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25 PICKMAN ST - BUILDING INSPECTION '] :� - ------ The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 C NIR SALF\l 'L,'•• Rrri.crd.I lur'tl!l Building Permit Application 'ro Construct, Repair, Renovate Or Demolish a One-or Two-Family Divellilig This Section For( ' •ial Use Onl Building Permit Number: ate Applied: Budding Ofiicial(Print N;une) Sign Date SECTION I:SITE INFORMATION 1.1 Property Address: f 1.2 Assessors Map d(t Parcel Numbers L la Is This an accepted street?yes no_ Nfap Number Parcel Number I.J Zoning Information: 1.4 Property Dimensions: Tuning District I'ruposcd tJsc Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(It) Front Yard - Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone- Check it' es❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Mane(Print) C ity,State,ZIP Nu.and Strcel f elephone hmail Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Den Olition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Spccily: Brief Description of Proposed Work=: SECTION�: ESTIDIATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and .Materials) Official Use Only I. Building S I. Building Permit Fee: E Indicate how fee is determined: 2. lilccirical g ❑Standard CityiTuwn Application Fee i, Plumbing S ❑Total Project Cost'(Item 6)s multiplier ____x - _. Other Fees: 5 a. \Icch;mical illy:\('1 S List: _ 5. Mechanical (Fire Su„ression) S Tuull All Fees: - t,. Tidal Project Cost: J G Check No. __('heck Anwunt: - --- Cash Amount: ❑Paid in Full IJ Outstanding BaLmce Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supen isor License(C'SL) Z 11 mbe- - ._. ~ L Limnsc NumberFNpir;niou Date lolder List CSI.1)pe lscc halos)--__--- 1 —+LkseJ_t-4401--- -=-- -------- 'I)pe Description No. and Street U I icicmJ I IhlilJin,s Ii to 15,11110 cu. It.) R IteArcslricieJ Dttcllin Citvl'utsn,.Sl;ue.Z1 M Nlasonry RC Rooting Co%erin ---_. WS Window and Siding SF .Solid Fuel Burning Appliances G S71 Va I hsulation I cic hone ('.mail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) i / /lO'/`Lr f3`�e.t C IIIC Registration Numl+cr lispiratiun Uatc I lie Coot any Name or I IIC Rc istram Name No�unJ tract�� �`� Email address Ci lCown,State,ZIP Tcic hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L,c. 152.1 2SC(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,9f the building permit. Signed Affidavit Attached? Yes ..........0Z No........... ❑ SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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. Print Otmcr's Name(Electronic Signature) Dale SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. h'ril Otwer's o :\uthowoel,agent's Name(Elcetrunie Signature) Date NOTES: I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contractor(HIC) Program),will a have access to the arbitration program or guaranty fund under M.G.L.c. la_'A.Other important information on the HIC Program can be found at stssa 111.1 11 ;„t i Information on the Construction Supervisor License can be found at St" lil, 2. When substantial%\ork is planned, pro\ide the information below: Total flour area Isy. ft.) _ 1 including garage, finished basentenL'attics,decks or porch) Gross liOng area(sq. ft.l _ Habitable room carat Number of fireplaces._— . _ Numberul'bedruums Nunlherofbalhroams _ - Numberofh;dfhadts F peof heating system _ ... . Number ofdecks, porches, _ f\pe of coolillg s\stein Fleloscd -011cri 1. ,l oial Project Square Footage—IMIN be StlbstllnleJ fir, l'olal Project Cost" � + CITY OF SALEM ' PUBLIC PROPRERTY DEPARTMENT .rim:MI I Y,,nlrl. l l \Irtrr 11C\VhrtIINGlU.\il%CL•1' a)dll•.N, MtU•tr.11I -a I IsJ1'77: I."