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26 PRESCOTT ST - BUILDING INSPECTION (2) I'he C'onunonsrcuhh of Massachusetts 1, 1) Board of Building Regulations and Standards CITY OF SALEM lssachusetts State Building Code, 73U C'hIR� Reviled tGu 'n//� Building Permit r\pplication 'ro Construct, Repair. Renovate Or Demolish a One.ur Tu o-Funuti,Umellinit` This Section For Olticial Use Onl Building Permit Number: D ��, ppplied: /�ksw9 Budding Olticial(I'rinl N;une) Sigl IaIU �c I SECTION I:SITE INFORMATION L I Rrop rty A res: 1.2 Assessors Map SI Parcel Number I.la is this an acce led street? es no Map Nunlhcr Parcel Nunlher 1.3 Zoning Information: 1.4 Property Dimensions: Luring District 1'mpwcd(lac Lot Area(sy Il) Frontage(R) I.S Bulldln8 Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Reyuircd Provided Required Provided 1.6 Water Supply:(M.G.1.c. JU•§Sy) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Privaic(3 Zone: _ Outside Flood Zone? Chock ifes0 Mumcipd 0 On site disposal s)stem 0 SECTION 2: PROPERTY OWNERSNIPI 2.1 Owilerl of Recara 1ri I� L5 rc�aly( rn .S'c �cl . /lira Nlunc Pant)t) (uy.watc.LIP d/rf,S'LOf Nu.and Street - Telephone Email Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteratlon(s) 0 Addition O Demolition 0 Accessory Bldg.❑ Numberaf Units Other ❑ Specify: Brief Description of Propo ed Work': d L SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: ILAburand.\huerialsf OMclal Use Only I. Building S D � 1. Building permit Fee $ Indicate how lee is determined: ?. rleclrical S 0 Standard City Tussn Application Fee Plunlh;ng S O Total Project Cost'l Item 6)x multiplier _. Other Fecs: S 4. .\tec1 lied III%Act i List: �. \Icchallical IFirc -- --- ------ -- --- . . . . �u+vessionl Tuull .\IlFces: S o Total Project Cusl: i l heck \b. _('heck :lmaum: _ _. ('.uh \mount: Orr ❑ Paid in Full ❑Outstanding Ilalamce Due: r SECTION 5: CONSrRUcri N SERVICE,' 5.1 C nstruction Supcn'isur Liceuse(('SI.) /¢ _.._ ��� r S (� I ieen.c Numhcr P�pinifioo hue N;une oll�l. InlJef 1 list(',VI. I..rw I•ec ---1—�---��-/`_�"---- - -- 'I')pe Description No. ing1mr t it i4lnstriUeJ llhlild illy' s,i h+)S.000 cu. 11.) Ne>IricleJ LC2V.mlil Il+tellin Cit)i Ili, �aIX . ' \) 1lusun RC Koot Coveri11 µ'$ µ'inJ I ,u,J 11 1 ` yh Solid Fuel Iluming,\ppliallcea C•y✓ „ Insulation I'e c hone Ifmailuddrexs D Denu+lilion 5.2 Registered liume Improvement Contractor(HIC) L/y Zr,y / ✓f C'.. Ili( I(egisuutiun Nrumhcr CslnnUiun Dale Fit IC L'ompan) Name or I IIC' Ceeggistrunt Nanle „/- /l „/I mary��r/ . �n sJL i Lcl tom/ r w — NJ.'.�1d$ •el 715 L'mall aJJmss /,ra n,•1 /�CCU G� o'ay— (ice d.� ,� Ci IT wn,Stale ZIP Tole hung SECTION 6.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e, 152.1 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 .......... D No..I.........O SECTION 7a:ONER AUTHORIZATION TO BE COMPLETED W HEN W OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize '1� Wa7 B y1 S t,& to act on my behalf,in all matters relative to work authorized by this building permit application. Date I 'm wer's Name(Electronic Signmum) SECTION NEW 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 a lication is true. the best of m knowled a an understanding. - �-9 NumeII:I¢' ..Si Prim ner s or� nn Nnuure) Dalo NOTES: Owner ssho o wins a building pennit to do his her usvn work,or an owner who hires an unregistered contractor (nut registered in the Hume Intpro'entent Contractor(HIC) Program),will no have access to the arbitration program or guaranty I'and under I.G.L.c. 141A. Other important information on the HIC Program can be round at ,,,,,, ni.i . o ,�, I lnform;uion on the Construction Supervisor License can be found at„>++' n • ' 8:^ h" 2. µ'hen subslantial swrk is planned,proidc the information below: rowl floor area 1'+ 11.1 _ _—__.._1 including garage. Imishcd bascntciu attics,decks or porch) Gross lining area i sy. It Habitable room count _ .. .... . .. ♦umber of fireplaces \kullher of hedrooms I �umherol'hathr.wms _ Numberuth:dl'haths I\pe al'heating s);tcm ' . . \'anther of decks pordtcs i 1�pe of c.ading s�slcm I?ndosgJ 011co 1. "I'o1a1 Project Square Farn.tge nw) he suhslilufcd Il,r..l•,swl I'rajed Cost., CITY OE S.ILE,N[, tbLlss.1CHC'SE-ITS !3L'tLDL`IG DEp.1RTtEVT I'O TURNGTON STRstBT, jw accit • •�. Ttr2. �91� 143�959! F,�x(91� 17846 .'U3SFJtLfiY DRLSCO[l, MAMA rRON UST.PMMS D IRSac 4 OP PL eLIC PROPEIt7Y/at:Q.D[NC CQ.