Loading...
12 POPE ST - BUILDING INSPECTION (7) The Commonwealth of Massachusetts Department of Public Safety %la.,sachuscits Slob Budding Code(780CJIR)Secenlh Edition City of Salem Building Permit Application for any Building other than a 1-or 2-Family Dwelling (This Section For Official Use Jnly) Budding Permit Number: Date Applied: Bwlding Inspector: SECTION 1: LOCATION(Please indicate Block N and Lot p for locations for which a street address is not available) 12 Pope Street, Salem, MA 01970 Salem Heights Apartments, No.and Street Ciw /Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK It New Construction check here❑or check all that apply in the two rows below Existing Building 0 Repair❑ 1 Alteration PSI I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Changeof Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No M Brief Description of Proposed Work:We will be constructing a wireless communications 'one facility on the rooftop and installing a total of a'aht antpnnag. an P=jnmpnt cabinet and related cabling. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDTTION,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): r 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(fr.) SECTION 5:USE GROUP(Check as ap licable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-0❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑ 1: Institutional f-I ❑ 1-2❑ 1-3 O 1-4❑ M: Mercantile.❑; _ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public 0 C hed It oul>Idr F6nat Lone❑ Indicate municipal ❑ A trench will not be Lice•n,ed Uin1>a<.d Site❑ rcquucd Our trench ur,peaty: I'nvah•❑ or u+den lilt Zone: or un,itr,c.tem ❑ permit n endo,nl ❑ _ Railroad right-of-way: Hazards to Air Navigation: \I:\ Ih,hm, (-•innm•in I:,, „ Pry \ a \pphcablc❑ I.tilniiwrr tulhm airport appnoch,vra' I.their net wi\ annplctrd' ,11 '.moil h, Budd rndu,ed ❑ 't v,0 ,,r.Nu 0 Ye,0 \u 0 SECTION 8:CONTENT OF CERTIFICA FE OF OCCUPANCY 1'ddnm 1 ("0'. _.-__ Lie(,rnu pl,r. ft pc„I l',m,uuiuon: t)ccup.mt l�,a.i )+er l-tune _- I L„,the buil,6nt;Cuntoin.m Spnnldrr?t,lem ?prCal SupLlhlwn, _ SECTION9: PROPERTY OWNER AUTHORIZATION dame and Address of Properly Owner Salem Heights Preservation Associates, 12 Pope Street, Salem, MA 01970 Name tPrint) Nm and Street C it/Town Lip Pnrpvrte Ocv ner Contact Information: Michael Donovan, Prop. Mgr. 401.451 -5472 =_ mdonovan®preservationhousing.org Title Telephone No. (business) Telephone No. (cell) a-mad address If applicable, the property owner herebv authorizes Goodman Networks-Heather Carlisle 30 Main Street Ashland MA 01721 Name Street Address City/Town titate Zip to act on the pro pert%aw ner's behalf, m all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL iPlease fill out Appendix 2) (If building is less than 35.tsx1 cu.ft.of encloe. J s vice and/or not under Construction CunWl then check here O and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control Ron Jackson 781 -686. 5727 27127 Name(Registrant) Telephone No. a-mail address Registration Number 21 B Street Burlington MA 01803 Structural 6/30/10 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Clearwire Corporation Company Name: Wayne Stott CS 67205 Name of Person Responsible for Construction License No. and Type if Applicable 2 Pillow Lace Lane R2VPrlV MA 01915 Street Address City/Town State Zip 781 603 2792 wstott®clearwire.com 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? Yes 13 No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 13 , 0 0 0 1. Building $ 13 000 BuildingPermit Fee=Total Construction Cost x_(Insert here 2. Electrical S appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6.Total Cost S 13, 000 (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I herebv attest under the pains and penalties of perjury that ail of the information contained in this applicatom is true and accurate to the best of my knowledge and understanding. Heather Carlisle Site Acquistion Specialist 214 543 4457 2/19/10 Pleo.c print and sign name title rdephone\o. Date Goodman Networks, 30 Main Street Ashland MA 017 7lrrat .lddre•, City/T,nvn titate G : q� Municipal Inspector to fill out this section upon application approval: \ame ato CITY OF SALEM PLANNING BOARD 01..0JAN 25 A, 10: 41 Wireless Special Permit Decision t, r LL <I ,r , For The Petition of Goodman Networks For The Property Located At 12 Pope Street A Public Hearing on this petition was opened on December 17, 2009, and continued to January 21, 2010. The following Planning Board members were present at the close of the hearing: Chuck Puleo, John Moustakis, Nadine Hanscom, Tim Kavanaugh, Tim Ready, Christine Sullivan, Randy Clark, Helen Sides and Mark George. Notice of this meeting was sent to abutters and notice of the hearing was properly published in the Salem News. The petitioner is requesting a Wireless Communication Facility Special Permit under Section 6.6, Wireless Communication Facilities, of the City of Salem Zoning Ordinance, to allow for the installation of 3 panel antennas and 5 backhaul antennas located at 12 Pope Street, Salem, MA. The Planning Board reviewed the application and plans submitted and found that the petitioner addressed the requirements of this section for the issuance of a Special Permit. On January 21, 2010, the Board closed the Public Hearing and the Planning Board voted by a vote of seven (7) in favor (Puleo, Moustakis, Hanscom, Kavanaugh, Ready, Sides, and Sullivan), and none (0) opposed, to grant the Wireless Communication Facility Special Permit for the location stated above, in accordance with the application (dated October 30, 2009) and site plan last dated December 21, 2009, titled "MA-BOS7165-1 Salem Heights Apartments, 12 Pope Street, Salem, MA 01970" (Sheets T-1, GN-1, GN-2, C-1, A-1, A-2, A-3, S-1, S-2, S-3, E-1, E-2, and E-3) and prepared by EBI Consulting, submitted and now part of the file. This endorsement shall not take effect until a copy of the decision bearing certification of the City Clerk that twenty (20) days have elapsed and no appeal has been filed or that if such appeal has been filed that it has been dismissed or denied, is recorded in the Essex South Registry of Deeds and is indexed in the grantor index under the name of the owner of record or is recorded and noted on the owner's certificate of title. The fee for recording or registering shall be paid by the owner or applicant. I hereby certify that a copy of this decision is on file with the City Clerk and that a copy of the decision and plans is on file with the Planning Board. Charles Puleo, Chairman 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 .TEL: 978.745.9595 FAx: 978.740.0404 ♦ WWW.SALEM.COM f Date FEB 1 7 2010 1 hereby certify that 20 days have expired from the date this instrument was received, and that NO APPEAL has been filed in this office. ATrue Copy -_ - ATTEST:,�._.CITY , ERK, Salem, Mass. CTI'Y OF S.�l�i9 NLksS.-1.cHusETTS ' 3UMDING DEPARTNIENT \ 120 WASHINGTON STREET,r FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KlmBERLEY DRISCOLL MAYOR THObw ST.PIERRE DIRECTOR OF PUBLIC PROPER7Y/BVII.DING COM NIISSIONER SECONDARY CONSTRUCTION CONTROL DOCUMENT (for Professional Engineers/Architects responsible for only a portion of a controlled project) Project Title: Clearwire Corporation Date: 2-18-10 Project Location: 12 Pope Street , Salem MA 01970 ScopeofProject: Installation of Wireless Communications (MA-BOS7165) In accordance with the sixth edition Massachusetts State Building Cade,780 CMR SECTION 116.0: I, ���Q! �r/QG � /% Mass.Registration Number 7 f 0/ being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: [ ] Entire Project [ ] Architectural KStmctural ( ] Mechanical ( ] Fire Protection [ ] Electrical [ ] Other(specify) for the above named project and that to the best of my knowledge, such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Cade,all acceptable engineering practices and all applicable laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that the above mentioned portions of the work proceed in accordance with the documents approved for the building permit. Upon completion of the work, I shall submit a final report as to the so ' completion of the above mentioned portion of the work. OF MASS �Q p J• JF 3 PONP SaN � N o Signature and Seal of registered professional: " p ILI B Si i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individwl): L(-6 A I RL✓ Cog P . Address: q�JQO 121 LL0AI POIA/7-- City/State/Zip: WkKtArib i Cy4 98-b33 Phone#: ar)A 7ti�% y�b0 Are you an employer?Check the appropriate box: Type of project(required): 1. X I am an employer with 1 1$CO 4. 