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7 POPE ST - BUILDING INSPECTION (2) t The Commonwealth of Massachusetts CCi�E17 CITY OF Board of Building Regulations and Standards RECEIVED SE RVJtf�LEM W Massachusetts State Building Code, 780 CMR- D Revised Mar 2011 Building Permit Application To Construct, Repair,Renovate o``t One- or Two-Family Dwelling l4aP This Section For Official Use Only. V— Building Permit Number: Date Appli i Building Official(Print Name) Signat e D SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 7Ao ae S trrP e y- N t 1.1a Is this an accepted street?yes no Map Number Parcel Number t� 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 ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1r�Ownert of Record: o eprr'ert (J C;I 'A) $PaveC I'( sca �eµ^1 �•t.4 p / 470 Name(Print) City,State,ZIP 7 Po Pe 77 S4 ree`t- / iP9 rdo //l7 /Dn 9rr4r I// n No.and Street Telephone Email Address 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 0,Specify: /l a e /e Brief Description of Proposed Work': D e ws cn I(, S 1, 5`..n e- 1 ro ` Lo f i�U I3 (� �'Sao (� (•-'fa WIC jn B,PP N`^q tNP AC 1"V V6 u'nv{ �, /l • h in 'Se•1� 6e1 �'r rS Qe✓^owe i9r.ldi.. Sig .r. 4 d e �(aef i SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ O o 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: $ `'I �,o V ❑Paid in Full ❑ Outstanding Balance Due: -7 `PPIc SECTION 5: CONSTRUCTION SERVICES i 5.1 Construction Supervisor License(CSL) CS I OBI 0 It 0 I y 0 J l ly 9,1 f `l a-'e...'c,n c�' License Number Expiration Date Name of CSL Holder 1 [ List CSL Type(see below) V` 2"1 AQ A,,si k10 04 T e Description No.and Street Unrestricted(Buildings up to 35,000 cu.ft.) /7, Restricted 1&2 Family Dwelling City/Town,State'ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances qj7 r $/D /,2 39 /jr�t e /yu�u'.�.. C" to/P I Insulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /`7GSS -1 Mar i_t'p n o Cum S v rw a t-:o N `t)+09NO, HIC Registration Number E piration Date HIC Company Name or HIC Registrant Name 7 tbo lL .••� ,,AGE CenJ_ar Stt'tr 1-o9 Ever " (/tilart_,'odeoCONSNwChi' (�Jf�. lOv't No.and Street Email address e r i OtCrlb 0/7d' ll6y /HS-/ City/Town, late,ZIP 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 .......... 19- No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILD�MtING PERMIT I, as Owner of the subject property,hereby authorize p t e t b act+' an o rI-ur r C�a�� Co n St iK t t+o•t1 �/p� to act on my behalf,in all matters relative to work authorized by this building permit application. wner's � �Gt- Name(Electronic Signature) Dale SECTION 7b: OWNEW 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 e best of my knowledge and understanding.&e+ Poetipnro fit/ I'1 / 6 Print Owner's or Authorized Agent's Name(Electronic Signature) ate NOTES: 1. 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 can be found at www mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.izov/dps 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. 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" A�o CERTIFICATE OF LIABILITY INSURANCE DAT4115/2OIYYYY) 04I15I2016 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 CONTACT NAME: PHONE FAX Automatic Data Processing Insurance Agency,Inc. AIC No EXt: (A/C,No: 1 Acip Boulevard AADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC M INSURERA: NorGUARD Insurance Company 31470 INSURED MARCIANO CONSTRUCTION CORP INSURER B: DBA:Marciano Construction Corp INSURERC: 110 Cabot St INSURER D: Beverly,MA 01915 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 477404 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 UNITS LTR INSD MD POLICY NUMBER MMIDD MMIDD COMMERCIA GENERALLIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 7 PRO-JECT ❑ LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINE accid D SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTO NON OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Peraccident $ UMBRELLA LMB OCCUR EACH OCCURRENCE $ EXCESS LWB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ ER $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ER H ANY PROPRIETOMPARTNEWEXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000 A OFFICERAIEMBER EXCLUDED? F N/A N MAWC697265 11/28/2015 11128/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under 500,000 DE SCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT I $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Job Reference:Benedick CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street Salem,MA 01970 AUTHORIZED REPRESENTATIVE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i1 CITY OF SAL.EMI NAkSSACHUSETTS • BUILDING DEPARTNIEZ%iT .• + 120 W.3SHINGTON STREET,3"FLOOR TEL (978) 74S-9595 FAX(978)740-9846 [O%tBFRi FY DRISCOLL MAYOR DIRECTOR Sr.P¢xRE DIRECTOR OF PUBLIC PROPERTY/BU DLNG CONMSSIONFR Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Natrie(Busitx Organizaliorvindividwl): {ha.r Lt'a n O l/�ti m t y o,v e t A,eOAJ L�o ( n Address: I b rJ (ItJ.r—r^ :t, � S C T 1?, Zo l? City/State/Zip: 15f-1e f lv= , ,-4.4 O If t S— Phone #: `i S 0' /y / 3 Are yo mployer?Cheek the appropriate box: Type orproject(required): I. 1 am a employer with [- ;1- 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These subcontractors have 8. ❑ Demolition working for me in any capacity, workers'comp.insurance. 9. ❑ Building addition [No workers'comp, insurance 5. ❑ We are a corporation and 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 I I.❑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' l3.®Other Due Ie comp. insurance required.] Any applivAnt that checks box al mutt also fill out the section below showing their workers'compensation policy information. T 1 fimeowners who submit this affidavit indicting they ate doing all work and then hire outside contractors most submit a new affidavit indieaing such. =Comrocion that cheek this box must"ached an additional aheet showing the name of the sub-contractors and their workers'comp.polity infomution. I am an employer that is providing workers'compgnsadon insurance for my employees. Below is the policy and job sire information. Insurance Company Name: Wit ✓ ✓J 9 /' _ v� •�-r'�'� �G $t.. �` "C C' , Policy 4 or Self-ins.Lis#:1q,4#_� 9 //t ii/ Expiration Date: 1��� r Job Sire Address: ! pope S 4, City/State/Zip: M , ✓t'f.,,;t 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 of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations or the DIA for insurance coverage verification. I do hereby certify under the to m naldes of perjury that the informadon provided above is true and correct Siantire' Date 61YI/Li Phone 4: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitfLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: CITY OF &U EN1, 1N'LkSSACHUSETTS Bt:1LDLNG DEPARTMENT • 130 WASHL*IGTON STREET, 3"FLOOR a TEL. (978) 745-9595 Fax(978) 740-9846 KINtgFRi F.Y DRISCOLL MAYOR Tmomm ST.PwYAE DIRECTOR OF PUBLIC PROPERTY/BUUMLNG CONLMIISSIONER 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 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit # 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: /llaru'an > (/v� ShdffC/-I'a (name of hauler) (The debris will be disposed of in c7 ' a SlPer gA#-,'d _) (name of facility) 20 �, M Gt inn S3. g e f.; (address of facility) signature of permit applicant 7//e111 date Jcbriv0'.dce