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18 PLANTERS ST - BUILDING INSPECTION The Commonwealth of iblassachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 730 CMR SALEM Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised bMar 2011 One-or Two-Family Dwelling Building Permit Number: This Section For Official Use Only. Date Applied: Y Building 0 tidal(Print Name), _ Signature- Date SECTION I i SITE INFORh1ATION I.t P'r�Operl�Nt��; SnW7FJ_ C- 019 1.2 Assessors tVlap g parcel Numbers I.In Is this in accepted street? es '�t�l Y no_ Map Number 1.3 "Coning Information: Parcel Number LJ Property Dimensions: Zoning District Proposed Proposed Us�— Lot Area(sq ntage(R) 1.5 Building Setbacks(ft) a) Fro Front Yard Side Yards Rear Yard Required Provide) Required Provided Required y Provided 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: Public❑ Private Cl Zone: _ Outside Flood Zone? 1•S Sewage Disposal System: Check ifyes❑ Municipal❑ On site disposal system ❑ 2.1 Owners of Recor SECTION2: PROPERTY OWNERSHIP!' d: PAuuW tlme(Pdnq �1-C'^i1 MA 7� � C�� ' City,Styatfe,ZI/P� / l - No.mtJStrict a" 1 - ` S-e TDl11�C�01 'CO cam,ta r-144— Iclephone Lmatl Address SECTION 3: DESCRIPTION OF PROPOSED WORK?(check all that apply) New Construction Cl Existing Building Owner-Occupied Repairs(s) ,�,,{t Demolition ry g 'y Altention(s) ❑ Addition Cl ❑ Accessory 81d . ❑ Number of Units Brief Description of ProposedlVOrk'; StTtvt- Other ❑ Specify; to-un' it AEl'MR SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials) Official Use Only I. Building tZ,}0O I. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee 3. Plumbing ❑Total Project Cost'(hem 6)x multiplier x 2. Other Fees: $ � ` d. Mechanical (HVAC) $ List: (xJ 5. Mtchinical (Fire Su )ression) 'S TOtnl All Fees:S 6. Tot;d Project Cost: $ Check No.__Check Amount Cash Amount: ❑Paid in Full ❑Outstandiug Balance Due: SECTION 5: CON STRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 'bSe'> � gv iration Date f CkITU�StT�tl'��'l.i I,ytr1�1S License Number P Name of CSL Holder List CSL'fype(see below)�-- b7(O MUD Sq Type._ Description i No, and Street W F!+T"M P J U Unrestricted Buildin s u -to 35,0U0 cu. ft.) W 141 rmA,\j r MA R Restricted 1&2 Fmnil Dwelling Mason Cityfro vn,State,ZIP RC Rootin Coverin WS Window and Sidin SF Solid Fuel Burning Appliances Insulation r70b 7'r two Demolition Email address Tcle Lune t�Jbl�} 6�� W1 5.2 Registered dome Im ¢merit Contractor(HIC) HIC Registration r Expiration Date 1�'Ws+rl,pt� ,_J IilC Conrp;my Name or HIC Registry t N:une C S Q fe)olltl (.tSYh I, GQry 1�� 1rN - Email address No.and Street p' Z�(� Q�•� Zj GKtfU-rn , Mfg Tel--- — Cit /Town,State,ZIP e hone N INSURANCE AFFIDAVIT(M.G.L.c. 151.§ 25C(6)). SECTION 6:WORKERS'COMPENSATIO ith this application. Failure to provide Workers Compensation Insurance affidavit must be completed and submitted w this affidavit Will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... SEC TION-'a:OWNERAUTHORIZATION, '0BE.COMPLETED.WHEN: . OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERbIIT 1,as Owner of the subject property,hereby authorize thorized by this building permit application. t9 act oft my behalf,in all matters relative to work au Date Print Owner's Name(Electronic Signature) SECTION 7b:OWL OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 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. w —)\1 M0r1.1lR1ll, ( Z!'Q�V%Loe7Date Print Owner's or Authorized Agent's Name(Electronic Signature) NOTwerES: I. An Owner who btains a building permit to do his/her own work,or an ho res an registered o will shavvetac�ss to'tthe arbitration tractor (not registered in the Honre improvement Contractor(HIC)Program), am can be found at program or guaranty fund under I www.ma____._,_s±,,Lv_oc9lnformation on the Construction Supervisor License can be found at www ma.'s.eoy=dpti n When substantial work is planned,provide the informcludiationng garage,age, finished basement/attics,decks or porch) Total floor area(sq. 11•) ( Habitable room count Gross living area(sq. If.)_,___------ Number of bedrooms Number of fireplaces Number of half/baths Number of bathrooms Number of decks/porches Type of heating system Enclosed Open 'type of cooling system 3. "total Project Square Footage" inay be substituted for"total Project Cost" is o, C["I'YOF SALEM, NL-�SS:ICHL'S.ETTS s, BUILDING DFP.{RTN,[F-NT 120 WASHINGTON STREET, 3"FLOOR TE1_ (979) 745-9595 PAX(979) 740.9W W\tgB Rt FY DRISCO11 �Y iYOIt THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information y� Please Print i,epibly V;I n1C (0usiness.Organiration;lmlividual): "-��111�1� Address: City/State/zip: Cminle-yu , MA 07.330 Phone Are you on employer?.Check the irppropriate box: Type.gf project(required):. 1.El I am a employer with 4.IR I am a general contractor and I 6. ❑New construction employees(full and/or pan-time)." have hired the sub-contractors 9.