13 I am a general contractor and 1 6.ri New construction employees(full and/or part time).' have hired the sub-contractors �,❑Remodeling 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8.0 Demolition working for me in any capacity. employees and have workers' q,0 Building addition [No workers'comp.insurance comp.insurance.$ required] 5.0 We are a corporation and its 10.0 Electrical repairs or additions 3. 0 I 1 am a homeowner doing all work officers have exercised their 11.I;Plumbing repairs or additions ( myself [No workers'comp. right of exemption perm MGL insurance required]t c. 152,§ 1(4),and we have no 12.IJ Roof repairs employees.[no workers' l3. fi Other comp. insurance required.] 4 *Any applicant that checks box#1 must also nil out the section below showing their workers'compensation policy information. tnomeownen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContacion that check this box must attach an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have_employees,they must provide their workers'comp.policy number. I am art employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: {BOA) RISK Jy($Jti1JC£$ Edf T - 1 AM Policy#or Self-ins.Lic.#: 2 '5&JE Z L cr 5 F G Expiration Date: Job Site Address: _ City/State/Zip: 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 152 can lead to the imposition of criminal penalties of a fine up to$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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby cet n Wfy er the pains and penalties of perjury that the information provided above is trite and correct Siggnat ire: 4 Date: Print Name: WA`01L Sr0'r-r Phale#: Jr/ 603 a'7(L Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license#: Issuing Authority(circle one): I.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: e ' , Massachusetts- Dcpallmcnt of Public Safely Board d of Building Regulations and StandarAx i V.CbhstFddtion Supervisor License -License: CS 67205 Restricted to:.00.._,,,;,,,,_,9 " TSA , w S � „WAYNE P STOTT t k 2 PILLOW LACE LN y IBEVERLY, MA 01915 �.*• - « '.tax• -"' Expiration: 0Y19P2011 t'owidisinngri ga:,. Tr#: 10029 .1 ACORO® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/09/2009 PRODUCER Risk InSUrdOCe services West, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY A Seattle WA Office AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 1420 Fifth Avenue CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE Suite 1200 COVERAGE AFFORDED BY THE POLICIES BELOW. Seattle WA 98101-4030 USA PHONE- 206 749-4800 FAx- 206 749-4860 INSURERS AFFORDING COVERAGE NAICk �.. INSURED INSURER A: Hartford ins co of the Midwest 37478 are Corporation 4400 Carillon Point INSURERS: Zurich American Ins Co 16535 e 4400 C Kirkland WA 98033 USA INSURER American Guarantee & Liability Ins Co 26247 v ' nascmeR D: a, INSURERE: 9 O COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS SHOWN ARE AS REQUESTED INSR ADD' LTR INS TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTD'E POLICY EXPIRATION LIMITS DATE MM/DD/YYYY DATE(MM/DD CLjOERAL LIABILITY GLA 6555971-00 11/01/2009 11/01/2010 EACH OCCURRENCE $1,000,000 H COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $500,70 CLAIMS MADE ® OCCUR PREMISES(Esaccurtence) EDE ( ny one Ottson $10,000 O PERSONAL&ADV INJURY $1,000,000 y n GENERAL AGGREGATE $2,000.000 GENT AGGREGATE LIMIT APPLIES PER: sD ❑X POLICY ❑ PRO- ❑ PRODUCTS-COMP/OP AGO $Z,OOO,BOB Ct O ECT OC O H B AUTOMOBILE LIABILITY GLA 6555971-00 11/01/2009 11/01/2010 COMBINED SINGLE LIMIT p X ANY AUTO (Ea accident) $1,000,000 z ALL OWNED AUTOS BODILY INURY W SCHEDULEDAUTOS m (Per person) HIREDAUTOS •' BODILY INJURY V NON OWNED AUTOS (Per ae,efdent) PROPERTY DAMAGE (Per awAerrD GARAGE LIABILITY AUTO ONLY-EA ACCIDENT ANY AUTO OTHER THAN EA ACC AUTO ONLY: ADD C EXCESS/UMBRELLA LIABILITY UM6655596700 11/O1/2009 1110112010 EACH OCCURRENCE OCCUR ❑ CLAIMS MADE AGGREGATE $5,000,000^o O C O� eDEDUCTIBLE Y RETENTION O C O C (O K A WORKERS COMPENSATION AND