%Oi13sf ON E; Construction Debris Disposal AlRdavlt (required for A demolition and renovation work) In accardanee with the sixth edition of the State Building Cade, 130 CUR section I 1 I.1 Debris, and the Provisions of MGL a 40, S 34I Building Permit a is issued with the condition that the debris resulting from ibis work shell be disposed of in a properly licemed waste disposal facility as defined byNIGL c 111, $ I JOA. The debris will be transported by; v (name of hauls) The debris will ba disposed of in : rr (name of facility) IIddrefr or f�cilty) r f,^ermrt t _ Jtp ( AC a CERTIFICATE OF LIABILITY INSURANCE °"'E'M""°WY"Y"' s/29/2012 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 poliey(iss)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 endorseme s. PRODUCER NAME: CT Select Dept aid 66807 Eastern Insurance Group LLC-Main PH1,508-653-8089 CHE FAX 508-651-7700 INC.No 233 West Central Street MAIL Natick MA 01760 ADDRESS INSURE S AFFORDING COVERAGE NAICd INSURER A INSURED 40761 INSURER B.'Charter Oaks Fire ?5615 DSD Enterprises Inc INSURER C: 44 Clark Street INSURER D: Lynn MA 01902 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:25898752 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. ILTR NS BR TYPE OF INSURANCE POLICY NUMBER MMILUOY EFF MPOWDDD EXP LIMITS A GENERALLUIBUTV 80256SN822 7/2012 27/2013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Es ccxunenoel $300,000 CLAIMS�MADE K OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATELIMITAPPLIES PER: PRODUCTS-COMP/OP AGO $2,000,000 X POLICY PRO- LOC $ B AUTOMOBILE LIABILITY BA335SN992 51SQ012 52013 COMBINED SINGLE LIMIT I Ea acddem ANYAUTO BODILY INJURY(per person) $100.000 ALL OWNED lX SCHEDULED BODILY INJURY(Per accident) $300,000 AUTOS AUTOS HIREDAUTOS X NON-0MMED PROPERTY DAMAGE $100,000 HAUTOS Perecculen $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ L I EXCESS U AB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION N/-STATU- OER YIN Y 1 ANY PROPRIETOR/PARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ I(Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,AddRional Remark;Schedule,Imone space is requlmd) 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. Inspectional Services 120 Washington Street, 3rd Floor AUTHORIZED REPRESENTATIVE Salem MA 01970 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD / I ,?CID 2w1 OG r CLbl� t x T • • 'i r 4r w.^. n,..�.. . r .ate.. .=per...�n r ✓/LC �0'pl0)i0'Itf!/P O�✓ULQ.k1CLC�tLdC office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR (y' + .•Reglstratton'r:161972 TYPe . {� Expiration 12/15/201(2(z DBA {t1 DSD ENTERPRISES f • IF DANIEL DAVISON � � � 44 CLARK STREET LYNN,MA 01902 UnJersecreiary ..; 1.., '„ JI wsacbttY�tt Dcp rrtruent.iA l wmi S:ifc is g_ ? Bo trd of 81,ddtn , ; , 4 w mono tntl St tnd tr( Construction Supervisor' License,, License: CS. 101911 ' ..; - '• Restricted to: 00 •-� ,Y Y DANIEL DAVISON 49 BAYVIEW AVE NO 3:=, LYNN; MA 01902 E piratiA&�5f�Mv r From:Colleen Malakidis Fa%ID:Fitzgerald Insurance Page 1 of 1 Date:5/30/2012 10:31 AM Page:1 of 1 OP ID: CM CERTIFICATE OF LIABILITY INSURANCE DAT 05130DIYYYY, 05/30/12 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 508-6684100 NAME Fitzgerald Insurance Agency 508-668-4199 PHONE FAX FAX- Walpole,East Street-Route 27 AIC IL Fall: AIC No Walpole,E. F tiger E-MAIL Stephen E.Fitzgerald ADDRESS: CUSTOMER ID I.DSDEN-1 INSURERIS)AFFORDING COVERAGE NAIC N INSURED DSD Enterprises Inc. INSURERA:National Continental Ins Daniel Davison INSURERS Assoc. Employers Ins Co. 44 Clark Street Lynn, MA 01902 INSURER C: INSURER D INSURER E INSURER F' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYI'Y MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE I In PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR RED EKE(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOPAGO $ POLICY PR0. LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ A ANY AUTO 07771029-1 12123111 12123/12 (Ea e0den0 BODILY INJURY(Pei person) $ 50,000 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Pei accident) $ 100,000 X _ PROPERTY DAMAGE $, 50,000 HIRED AUTOS (Per accitlen) NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ I$ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY x TORY LIMITS 1 ER B ANY PROPRIETOPiPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? NA A 0013684.14583 04104112 04/04113 E L EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L.DISEASE EAEMPLOYEE $ 100,000 I yes.Describe under DESCRIPTION OF OPERATIONS below E.LDISEASE-POLICYLIMIT E 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SALEM-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St Salem, MA 01970 AUTHORIZED REPRESENTATIVE Stephen E. Fitzgerald OO 1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD