BRADLEY - 14 WESTRIDGE DR HAMPTON, NH 03842 Expiration: 1221/2013 ("noon isionrr Tr#: 104055 7/.e &idrnnaao... Wa o�✓�aaaae/zone ° . Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR 1 before the expiration date. If found return to: Registration: 162701 Board of Building Regulations and Standards Expiration: 4/62011 Tr# 282565i .ram One Ashburton Place Rem 1301 ' -Type: Private Corporation .,� 2 2 x Boston,Ala.0 ., 01 ALL IN ONE CONTRACTING SERVICES,INC. DAVID BRADLEY 38 MAPLE AVE. ELIOT,ME 03903 Administrator o alid without signature r ac . x COR� CERTIFICATE OF LIABILITY INSURANCE OP ID MS DATE(M$UDDYYVY) ODSSI-1 01 06/10 PRooucE _ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Metro West Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Northeast Insurance Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 648 Highland Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Needham Heights MA 02494 Phone: 781-444-6790 Fax:781-444-3318 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A-- Pwra:raa IftL L :nanran® cn. 15024 INSURER B: A io InL mauona Group ODS Siding Application Inc. INSURERC: 24 Auburn Street INSURER Everett MA 02149 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT,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 COMMONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NS TYPE OF INSURANCE POLICY NUMBER GATE MYIDD DATE MMID LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A x coMMERc1ALGBNERALLIABILDY CPP 0160561823 05/30/09 05/30/10 PREMISESEaacarence) $50,000 CLAIMS MADE X❑OCCUR MED EXP(Any one person) $5,000 PERSONAL a ADW INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GENLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMWOPAGG $2,000,000 POLICY J LOC AUTOMOBILE LIABILITY COMBINED SINGLE UNIT ANY AUTO (Ea amdent) $ ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Pw PM n) $ HIRED AUTOS BODILY INJURY NON-0WNED AUTOS (Per accidmt) $ PROPERTY DAMAGE $ (Per acadmt) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE s $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY TORY LIMITS ER B OFFICEOPRIET0FRMIXYCNIERtE CUTA�G� WC009872749 08/13/09 08/13/10 EL.EACH ACCIDENT $ 1000000 (Mandatory in NH) _ EL DISEASE-EA EMPLOYEE $ 1000000., . tt dmaibeunder•' SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ 1000000.,;-.. OTHER A Commercial Applica CPP 0160561823 05/30/09 05/30/10 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS SIDING CONTRACTORcarpentry — if any CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 All In One Contracting IMPOSE NO OBUGA N LIABILITY OF ANY gI1D E INSURER,ITS AGENTS OR Services Inc- REPRESENTATNES 14 Westridge Drive AUTHORREOR Hampton NH 03842 House Acc T1I1 ACORD 25(2009101) ©198 200 ORD RPORATION. All rights reserved. The ACORD name and logo are registered me A 0