WEZL 1 X WC STATU- OTH- u EMPLOYERS'LIABILITY Y/N TORY LIMITS ER C E.L.EACH ACCIDENT $1,000,OOOC ANY PROPRIETOR/PARTNER/EXECUTIVE � © C OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,000 (Mandntorr,in NH) N If Ws,descrdw under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000�ut rD G OTHER p M C Mr NuD u U N C DESCRIPTION OF OPERATIONSILOCATIONSNEHICLEEIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS a)C See Attached List of Named Insureds. Evidence of Insurance. C, c N C C)C O� CERTIFICATE HOLDER CANCELLATION Clear wireless LLCSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION c3 4400 sari 11 i n Point DT DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL r P Kirkland wA 98033 USA 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Onr BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY O C OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. O C / AUTHORIZED REPRESENTATIVE .af/f�>WNLNAm nN ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION.All rights reservedn n The ACORD name and logo are registered marks of ACORD r r I INSURED Clearvvire Corporation 4400 Carillon Point Kirkland WA 98033 USA List of reamed insureds Clearwire Corporation Clearwire US LLC Clear Wireless Broadband LLC Clear Wireless LLC C1earmedia, LLC Certificate No: 570036777440 R E Er Vr A UT11 V R,4.I9 T,ON' SITE No.: MA-BOS7165 SITE NAME: Salem Heights ADDRESS: 12 Pope Street,Salem, MA 01960 DATE: DecemberL2, 2009 Salem Heights Preservation Associates, LP, owner of the above-described property (the"Owner"), authorizes Clear Wireless LLC and/or their agent, ("Clearwire") to act as its nonexclusive agent for the sole purpose of filing and consummating any land use or building permit application(s)necessary to obtain approval of the applicable jurisdiction for Clearwire's modification and/or installation of telecommunications equipment on the above-described property, as described in and pursuant to a Lease Agreement between the Owner and Clearwire concerning the premises, to be entered into simuitaneousiy with the execution of this Letter of Authorization(the"Lease"). The Owner and Ciearwire confirm to each other that this application may be denied, modified or approvea with conditions, and that any such conditions of approval or modifications will be the sole responsibility of Clearwire and will be complied with prior to issuance of a building permit. n.,...,s:......t..i,,..,b.. rr........:... .�,..u.:� Lc or.,f n..,�,Or:� a...... ..d ...,ny owvno anon y �.,ccinnc tiiuc� unu c u �uu wncauvns, a an"y relation to any application, permit or approval obtained hereunder, shall be done at Clearwire's sole cost d . a.�.. xpan 3o. Clearwire agrees to indemnify, defend and hold the Owner harmless from and against all claims, losses, liabilities, damages, costs, and expenses(including reasonable attorneys' and consultants'fees, costs and expenses) (collectively"Losses")arisino from Clearwire's breach of anv term or condition of this Agreement or from the negligence or willful misconduct of Clearwire or its agents, employees or contractrim in nr ahnut the Pmr)ertv This nrovision shall survive the terminatinn of this I Pifer This Letter of Authorization shall be effective as of the date first above written and shall terminate at the earlier to occur of 1)the end of eighteen(18) months from the date of this Letter or 2)termination of the Lease under the terms of said Lease. This space intentionally left blank. Signature page to follow. Salem Heights Preservation Associates, LP, a Massachusetts limited partnership By: POAH Salem Heights, LLC, a Massachusetts limited liability company, its general partner By: Preservation of Affordable Housing, Inc„ an Illinois non-profit corporation, its sole member ma tiger i Name: W.