13 PICKMAN ST - BUILDING INSPECTION ' The Commonwealth of Massachusetts Town of
� r
p�} Board of Building Regulations and Standards
4y; Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
\\l Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nu m Date Applied:
Signature:
Building Commissi r/Inspecto of Buildings Date
S C ION 1: SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
1.1a Is this an accepted str t?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ . Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: 13
" Name(Print) C Address for Service:
J� �I 1 itt R"(•�J
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(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 DescriptionLo�f�Proposed Work:
V'C—.-oVe ae UViS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
�4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 44.0 6-:40o 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) r
,,.
License Number Expiration Date
Name of CSL- Holder List CSL Type(see below)
Type Description
Address
U Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
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
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.
p tr ev
Print Name /
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 1 IO.R6 and 110.115, 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 Cost"
01 CITY OF SALEM
A PUBLIC PROPRERTY
DEPARTMENT
:,Ilt 611..; 1 H " :I -
.'.I , , r
Construction Debris Disposal Affidavit
(required tier all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Ch9R 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
111. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed ot'in
,�•1.4 o•u�.._.M�e.Cla y 1 y4^S�`"` S�A���o �
(nume or laality)
(ur Iress u(ILcilit_ )
signature of permit applicant
ale
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ROB,ERT:_W�GROI s
� 9 RAINBOW
GLOULEST.ER„MA-0193 r ,Cornmjs$ione� i _,
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a-cs� Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR -
i Registrat �, 104751 '
vlt ' Exni�raf ra o15/2010 Tr# 270837
(� I;yp� ate Corporation _
�,
BOB,GROVER�ts T CTLIN
Robert Grover III t��\
9.RAINBOW LN
f Gloucester, MA 01930 Administrator .
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ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID DP DATE LMM/DD/YYYY)
GROVE-1 11 11 08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Cape Ann Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
23 Dale Avenue Ste 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Gloucester ,MA 01930-5935
Phone: 978-283-7757 Fax:978-283-2401 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA'. Western Heritage
INSURERB. Liberty Mutual Insurance
Robert Grover Contracting INSURER C:
9 Rainbow Lane INSURER D.
Gloucester MA 01930
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 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.
POLICY EFFECTWE LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DDm LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
A X COMMERCIAL GENERAL LIABILITY SCP0687899 03/24/08 03/24/09 PREMISES(Eaoccurence) $ 100000
CLAIMS MADE FX7 OCCUR MED EXP(My one person) $ 5000
PERSONAL&ADV INJURY $ 1000000
GENERAL AGGREGATE s2000000
GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1000000
POLICY PROECT LOC
J
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident)
$
ALL OWNED AUTOS BODILY INJURY
SCHEOULEDAUTOS - (Per person) $
MIRED AUTOS BODILY INJURY
(Per accident) $
NON-OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION S $
WORKERS COMPENSATION AND TORY LIMITS I j ER
B ANY PROPRIETOR/PARTNER/EXECUTIVE
EMPLOYERIETORIILITY WC231S460718-027 08/19/08 08/19/09 E.L.EACH ACCIDENT $ 100000
OFFICERIMEMBER EXCLUDED'! E.L.DISEASE-EA EMPLOYEE $ 1 OOO OO
If yes,describe under
SPEC IAL PROVISIONS below E.L.DISEASE-POLICY LIMIT s500000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
carpentry,residential not exceeding 3 stories
CERTIFICATE HOLDER CANCELLATION
SALEMBU SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
SALEM BUILDING INSPECTOR NOTICE TO T C TIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
CITY HALL IMPOSE• OB ATION OR LiABILI A KIND UPON THE INSURER,ITS AGENTS OR
SALEM MA 01970 REP SENT IVES.
A OR I
ACORD 25(2001/08) o ACORD CORPORATION 1988
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PROPOSAL SUBMITTED TO -DATES `
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- JOB NAME" '
3 HLGH.- PILL LANE
CITY STATE and ZIP CODE .., „ a i 1. JOB LOCATION J
hEVERLY: MAPZCRP,AN aT, SA -Ell 1 ^ ° ARCHITECT ,DATE OF PLANS +- o 't ,` a
tr"" JOB PHONE
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e hereby sutimlt specifications and estimates for
W
STRIP ALL ROOFING FROii MAIN ROOFS OP ;H{2USE
"I 1PERE 1S QNLY ONE LAYFR ON RCOP PRICE2,WILL IE bISCGirNTED BY $400r00
., as. '. c.a
SPR]i ;ALL HFtEE CdIMNEYS OF IaLL,' LEADrf.As7 r crra^ ri a r r r , .,