- 715-9i'ti It l'rx 9711.74C.10y46 Workers' Cumpensatlon insurunce :'llfldavit: Iluilders/Contractors/ElectriciansiPlumbers \ ) 111cant Inrtmndtion Nome aNrYuYL1I._(�{` / Plca� PHnt le 'hl ZP/9n G. Address, /�!h �.r� /r�a 215/ Cily,5rlrc%ip. 0E/a/i ><�,� f� Q3S�L 5 I'huneil: k�5- 1'77c, to .\rc)ou an employer:'Chvuk Ihe:ylproyrlate boa., I 1.❑ 1 am a cm lu ur with 4. f)pe of project(reyulred): P l ❑ I:un+general contractor and f mnpluyccs(full Jnd/ur part•linle).' have hiruJ the suh•cunlracturs (1• ❑New construction ?.❑ 1 ,on a sole pmpricttlr or partner• listed on the anached sheet 1 y ❑Relntldelind ship and have no ulnpluyccs These subcontractors have working Ibr Inc in any capacity workers'comp• insurance. V. mmolirion I No wnrkl:rx'sump, insurance S. ❑ We are a cnlporation and its 9• ❑ouildind addition rcyuireJ.j officers have exunisc'd lhcir 10.❑Electrical repairs or additions 1. I am a homalwner Juind all work right of exemption par hf(, 1 L❑Plumbing repairs(or aJJitinru myself.(fv'o rvorkurs'cutup. C. )37,§I h).and insurance]. no insurance reyuired.j r mnployccs. (No worken' I�•❑Ruul'nPla's crnnp insurantvnyuind.j l�•�Uthar •%ny.yq/hcne Ihw chats boll el musi.11w Jill uw the u;chan Iwluw slowing flivirwimitcast,cumpentmiun pldiuy mfurmwwn 'It„nvnwlwre he rWrmil this arlldevil irulluliny IIwIy Jre suing ell wurk one then hire uwride ca rmsm mxal.ut"il a now Jlnderil imliu,liny rah, {',nllM11"lhel chuck this box muta Joshed JII addillarol.hart rlluwiny Ih,l uaele of IM uuk.omraaon and Ihee wuAen'coop.polcy tnrbrntaliue. /tun un employer thus tr ptroviJing Jvurkerx'ruunpermdon hrrumnee�er my nnpluyrex Brlmv Is rhelsuq�y and/ob.rih in/unnur6ra Insurance C'unlpany Vame:4z--I2Y Iillicy y or Sclf•ins. Lic.M; �uPP / q,�s CMG Expiration Data �G f 2 Job Site Addre.\A: 4 \teach it copy of the workers'emnpematloe pulley declaration page(showlnK the Polley number and expiration date). I'Jllure to xrure cuserage as required under Sct:tiun?3A of MGL c. I S2 cam lead l ne u to t11e imposition oferiminal penalties of a ip ro.1 1.5110.t1A and/or une•year i nprisulnnent, Js well Js civil punaluus in the Ivrin of a STOP WORK ORDER and a fine or'tlp at i'S01M It Jay.Iguinsl Ille viohuar. Ile advi.kd that a copy orthe stmcment may be forwarded to the Olfice ul' 1111 ul llla I)1,\ loll ulruraca a;vcrJyc rcrilic Jlmn. /du hereby certify under the painr wid ppwwnohieev of/yp]er/nry rhur the in/uronurlon prvriJ/tyJ/upbuvd is true ruu/d earrceG I)Jll —/(Z -2 I'I rI: • r 1)/)friul ore wily. /ld nor aria in dull ureu, fu be rwnpleted by city or tolrn a//lriul I ('i)y ur Town: _— Pcnnivl.lcenle e. Irvuiny.\ulhurity (circle one): II. illuJ of Ilrahh 1. Iluddiu� Dcp.trtlnul1l 1. Cit)r'I'ulut Clerk J• Ucctric.li filsin fur :, plumbing Inrycetor L. I)Ihe► _ l'rnl.lcl I'll nun: I � I Information and Instructions ir�tl, to a«. 2 rc tyres all enploycrs to provide workers' compen it'011 or their of hire. 1) un Y • a to 4 oilier �neral laws vh p service of an �lassachu:ens V person in the 1'unu:ute to[ilia+latule,an rmpfuYlre Is detineJ as ...every Pcl _ ;.press or unplied, oral or written." \n umpluyer I%defined ay"an Individual,partnership,Association.corporation ti other legal eased or any two r t more [oboes or other legal entity,employing employees. However the �t the t�xegoutg engaged in a)u'N enterprise-and including the legal representatives of a deceased employer,or the Leemver or rustea ul'.m individual, psstnershlp,assoc the owner of a dwelling house having not more than three aparanenu and who resides therein at theuction of repuir work n such dt of ,iwclling ltuuia of another who employs pert ns to do shall not because of such employment be dtemed tuba aner'nPluyer." or ,it the grounds or building appurtenant -,IGL chapter 152, 425C(6)also states that"every state or legal"ceasing agaaey shall withhold the Issuance a or renew construct buildings In the cOmmo0w al of a license or permit to operatefable a I business