•Bart LI Title: Vice-Presid t Name: Laura J. Vennard_ Title: Treasurer Agreed to and confirmed: Clear Wireless, LLC Name: ER11CFJDUK Title: Dt tI CTi,zt-i\4:_t ; iiiil Il:l'I.l')`('/ti",Nf 00 44Carillon Pointdearw re Kirkland.WA98033 1Z"S'.;2 16.7600 1'4A2x5.216.7900Iaa no wwwxlearwiretom February 9, 2009 s Re: Clearwire LLC-Leasing,Zoning and Permitting Authorization To whom it may concern, li Please be advised that Goodman Networks is performing work for Clearwire US LLC ("Clearwire") in the Boston, MA market. Clearwire hereby authorizes Goodman Networks to act on behalf of Clearwire for the sole purpose of leasing and acquiring zoning and permit approvals to ensure Clearwire's ability to construct and operate its broadband services network. This authorization shall not be construed as a commitment of any type, and all final terms will be subject to Clearwire's approval. Sincerely, CLEARWIRE US LLC John A. Storch VP Network Deployment is {t f 1' I V HIGHSPEED INTERNET MADE SIMPLE. WAY SIMPLE. } The Cumnlonwealth of Massachusetts Town of Board of Building Regulations and Standards �w �.,?� Massachusetts State Building Code, 780 CMR. 7*edition Building Dept Building Permit Application To Construct. Repair, Renovate Or Demolish a tlk�► doom One•or ruu-Furpuls Divelling This Section For Official Use Only Budding Permit Number Date Applied: 2 f Signature: Bwldin C m alone/Inspector of Buildings Dsit Budd,�C& SECTION 1:SITE INFORMATION 1.1 Pro rt nr. r 1.2 Assessors Map d Parcel Numbers 1.I a Is this an acce led street'?yes no Map Number Parcel Number l..) Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage-f(l) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:IM.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Public 0 Private 0 CheckifyesO SECTION2: PROPERTY OWNERSHIP' 2.1 Owe 'of Record: v Name IPrinq - Address for Service: �� 78/ D Signature Telep SECTION 2: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building 0 Owner•Occupied O Repoirs(s) 0 I Alteratio a 0 Addition 0 Demolition 0 Accessory Bldg.O Number of Units Other 0 peci Brief scrip 'on o posed Works: SECTION 4:ESTIMATED CONSTRUCTION O S Estimated Costs: Official Use Only Item Labor and Materials I. Building S I. Building Permit Fee: S Indicate how fee is determined: O Standard"act Application Fee I Electrical = O Total Project t C Coosta(ltem 6)a multiplier `�Jifl_J{Ili I Plumbing S 2. Other Fecs: S a. .Mechanical (HVAC) S List: s Mechanical tFire S Total All Fces: S suffresa-on {i Gip Check Vo. _Check Amount: Cash Amount:_ it Total Project Cost. f [7 �✓ r 0 Paid in Full 0 Ouwandmg Balance Due- { SECTION 3: CONSTRUCTION SERVICES 3.1 Lice Cotntr rtlion ervisor(CSL) 124� 71 Li.cnxNumRr Espu ion to N.,pae ul SL l 91 List CSL Ty pe below) AWwsa Tvoc I Description 9�c/ Unrestricted(up to 17,000 Cu, Fl R I Restricted IA2 Family Dwellinji Sigiutu � 6 `�� N 1 Masonry Only RC Residential Rooting Covering Telephone wS Residential Window and Sidra SF Residential Solid Fuel Burning Appliance Installation D I Residential Demolition 3.2 R Ho 1 p eat Contractor(HIC) Q HIC Co r C Rep aqt N Relpstrati Number Aram. p � /ration Du Signature Telephone SECTION 6: ORICERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL ISC(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 ARidavit Attached? Yes..........of No...........O SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 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. SignanusyofOwner Date SE ION 7b: WNERt OR AUTHORIZED AGENT DECLARATION I, as Owner or Authorized Agent hereby declare that the statements and information n the foregoing application are true and accurate,to the best ofmy knowledge and behalf IVA Print Namt z /o Signature of Owner or Authorized Agent Data Signed under the pains and penalties ofperjury) 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 q&have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R3,respectively. r When substantial work is planned,provide the information below: al Goon area(Sq. Ft.) (including garage, finished basemenVanics.decks or porch) ss living area(Sq. Ft.) Habitable room count mber of freplaces Number of bedrooms ber of bathrooms Number of half baths Type of heating system Number of decks porches T�peofcoolmgayctem Enclo%cd Open I "Total Project Square footage"may he.uhsmulcd for Total Project Cost' ACID oR ® CERTIFICATE OF LIABILITY INSURANCE DATE] M'°""'"') PRo01)iER 2/23/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Divirgilio Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 270 Broadway HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 8065 