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17 PLEASANT ST - BUILDING INSPECTION (2) :A M1 e The Commonwealth of Massachusetts R l y Department of Public Safety �\ v_„✓ .\lassachuwtls State Building Code(780 CMR)Seventh Edition I `\ City of Salem Building Permit Application for any Building other than a 1-or 2-Family Dwelling (This Section For Official Use Only) Building Permit Number Date Applied: TVBuilding Inspector: SECTION l:L CATION(Pleas indi ate Bloc N d Lot N for locations for which a street address is not available) No.and Street City /Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ ( lease fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other 0 Specify:Are building plans and/or construction documents bring supplied as part of this per it application? Yes ❑ No Is an Independent Structural Engineeri#Peview rec uired? Yes No Brief Description of Proposed Work: SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ ' Existing Use Group(s): Proposed Use Group(s): �• Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTTON 5:USE GROUP(Check as a licable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A•5❑ B: Business ❑ E: Educational ❑ ` F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 O 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2 ❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ _ .U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) I AIB ❑ IIA ❑ IIB ❑ IIIA ❑ 11111 ❑ IV ❑ VA ❑ V80 SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) ply: •Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: ❑ Check it outside Flood Lune❑ Indicate municipal ❑ A trench will not he Licensed Disposal tine❑ ❑ or indentifv Zone: oron sitesrstem O required❑ur trench or.pccil%: + permit is enclosed ❑ road right-of-way: Hazards to Air.Navigation: \I:\ I liaoru (�n+Lni��i1 n+IL.vio.+ Prnrr..:ol :\(�(+hcabh•❑ I,Stniclure+,nhu+airport approachare.t.' Is their re%jet% completed, n1 to Build endn.ed ❑ 1e.❑ urNo❑ 1" ❑ Xo ❑ SECTION &CONTENT OFCERTIFICArE OF OCCUPANCY ode: L".(, oupl.I: rc +v ul Cunstnichun: ). i C ccupant Load per I Ivor: dding;contain an Sprinkler S%,tem': Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION V.im" iv 1 Anilner 'rolJU� cvF/Y l/ �G�A.S/r��/ �J� ✓/�Y��/ c , Name(Print) No.and Street City/Town Zip Property Uwner Contact Information: Title Telephone Nu. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address City/Town Slate Zip to act on the poi perte opener's behalf, in all matters relative to work authorized by this building permit a p plicalion. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If building is less than 35,1100 cu It-of enclosed space and/or 1101 under Com traction Contnpl then check here O and skip Sealion 10-1) 10.1 Re isle d Profes4ionA Responsible for Construction Control Na ne( rgi /��Telephune o a-mail a �ss Re i iu Number Street Address City/ wn State Zip Discipline x on Date 10.2 Genera ontractor i Cumpany am Name of Person 111rponsible for Cuns ctiun License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yee No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=$ 3. Plumbing $ Note:Minimum fee=$ (co act municipality) 4. Mechanical (HVAC) 5. Mechanical (Other) $ Enclose check payable to 6.Total Cost (} �i (contact municipality)and write check number here I SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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 knoe d, rid Understanding. ersz��ssy I'le, print ane/ti l name Title Tclephone.Nil. �� Sheet A'ddress ltc/Town State Zip .Municipal Inspector to fill out this section upon application approval: T�(D ..Name Dote Ac��® CERTIFICATE OF LIABILITY INSURANCE °A'E'�"/10/1 2/l0/10 RTODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Divirgilio Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 270 BroadwayHOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 8065 Lynn, NIA 01904 INSURERS AFFORDING COVERAGE NAIC# MMED INSURFRA ATLANTIC CASUALTY RYAN ROOFING 6 CARPENTRY .INSURER B: MARK RYAN INSURERC: 165 LYNNFIELD ST INSURER D LYNN, bjA 01904 INSURERE' COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW IT FISTANDING 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 PCLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS. INSR ADD' rYPEOF INSURANCE POLICY NUMBER POLICY EFFECTIVE POUCY EXPIRATDATEIMMIDIYYYION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COERMALGENERALLIABILITY L143000353 9/24/09 9/24/10 DAMAGE TORENTEDn a $ MIAIMS MADE �OCCUR nED EXP(Any ore pesml $ =,Q00 PERSO NAL$ADV I WU RY $ 1,Q00 QQQ GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PRO-IEC LOC AUTOMOBILE UAB UTV COMBINED SINGLE LIMB PNYAUIO (Ea accided) $ ALL O WNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Peramident) $ PROPERTY DAMAGE $ (Per acaldent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANYAUIO OTHER THAN EAACC $ AUTO ONLY: AGG $ rRETENTION ESSIUMBRELLALIABILITY