esse of to umpUaeto with the Insurance coverage lrequiredr e rites[ subdivisions shall doted ace p of its Political al ro ran D "Ito has n P ., commonwealth nu Y applicant , ,5C 7)states Neither the wmmo t.Jddwnully, �IGL dtapter 1 S_, i- ( :nter into any contract for the performancefpub the convect a authority ul'cuuspliatice with the insurance requirements of this chapter have been presented Applicsnts ` p to our situation and,if Please till out the worker' compensation atlt�a�vlet cs)andlphone ntei,beds)allong with theirlcestiticate($)of ' wish no employees other than the necessary,supplysub controctor(s)name(s), insurance. Limited Liability Companies(LLCworken'teompens[ttioe imurance'(If an)LLC or LLP does have members at punnors, are not required to carry employees,u policy is required 8e advised that this affidavit may be submitted to the aMdaviettt of industrial Accidents for confirmation of insuranco coverage. Also be auto to slap sad dale the ufsted,n Tiro affidavit should udOn fo regarding the low ur it'you are required to obtain a workers' he rcu[meJ to the city or town that the upplicats°^for the permit or license is being requested,not the D,:Panment o Industrial Accident. Should you have any y compensation policy,pleato call the Dapuranent at the number listed below. Self-insured companies should enter rhea self-insurance license number on the apPrOgtiatic lino. City or Town O fflelals you to lilt out in the event the office of Investigations has to contact you regarding the applicant Please he sure that the affidavit is complcte And printed legibly. 'rho Department has provided u sputa at the tusea of due affidavit for y Please be Sara IO till In Ilia P,:nrlll/heCllae I1Wllb,:f which w111 b0 Uied as a reference number. In addition,an applicant that muse submit multiple pt:mitllicmtsa applications in any given year,need only submit one atyidovit indicating current ol'�ho uffidovit that has been officially stamped or marked by the city or town Inay be provided ro the policy information of necessary) and under"lob Site Address"Ilia appllcallt should wf1I0";III IUGallanp o (coy or town)."A copy applicant as proof chat a valid affidavit is on file for future permits it licenses. Anew atusines must m tilled out each Year. Where a home owner or citizen is obtaining a licenses ur permit not related to any business id commercial venture ;1 dug license or permit to burn leaves ctc.)said person is NOT required to complete this affidavit. uous, I he �)!lieu of Inverigations would ll�e to thank you in advance fur your cooperation and should you have:'toy yesti please Ju not hesitate to give us a call. fhc U,P,unncnl's Address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accident Offlee of Investigations 6W Washington Street Boston, MA 02111 leis q 617-727.4900 eat 406 or 1.877•MASSAFE Fax M 617.727.7749 t , „ 4.+4.u5 www.mus.gov/dia CITY OF S.0 E.`f, ,1LASS.iCHL'SETTS OULDLNG DEPARTMENT 110 W ML%4GTON STIM. 3i4 FLOOtt rM (978) 745-9595 KIMBER? Y DRISCOLL FnX(978) 740-9846 MAYOR IkoMUST.PMK" Diacro4 OP PL eL c PROPERTY/SuMOLNG CO.Nallssl0:r ER Construction Debris Disposal Aflldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL a 40, S 54; Building Permit tl 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 I 11, S 150A. The debris will be transported by: pp (name of hauler) The debris will be disposed of in (name of fauimy) (address or facihty) --��1�/ �gnamre of rmit appliant date b1141�,�.p i Page No. of Pages Roofing Siding iinJerryP. LeBlanc PROPOSAL AND ACCEPTANCE •Siding Gutter Construction Supervisor Specialty License 9 Atkinson Depot Road License:CS-SL 99633 Restricted To: RF WS Painting Plaistow, NH 03865 Expires: 10/15/2011 Carpentry Windows Home (603) 382-0817 Home Improvement Contractor Snowplowing Cell (978) 835-7740 