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lynn, MA 01904 INSURERS AFFORDING COVERAGE NAIC# INSINm RYAN ROOFING 6 CARPENTRY INSURERA ATLANTIC CASUALTY INSURER B: MARK RYAN INSURER C: 165 LYNNFIELD ST LYNN, 01904 ' INSUWRD INSURER E: COVERAGES THE POLICES OF INSURANCE LISTED ff LOW 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS. INS R ADD' TYPECIFINSURANCE POLICY NUMBER POIICY EFFECRVE POLICY EXPIRATION U NITS GENERAL LIABILITY RENCE $ 1,000,000 A ][ C: ERCAL GEVERALLUABRITY L143000353 9/2d/09 9/24/10ENTED $ CLAMS MADE ❑OCCUR ons P.sm) S $ 000 ADV INJURY S 1,000,000 REGATE S 2,000,000 GEN'LAGGREGATE LFUTAPPLIES PER OMPQP AGG $ 1,000,000 POLICY PRO. LOC AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMB S (Es emiderl) ALL O WNEO AUTOS SCHEDULEDAUTOS BODILY INJURY S (Pwpssm) HIREDAUTOS NONOWNED AUTOS BODILY INJURY $ PROPERTY DAMAGE S (Peremitle,n) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT E ANYAUTO OTHER THAN EAACC S AUTO ONLY: AGO E EXCESS I UMBLELLAUABILITY EACH OCCURRENCE $ OCCUR CLAMS MADE AGGREGATE - $ S DEDUCTIBLE RETENTION S YORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETDRIPARTNEME KECUTw ` OFFICE RM.EMBER EXCLUDED? E.L.EACHACCIDENT S VMsnOebry In NH) EA EMPLOYE S Byyes,d-a' under E.L.DISEASE- SPEGALPROVISIONSECow OTHER E.L.DISEASE-POLICYLMR $ DE SCRIPTON OF OPERATIONS/LOCATIONS I VEWCLES I"Q.USIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ROOFING COMMERCIAL/RESIDENTIAL re: DENISE JOHNSON 13 WEST CIRCLE SALEM MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBEDPOUCIES BECANCELLED BEFORE THEEXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 0 DAYS WRTTEN City of Salem NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SWILL Building Dept IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR 93 Washington St REPRESENTATIVES. Salem MA 01970 AUTHORIZED RE PRESENTATNE , G' ACORD 25)2009101) ©1988,2009 PCORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD J RTIFICATE I8 ISSUED ABA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE [ETTPUFFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN E ISSUING INSURER 8 AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER, MPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(ieM)must be endorsed. If SUBROGATION B WAIVED, aub)ect to the tense and conditions of the policy, certain policies may require and endorsement A statement n this certificate does not confer ri htB to the certificate holder in lieu of such endorsement PRODUCER Dlvlrglll0 Insurance Agency Inc 270 BroadWey Lynn,MA 180E COMPANIES AFFORDING INSURANCE INSURED COMPANY A GRANITE STATE INSURANCE COMPANY Mark J.Ryon , 186 Lynndleld Street Lynn, MA0190E4000 THIS 18 TO CERTIFY TWAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 18BUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANT 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 18 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY WIVE BEEN REDUCED BY PAID CLAIMS. Lmt TPI CF NIURAMSI F0.10Y MMMEIM1 FOUOYIFFIQmVI m F...PM1IN1 NIATION DA1e A DEMPLOYBRf LMa1LRY E PROPRETOR/ LIMITS PARTNER&WCMTIV6 OFFICERBMI: NCL❑on 13 4B817g0 B/Y3IYDDB 9/23/2Q10 ANTOM1Y LIMIT6 OfXE Caany�AW=tu MA OPrdm*O*. X ACCIDENT S 100.00 MAN POLICY LIMIT S 500.00 Descw r L r TTE RE THE WORKERS COMPENSATION POUCY DOES NOT PROVIDE COVERAGE FOR MARK J RYAN-LOCATION:DENIBE JOHNSON.13 CIR 8AUEM MA 01 M. CERTIFICATE HOLDER ANCELLATION CITY OF SALEM SHOULD ANY OF TXE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE SLOG DEPT EIPIUTION DATE THEREOF,NOTICE WLL BE DELIVERED IN ACCORDANCE 83 WASHINGTON ST WNTE THE POLICY PROVISIONS. SALEM, MA 01070 AUTHIORIZED REPRESENTATIVE CITY OF SALEM PUBLIC PROPRERTY 'AL�,, i DEPARTMENT .?,Poi I`,t n I�0 VI'.�it II\G:iLN 1'NLr'T 1).\I I M.%t.Ni.\�I II it I 1 "'I Tr1:978-745-9395 •Fm 978-740-944e Construction Debris Disposai Atridavit (required lur all demolition and renovation work) In accordance with the sixth edition of the Slate Building Code, 730 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit p _ is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I 11. S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in 1-7 ftf (name of aci Ity) ' (address ul'ladlity) .gnature 72� applicant ;late