❑ 1 ani a sole proprietor or partner. listed on the attached.sheet.: 7. W Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity, workers'comp. insurance. y, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation mid its required.) officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. (No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.( t employees. (No workers' 13.0Other cutup.insurance required.] . -Any applicant Ilut specks box AI must also fit out the action belowshowing their workeri cumpenemiun pulicy intbrmatiun.'I l,"cownsa who mhmit this affidavit indicating they ass doing all wok and then hire outside controctoro most.nthmit a new aifdavit indicating such. $,n,tm aura thus chvvk this box must anachvd an addiliuml shun showing the nmne or the subeunlracton and their wokero'comp.policy information. 1 um un entpluyer t/tut is providiii workers'contprasatlaa insurance for my employees. Below is the policy and job site information. Insurance Company Name: �-U-P,Lie, INS - f_o-or+", Policy 4 or Self-ins. Lic. 0 we. 000231S Expiration Dale: 1Z I31 14 Job Site Address: lb R, hEL City/State/Zip: 5qLL"r Mpv 009-0 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A uf.MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of u STOP WORK ORDER and aline of up to S250.00 a day against the violator. Be advised that a copy of this Statement may be forwarded to the Ol'lice of i it vest igwions oft lie DIA for insurance coverage verification. l do here AY under the pains and pen allies of perjury that the infonnattoet provided abuve is true and correct S', rr I Ire' Data. Phone oflicial rue only. no nor write it,this area,to be completed by city or larva ofjiciuL City car Town: Pcrmitfl.lccnse Al Issuing,luthurily (circle one): 1. Board of Health. 2. Building Department 3.Cityrrown C'ierk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Tenon: Phone 4: ( CITY OF SiU.El,t) A-USACHUSE M ©uiLDL\,G DEPART- LENT 120 W-ASHLNGTON STREET 110 FLOOR T'EL (978) 745-9595 F,mx(978) 740-9846 K13BERI.EY DRISCOLI. NL-%YOR THosas ST.PIEW DIRECTOR OF PUBLIC PROPERTYXBt.'t -DLNG CO)0%1tSSIONER Construction Debris Disposal affidavit (required for all demolition and renovation work) Jn accordance with the sixth edition of the State Building Coda, 730 CMR section l 11.5 Debris, and the provisions of MOL c 40, S 54; Building Permit A 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 IV1GL c 111, S 150A. The debris will be transported by: ti (name of hauler) The debris will be disposed of in -- (narne of racility) _--- (address of rdcility) , Signature orpermit applicant k<I. 2crA (late -- REBULLC-01 CANSTEAD ,a►`oizo CERTIFICATE OF LIABILITY INSURANCE 1 D 1 2/3 2/300/0 01/2013 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(les)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 CONTACT NAME Mason&Mason Insurance Agency,Inc. PHONE FAX 458 South Ave. 1AI�No`atl:(781)447.5531 (NO,No); (781)447.7230 Whitman,MA 02382 E"MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Nautilus Insurance Company INSURED INSURERB:SaVers Property&Casualty 000084 Rebuildex LLC INSURER C: 6 Commerce Way INSURER D: Carver,MA 02330 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 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 rypE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMMDNYYY MMIDDPIYYY GENERAL LABILITY EACH OCCURRENCE $ 2,600,000 A X COMMERCIAL GENERAL LIABILITY ECP01523579-13 1110112013 11/01/2014 PREMISES RENTED (Eaocnunence) $ 100,000 CLAIMS-MADE 1XI OCCUR MEDEXP(Anyone;oamon) $ 5,00 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GENL AGGREGATE UNIT APPLIES PER: PRODUCTS-CON PIOP AGG $ 4,000,00 POLICY PRO LOC S AUTOMOBILE LIABILITY COMBINED MBI EDtSINGLE LIMIT $ ANY AUTO BODILY INJURY(Porperson) $ ALLOWNED SCHEDULED BODILY INJURY(Peraccldent) $ AUTOS AUTOS OWNED ERNTAGE $HIREDAUTOS AUTOS P ACCIDE UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 • X EXCESS LIAR 7 CLAIMS-MACE FFX1523582-13 1110112013 11/01/2014 AGGREGATE $ 2,000,00 OED X TRETENTiON$ O $ WORKERS COMPENSATION X WIC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMIT ER B ANY PROPRIETOR/PARTNEIVEXECUTIVEY7 NIA WC'0002313 12/3112013 1213112014 E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDED? (Mandatoryin NN) E.L.DISEASE-EA EMPLOYEE $ 500,00 Il a%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 SHOULDANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE R¢bUlld¢x THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Commerce Way Carver,MA 02330 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD r • f3u:ird nl' Buildin' Rc_ulminm and Standard. Construction Supervisor License One-and Two-Family Dwellings License: CS 105578 -- CHRISTOPHER LYONS = 626 TEMPLE ST WHITMAN, MA 02382 -` Expiration: 4/4/2014 nmuin mrr Tr=: 105578 &A. Bite fCo m Afro&a"..R,miasua Ll aor regeealloa valid fins ladMdal me only ME IMPROVEMFMCONRtgOTOR Befom We eapivden date.Iffomd returnW 0lcealb i5S14] Office ofCoarumer Main and Business Regulafion . Tyw 10 Park Plass SuIre 61]0 BxPNMb,_Wf@013'I y SupplaaeMCal Boeoq NIA 02116 REBUIMV OF PLVMb&hfCOuRw CNISTOPNER LYORS,, +, ' ]J MEIN STREET �✓�61[�+_ CARVER,MA 013W Uadeu aul Nat valid a,dipfil rigoamm