Registration: 1 291496 Expires:2/16/2012 PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME 2 t< f CITY,STATE AND ZIP CODE JOB LOCATION 4 L ARCHITECT -DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: „�- t ( t fry_ A'Ic IGt' Xr C_.t°_. _ r a( Sjefell a A Qtre: 41 -4 e -- LAdd onl< t r CZ )eoa le ifteflnG r G We Propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: Pageyment to be made as fo lows: , dollars ($ 1. ! Lie f Ga All material is guaranteed to be as specified.All work to be completed in a workman- Authorized like manner according to standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only uri�on written orders, and Signature wdl become an extra charge over and above the estimate.All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado Note. his proposal may be and other necessary insurance. Our workers are fully covered by Workmen's Com- withdrawn by us if not accepted within days. pensation Insurance. Acceptance of Proposal -The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payment will be made as outlined above. Signature i Date of Acceptance Signature R �S' r.F Alassachusctts.- Dcpartnteilt rpowiv S<tP ` -Board of Building Re(illations.uxl StanAal i Construction Supervisor Specialty License, . Ucense: CS.SL,99633 ' •RjIstncted.to: RF,WS JERKY LEBLANC' ~* 9 ATKIMSON DEPOT ROAD ?^ PLAtsTOW, NH 03865 r „_ i t Expiration: 10/15120tt, ,Tr#: 99633:� E. .('ummisl,mer _ 3, p4i'Y.-r�� 'l�0'�f1M1091U0,[2♦A.�' � a� v A `�.ome of Consume'ARain&.Busicesa Re glanoa ,, `.µROMEIMPR9YEMENTCONTRACTOtt!, Jib§ ,t Regi9tratton�:-149881` 'A,` i tit; ' Expiratlon .2I1612012 Trlf�191495 f t E' Type li Indl'vidual� ; „JERRY P LEBLANC x ,,JERRY'LEBLp'�C'�F ATKINSON ' ;3PLAIST.dW, 038 UodTeeretery,�%' OP iD: SS ACC>�Ro CERTIFICATE OF LIABILITY INSURANCE DAT07122D,YYYY) 07/22/11 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 endorsements . PRODUCER 978-688-7000 CONTACT Durso&Jankowski Ins Agcy LLC 978-688-7001 PHONE FAXAID Nal: 198 Massachusetts Avenue NICC NO Eat: North Andover,MA 01845 E-MAIL ADDRESS: Durso S Jankowski Ins.Agcy. aHooucea LEBLA-4 _ DUST E ID,OMR _ INSURER($)AFFORDING COVERAGE a NAIC a _ INSURED Jerry LeBlanc INSURER A: 9 Atkinson Depot Road INSURER B:Preferred Mutual Insurance Co. 15024 Plaistow, NH 03865 INSURERC:Hartford Insurance Co. INSURER D:MSA Group 14788 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INOICATPir1. NOTINITHSTANDING ANY REQUIREMENT,-TERM OR CONDITION OF,ANY CONTRACT OR OTHER. DOCUMENT WITH RESPECT TO WHICH-THHS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE ADDL$UB POLICY NUMBER MMI 0 YYYY MML R DO/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE E 300,00 B DAMAGE TO R NTED X COMMERCIAL GENERAL LIABILITY CPP0120597590 05101111 05/01112 PREMISES Ea occurrencel It 100,00 CLAIMS-MADE F1 OCCUR MED EXP(Any one person) $ 5,00 ( PERSONAL BAOVINJURY $ 300,00 GENERAL AGGREGATE $ 600,00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 600,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 500,00 D ANY AUTO B1 B2755S 01/04/10 01104111 (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) E X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ _ E UMBRELLA LIAR OCCUR EACH OCCURRENCE IIIEXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE I $ RETENTION E _ _ E WORKERS COMPENSATION WC STATU- OTH- ANDEMPLOYERS'LIABILITY IN TORY., ° C ANY PROPRIETORIPARTNERIEXECUTIVE '6S601JByau1M71411 0810u/11 U6/06112 !E.L.EACH ACCIDENT S 100,000 OFFICERIMEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE�POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION BIDDINI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Bidding Purposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 P OSBS ACCORDANCE WITH THE POLICY PROVISIONS. 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