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44 PRINCE ST - BUILDING INSPECTION S • , The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 7m edition OF SALEM Revie'er/Jurrnun• Building Permit Application To Construct, Repair, Renovate Or Demolish a /• 201FAV One-or Two-Fumi.v Dwelling This Section For Official Use Only Building Permit Nu er:: I Date Applied: — Signature: 4d -D m L� Building Comissi r/Inspector of Buildings Date SECTION 1: SITE INFORMATION 11 Property Address: 1.2 Assessors Map& Parcel Numbers 4G I.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.3 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water upply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: _ Outside Flood Zone? Municipal Iron site disposal system ❑ Check if yesO SECTION2: PROPERTY OWNERSHIP' nertof ecord: ors/ee ze-9 �D l/N /�!/C Lr✓ 7�/ /" C 5`�J�L��"f� /r f/� Name(Print) T� Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check aB that apply) New Construction❑ Existing Building Owner-Occupied O 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 AdditioJO Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other Specify: Brie escri tion of Proposed Work-: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials . Building S I. Building Permit Fee:S Indicate how fee is determined: I. Electrical s O Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cast: S (� ❑paid in Full ❑Outstanding Balance Due: .,PE9-0-k6/ SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed/Construction Superrviisor(CSL) qqC /Z 3-,1 T�L =�c7 t6 iz L c- ./ License Number Expiration Date N c of 'SI.•I IulJer List CSL Type(see below) &) J YlJ c� o STD .. gCb f Description AJ ss O I Inrestricted(up to 35,000 Co.Ft. R Restricted IR2 FamilyDwelling Signature M Only Q Residential Rooting Covenn Telephone Residential Window and Siding Residential Solid Fuel Burning Appliance Installation p��r D Residemial D>em)olition 5.2 R bte w7/r �q t Contractor(HIC)121A01 lRt a.� .-5— f IIC um y Name ur f IIC Registram Name Registration Number AJJ -� Expiration Date Signature Te ep �e SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 2SC(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 ..........W No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 s'Zfy en?A/f 4:( 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. Si Lure of Owner Date SECTION 7b�:-OWNEW OR AUTHORIZED AGENT DECLARATION as Owner r Authorized Agen ereby declare that the statements and information on the foregoing application arc true and accurate,to e s o my knowledge and behalf. ^ �t Print Name �� Signature of Owner or Authorized Agent Date! (Signed under the pains and penalties of 'u NOTES: I. 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 pal have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IO.RS, respectively. Fof substantial work is planned,provide the information below: area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) g area(Sq. Ft.) Habitable room count f fireplaces Number of bedrooms f bathrooms Number of halt/baths aling system Number of decks/porches oling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALEM PUBLIC PROPRERTY !'-r' DEPARTMENT :J\1L'.'k LIIY DRIiC(�LL �lav(na 12C WASHIN(,IONStae[T 4 Snu:vt.M.ss:vnIt sr.'I'isOlri7.^ '11a:978-745.9595 • 1'sx.978-74C./8i6 Workers' Compensation Insurance affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information // Please Print Legibly VBmC(13usincs�/s/Or�a�nrvi�z�artioNlndiv�id�uu4: dt o `lr✓ �yL_L�teYi �srL n.�e/ o,e �i� _ O/lyd0 Phone -: 97tf -9�3—I/J 7L� �.IIyiSC1IC%�Ip:T `� - Are you a mployere?Check the appropriate box: 'Type of project(required): 4. ❑ I am a general contractor and 1 I. um a employer with G. ❑ New construction employees(full and/or part-tine).' have hired the sub-contractors 7. ❑ Remodeling 2.❑ 1 ant a sole proprietor or partner- listed on the attached sheet- t ship and have no umpluyucs These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition To workers' com insurance 5. ❑ We are a corporation and its I P• 10.❑ Electrical repairs or additions required.] officers have exercised their right of oxen, tion per MGL 11.[] Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work S P P' myself. (No workers' comp. c. 152, §1(4),and we have no 12. oof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] •Airy up plicaut that chucks box dI must also till out IIm section below showing Ihoir workers'compensation policy inliurnauion. 'I tumuowners who submit this affidavit indicating Ihcy,arc doing all work and then him outside contmeron must submit a new affidavit indicating such. ;C,,nwi uors that check this box must attxhod an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. l am ern employer that is providing workers'compensation insurance for sty etoplayees. Belorv_ is the pulicy and job site information. Insurance Connpany /Yvtrr'�r L policy 4 or Self-ins. Lie. *s: sY----..___._. .- --:__--- Expiration Date: 'fU—o1Ol Job Site Address: � �i'/.uG>°. ,�I City,,State/Zip: (oefft /j'14 a4f al Attach a copy of llte workers' compensation policy declaration palle (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of�IGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year i,nprisomncnt, as well its civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. lie advised that a copy of this Statement may be forwarded to the Office of luvratigatiuns ul'the DIA for insurance coverage vcritication. l do hereby certify under the pains and pernrltics afperjary that the iaforination provided above is true and correct.. — Q/ficial use only. no not Ivrite irr this area,to be cuatpleted by city or lawn official. C'ityorTown; .. Permit/Licenser-----._ __. -._.._.___. ...___ .. .. . Issuing Aulhurily (circle one): 1. Board of Ilc:dth 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Pluubing Inspector 6. 01 her Contact Person:. ____ .. - -..-_- phoned: r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of;at individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." NIGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to.construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence ofcompliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) namc(s), address(es)and phone nunmber(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be rctumed to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. ['lease be sure to till inlhe pennittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address" the applicant should write "all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Oilicc of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: e The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021 If Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 5-26-05 www,mass.gov/dia �' -�""-� � • �" '« rv1 ro'i' tVM'P-b) FROM: insurancevis ions .com-TO: 19785815142 Page: 3 of >,`fRD® CERTIFICATE OF LIABILITY INSURANCE °"'E`MWDGNyYH PRODUCER 6/10/2010 JOHN V ZANNINO INSURANCE AGENCY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 16 FOSTER STREET ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PEABODY, MA 01960 HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (978)531-5757 INSURERS AFFORDING COVERAGE NAIC k INsuaeD LIDIO VALENTE INSURER A. ' DBA RESIDENTIAL REPAIR SERVICE INSURER PO BOX 387 PEABODY MA 01960 INSURER INSURER D INSURER E. 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,TOALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR CD' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE GENERAL LIABILITY LIMITS EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY A PREMISES Ea occ,,, al $ CUIMS MADE OCCUR MED EXP iAny one mon) $ PERSONAL 8 ACV INJURY $ GENERAL AGGREGATE g GENL AGGREGATE LIMIT APPLIES PER: POLICY PRO. LOC PRODUCTS COMPIOPAGG $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ IEa nuidwvl ALL OWNED AUTOS SCHEOULEDAUTOS BODILYINJURY (Per P.'perao-n) £ HIRED AUTOS NCN-OWNEO AUTOS BODILY INJURY IPer ncudenp ; PROPERTY DAMAGE $ IPer ectldenU GARAGE LIABILITY MY AUTO AUTO ONLY-EA ACCIDE NT S OTHER THAN EA ACC $ AUTO ONLY. AGG s EXCE S31 UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE S DEDUCTIBLE S RETENTION S E A WORKERS COMPENSATION WC1-31S-366666-020 WC STATU $AND EMPLOYERS'LIABILITY YIN 6/42D1D 6/4/2011 / OTH ANY PROPRIETORRARTNER/EXECUTIVE OFFIOERIMEMBER EXCLUDED' ED E.L.EACH ACCIDENT $ 1010000 (Mandatory in NH) .I M.d eaaae under E.L.DISEASE EA EMPLOYEE $ 100000 SPECIAL PROVISIONS bebw OTHER E.L.DISEASE POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Workers Compensation Insurance: Part One of the policy applies only to the Workers'Compensation Laws of the State of MA. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR ILIDIO VALENTE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN ( NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATNE Jeff Eldridge : •. /, '��`1^J_ ( ,�(�.LGc1%�.�„ ACORD 25(2009/01) ! r r; All— chana L<c I: ©198a-2009 ACORD CORPORATION. All 7s5sc17 CLILIT CODE: 129) rved. aco;o 9:;I,oe AM Pa9` 1 0( 1 rights rese CITY OF SALEM ;. PUBLIC PROPRERTY DEPAR"I'MENT '.I 12CA uM,:,w tinn:r r • J.t i I M. %I\,s t' :f� ;l I ,'-I') _ Construction Debris Disposal Affidavit (rc(luired lbr all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.5 Dcbris, and the provisions of MGL c 40, S 54; Building Permit N _. is issued with the condition that the debris resulting front this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c 111. S 150A. The debris will be transported by: (- Utnme of hauler) The debris will be disposed of in ajz4g�l 6'V>9sfi�- (name ut iaalny) (address of facility) Smllutulc of permit applicant 'late — _ 1 VINYL TILT REPLACEMENT WINDOWS T N RESIDENTIAL REPAIR SERVICES O Y ROOFING R L M 60 Dump Truck Service • General Contractor is D 978-423-4574 0 N LI,C##13125 R \ GUTTERS STORM WINDOWS ROOFING ESTIMATE ESTIMAT SUBMITTED TO: r JOB NAME f JOB# .r) I e"e ADDRESS JOB LOCATION A/ /)./i5 i i d s? + 4` nilAk e 57' i Ae1,-.ter , 11fA Rio 9 d CITY/STATE/ZIP � DATE PHONE# _ ^ ^ / FAX# CELL# WE HEREBYAGREE TO SUPPLY THE MATERIALS AND LABOR AS SPECIFIED IN THE MARKED BOXES BELOW... rp NOTE: ONLY THE MARKED BOXES PERTAIN TO YOUR ESTIMATE. / WE AGREE TO: ❑ 1. COMPLETELY STRIP THE ENTIRE ROOF(S) OF THE EXISTING LAYERS OF SHINGLES. ❑ 2. INSTALL A NEW LAYER OF ! SHINGLES OVER THE �/ EXISTING ONE LAYER OF SHINGLES ON ROOF(S). U 3. INSTALL ANEW RUBBER ROOF(S)USING ALL NEW RUBBER ROOFING MATERIALS ON THE -MAi s) -FLAT ❑ 4. INSTALL NEW ICE&WATER SHIELD ON ROOF(S), ROOFS EDGE, RAKES, VALLEYS, DORMERS, SKYLIGHTS, CHIMNEYS & FLAT ROOF AREAS. ❑ 5. INSTALL NEW I.B.ASPHALT FELT ROOFING PAPER ON THE ENTIRE ROOF OF THE ❑ 6. INSTALL NEW 8 INCH ALUMINUM DRIP EDGE ON THE ENTIRE ROOF(S). ❑ 7. INSTALL NEW ALUMINUM STEP FLASHING ON ROOF(S). ❑ 8. INSTALL NEW(VENT PIPE BOOTS)ON"'� ROOF(S). ❑ 9. INSTALL NEW(ROOF BOX VENTS)ON 4 ROOF(S). ❑ 10. CUT&INSTALL NEW RIDGE VENT ON ROOF(S). ❑ 11. INSTALL NEW LEAD ON CHIMNEY ON ROOF(S). ❑ 12. INSTALL NEW SKYLIGHTS ON ROOF(S). ❑ 13. INSTALL FT. OF(ROOF BOARDS)OR(PLYWOOD SHEATHING)ON THE ROOD OF THE COSTS$3.00 PER SQ. FOOT, COVERS MATERIALS AND LABOR. ❑ 14. INSTALL NEW YEAR SHINGLES ON THE ROOF(S). �/ / t ,� C3 15fINSTALL pREPLACE/RE��PAI`R 7n_ . 1CrA L O:�Y&kJ ,17el0t'r QJr1t1` tJ f",4-r0 ,ICY TAr, l"./l/dfi j,- 16. SPECIAL CONDITIONS Ar-!. 1�'?.4 J-l S M/i ,flog d/.- OlPe t P-OA 1 4 1-1 72 tat! /, et/- NOTE: WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC AREAS.CUSTOMERS SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE STRUCTURE BY COVERING EXTERIOR WALLS,OBJECTS,AND FOLIAGE WITH TARPS TO HELP PREVENTANY DAMAGE DURINJ&T�HASTRIPPING OF TIjE ROOF.HOWE LR,SPME DAMAGE AND MARRING COULD OCCUR BEYOND OUR CONTROL... !!!////r41t.,�/4 erg I~ l�v; Ghf{I` r1'= c/ `, /C NOTE: (IF)MORE LAYERS OF ROOFING MATERIALS ARE FOUN THAN INDICATED ABOVE,ANiEk RA CHARGE WILL BE ADDED FOR THE (LABOR&THE REMOVAL OF THE DEBRIS)OVER AND ABOVE THE PRICE OF THE ESTIMATE. We propose hereby to furnish material and labor- complete in accordance with the above specificatio,,birts for the sum of: s $ 7ilf �iJ ' In r/c t J ll y f �„/. f, ,( '%f i N7-4c/ ���ff✓ Dollars with payments to be made as follows: =`.� / / /m Any alteration or deviation from the above specifications involving extra costs Respectfully ems _ J will be executed only upon written order,and will become an extra charge over submitted and above the estimate.All agreements contingent upon strikes,accidents,or ,1r delays beyond our control. Note-this proposal may be withdrawn by us if not accepted within Cl days. 01 C3kcelafam of Fropowl The above prices,specifications and conditions are satisfactory and are hereby Signature _ accepted.You are authorized to do the work as ecifietl.Payments will be made as outlined above. n / (\� Date of Acceptance ""-7 Signature 144 f l / .10 1 V