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22 PICKMAN ST - BUILDING INSPECTION t r The Commonwealth of Massachusetts (� ✓✓✓ Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR S ALEM Revised M�dMar v 2017 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Fwnfly Dwelling This Section For Official Use Only Building Permit Number: Date Wed: tc4st�ets v Building Official(Print Name) tr V Signature to SECTION 1: SITE INFORMATION 1.1 Prope ddress: 1.2 Assessors Map&Parcel Numbers Lin 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 O On site disposal system ❑ Check if yes0 SECTION 2: PROPERTY OWNERSHIP' 2.1 cq�y�wrner'otR ord: .l�lsoy .k'&J6'To/V SAi-f► i 0N70 Name(Print)+ City,State,ZIP /�` / 'Rx ,7.r.r�ItC4. 0 � 1q q lZ .3YQUi/Iy'S*AJ ')d't'�c��Lu' ioul. coi`I No.and Street Telephone E Address SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) X I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Do - of Proposed Workz: � tL JVf_,E f n SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) - 1.Building $ I!S4- 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑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 $ Suppression) Total All Fees:$ - Check NO. Check Amount Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: Y SECTION 5: CONSTRUCTION SERVICES 5.1 Cofnstructi/'on//Supervisor License(CSL) j0 IS g y., w i3 I J00 �11i�7Tf License Number Expi on ate Name of CSL Holder 11 0 A�71l L `� ' List CSL Type(see below) No.and Street Type Description rt/I. _ ,�/1 ,•,r, �19�� U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Rooting Covering WS Window and Siding 366 J ) /I f7 SF Solid Fuel Burning Appliances QfGIL,� Is��av�,�o/6. I Insulation Telephone Email I D Demolition 5.2 Registered Home Improvement Contractor(HIC) -/'d J49d Aaile HIC Registration Num 9xpirfition Date HIC Co _pa I�Jgpis r L�HIC Le�r t t Name xmw /)I ��fL 7 S t/Le�.Er7 No.and Street Email address Alooe&jp"o- CItY/TOwr4 State ZIP Telephone SECTION6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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 RA O APPPLIIES FOR y/BUILDING PERMIT I,as Owner of the subject property,hereby authorize ✓ EC. /r .le to act on my behalf,in all matters elaative to work authorized by this building permit application. JOV YARXIAA(MAO Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER/OR AUTHORIZED AGENT DECLARATION By my name below,I hereby attest under the pains and penalties of perjury that all of the information conta' in this appli on is a and accumleAo the best of my knowledge and understanding. PrintOwner's or th med Y2Ws Name(Electronic Signature) Date NOTES: 1. An Owner o 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 can be found at www.mass.sov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.fL) 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" JOELW-1 OP ID:KS1 CERTIFICATE OF LIABILITY INSURANCE DAT 01131/IYYYY) 1131113 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: If 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 781-914-1000 NAMEpCT Kelly Sturtevant TGA Cross Insurance,Inc. PHONE FAX 401 Edgewater Place,Suite 220 -M.xc J`781-914-1000 ac xoc 781-224-9490 Wakefield,MA 01880 E-MALss:ksturtevant@tgacross.com Chris Hawthorne INSURER(S)AFFORDNG COVERAGE NAR:p INSURERA;NGMIrIMr .Company - 14788 INSURED Joel White Construction,Inc. INSUR M B: 3 Bessom Street,Box 207 Marblehead,MA 01945 INSURE c: INSURER D: INSURER E NSURER 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 TYPE OF INSURANCE AT Lr POLICY NUMBER Y UCYEFF MPNLICYEXP "am LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIALGENERALIJASILRY MPP0878V 06119/12 05/19113 PREMISES Eaa omuEnexe $ 500,000 CLAIMS-MADE 1XI OCCUR MED EXP("me pemm) $ 10,0 PERSONAL&ADVINJURY $ 1,000,00 GENERALAGGREGATE $ 2,000,00 GEN'LAGGREGATEUMITAPPUESPER: PRODUCTS-COMP/OPAGG 8 2,000,00 X POLICY PR0. LOC $ AUTOMOBILE LIABILRY COMBINED SINGLE LIMIT(Ea ami�njt $ 1,000,00 A ANY AUTO MPP0878V 05119112 05119113 SODILYIWURY(Perperson) $ ALLOWNED SCHEDULED BODILYIN.NRY(Peral ffl) $ AUTOS AUTOS X HRED Alfr05 X NON-OWNED PROPERTY DAMAGE $ AUTOS (Paz actldem UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB IMms-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERSCOMPENSATION I WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY UMIT$_ ER ANY PROPRIETOR/PARTNEF/EXEGURVE ISSUED BY WC CARRIER E.L.EACHACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Ift a ryln NH) E.L.DISEASE-EA EMPLOYEE S I(yes,describe mker DESCRIPTION OF OPERATIONS W. E.L.DISEASE-POLICY UNIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Ae ACOND 101,AddI Remarks Schedule,If mma spare is rpubed) CERTIFICATE HOLDER CANCELLATION YARRING SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Jason Yarrin tOn THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELWERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. 22 Pickman Street Salem,MA 01970 AUTHORED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Joel White Construction Inc Stlmate 3 Bessom St Box207 Marblehead, Ma 01945 .Qm Phone# 617-388-3667 Joelwhiteconstruction@gmail.com 2/12/2013 3 Joelwhiteconstruction.com Jason Yarrington 12 Gifford crt Salem, MA 01970 General Labor Fix and repair Sill around house as necessary. 0.00 0.00 General Labor Repair any rotten sill and wall framing as needed 0.00 0.00 General Labor Work to be performed as T&M with labor cost at$65 per hour 0.00 0.00 General Labor Estimate value of work 10,000.00 10,000.00 Please sign for ap va o work Total $10,000.00 i -=� CITY OF SiU EM) ANSSACHUSETTS I3UMDC%GDEPARTMENT 120%V-k3HLgGTON STREET, 3w FLOOR �C TEL (973) 745-9595 FAA(978) 740-93 6 :CI\iL3ERLEY D1tISCOLL 1 %YOR I110,% s ST.131ERaa DIRECTOR OF PUBLIC PROPERTY/BUILDING COSL\QSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section Debris, and the provisions of tN101. c 40, S 54; l l 1.5 Building Permit i# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: l €l ftJ4 L- "A,7L- (name Of hauler) The debris will be disposed of in (name of taciIIty) --(iddiI ess of taCltyty)-- I s gnumre Of permit applicant � 1913 We — f