EACH OCCURRENCE $IM OCCUR CLAS MADE AGGREGATE $ DEDUCTIBLE $ V40RKERS COMPENSATION WC TnRYSTATIMIU- OTH- AND EMPLOYERS'LIABILITY YIN - ANYPROPRIETORMARTNER/EXECUTNE E.L.EACH ACCIDENT- $ OFFICE WE MBER EXCLUDED? (Martlabry In NH) E.L.DISEASE-EA EMPLOYEE $ Dee,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ROOFING COMMERCIAL/RESIDENTIAL re: Darwin Suelen, 17 Pleasant St Salem MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBEDPOUCIES BECANCELLED BEFORE THEEXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 0 DAYS WRITTEN City of Salem NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SOSHIALL Building Dept IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR 93 Washington St REPRESENTATIVES. Salem MA 01970 AUTHORIZED REPRESENTATIVE 'G*�(N O ACORD 25(2009/01) 0 1988-2009 ACORD CORPOFEATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 7188UINGINSURER(§� FICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE TE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED LICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN NSURER B AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. : If the Cartifiats holder is an ADDITIONAL INSURED, the policy(in)mutt be endorsed. If SUBROGATION subject to the terms and conditions of the policy, certain policin may require and endorsement A statement cate don not confer ri hts to the certificate holder in lieu of each endorsement PRODUCER Dlvlrglll0 Insurance Agency Inc 270 Smadxey Lynn, MA 1904 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED MarkJ.Ryan lea LynnOeld Street Lynn,MA 01904-OWO ;RR TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N.AMEDA13OVE FOR LICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER ENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 18SUED OR MAY PERTAIN THE INSURANCE AFFORDED THE ES DESCRIBED HEREIN 18 SUBJECT TO ALL THETERMS,EXCLUSIONS AND CONDITIONS OF OUCH POLICIES.LIMITS SHOWN VE BEEN REDUCED BY PAID CLAIMS. wre or atlYRANOB FOLM NUYBIR roucreFFIVMe DA7e FOIJOYMIRATNINDATe ... REMPLOYERS'LIABILITYROPRKTOR/ LIMITS NERSRDDICUTIVEERS ARE:IDXL o 4961790 9/23/2009 9/23/2010 ATUTORY LIMITS RS,Appllmla MA OpwdmlOrr/. ACCIDENT It 100.00 ISEABE POLICYL: 8 500.00 OEaCRIPTKIN P PE HIC P 1T! EM 1 RE:THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR MARK J RYAN-LOCATION DARWIN SURLEN,17 PLEASANT ST.SALEM MA. CERTIFICATE HOLDER ANCELLATION CITY OF SALEM SHOULD ANY OF THEABOVB DESCRIBED POLICIES BE CANCELLED BEFORE THE BLDG DEPT wRATION DATE THEREOF,NOTICE W LL BE DELIVERED INACCORDANCE 93 WASHINGTON ST WFITETHE POLICY PROVISIONS. SALEM,MA 01970 AUTHORIZED REPRESENTATIVE g/(5ffice of onsumer A airs an usmess e u a Ion 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 140212 Type: Individual Expiration: 9/22/2011 Tr# 700039 MARK J MARK RYANN 165 LYNNFIELD ST. LYNN, MA 01904 Update Address and return card.Mark reason for change. -' OPS-CA1 0 SOM-00/04G101218 Address E Renewal Employment Lost Card y� ✓/ee �oramarsuealGE ✓t/aatac%u,1eQ2 �\ Office of Consumer Again&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Reglstratlon'`,gg011p Office of Consumer Affairs and Business Regulation Expiration:=_'9/22/2011 Tr# 700039 10 Park Plaza-Suite 5170 Type IntirvxfUal Boston,MA 01116 MARK J RYAN ��'� MARK RYAN 165 LYNNFIELD — LYNN,MA 01904 \.�`t., ,� Undersecretary NotNot valid without signature i�'Ia9xaC11 U.rG[s- Depurtment of Public Safch Board of BuRdinK Rcylrtionv.anti,yt mitarilr Construction Supervisor Licen4e.,,'. . ;. License: CS 101571 . Restricted to: 00 'MARK RYAN% 3 STANWOOD STREET L,YNN, MA 01904 Expiration: 9/132012' t„nmii..Gmrr' Trp: 101571. - s � 0 <TonarnE:----> ,,Tofa=urn:7815985957, , CERTIFICATE OF INSURANCE 2/23/2010 HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE ISSUING INSURERS , 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement. PRODUCER Divirgilio Insurance Agency Inc 270 Broadway Lynn, MA 1904 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED ....Mark J Ryan' .. .. ... .. _ . 165 Lynrifield StreeY Lynri,MA 61904-0000- COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING 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 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. Co LTRPINCLOEXCLO OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE A COMPENSATION OYERS'LIABILITY LIMITS RIETOR/ /EXECUTIVE ARE: CL❑ 4961790 9/23/2009 9/23/2010 STATUTORY LIMITS pplies to MA Operations Only, EACH ACCIDENT $ 100,000 DISEASE POLICY LIMIT $ 500,000 DISEASE-EACH EMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONSIVEHICLESISPECIAL ITEMS RE:THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR MARK J RYAN-LOCATION: DENISE JOHNSON, 13 EST CIR,SALEM MA 01970. CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE BLDG DEPT EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE 93 WASHINGTON ST WIHTE THE POLICY PROVISIONS. SALEM, MA 01970 AUTHORIZED REPRESENTATIVE