68 PROCTOR ST - BUILDING INSPECTION The COmmonweaith of Massachusetts
��- PUN
QQ ► Board of Building Regulations and Standards
Massachusetts State Building Code. 780CMR, 7'"edition ,ItVl�itit:\lll '
�\ W Building Permit Application To Construct. Repair, Renovate Or Demolish a Ret ocd J,uur,u,
One- or Two-Farnilr D%elling 1. 'r Brg
This Section For Official Use Only
Building Permit No r: Date Applied: to •2. OCR
Signature: & - Zt7'0 �C)
But ing Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 PpertyQ�e�ss` 1.2 Assessors Map & Parcel Numbers
I.la Is this an accepted street?yesJ no Map Number Panrl Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 10 Frontage tit)
1.5 Building Setbacks 00
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner of R
_ c -e. fo �', JVacx kcr "rti
Name (Print) Address for Service:
t'ogt — & S-I/
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
NizX
Construction ❑ Existing Building ❑ Owner-Occupied Repairs(,) ❑ Alteration(s) ❑ Addition ❑
tion ❑ Accessory Bldg. ❑ Number of Units Z. Other ❑ Specify:
escription of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
(Labor and Materials)
ing $ 1. Building Permit Fee: E Indicate how tee is determined:
O Standard City/Town Application Fee
ical S ❑Total Project Cost (Item 6) x multiplier x _
bing I. Other Fees: S
anical (HVAC) 3 List:
anical (Fire 5Suppression) Total All FOGS: S
Q Check No. Check Amount: Cash Amount:
6. Total Project Cost: 5 � I� paid m Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Nantc of CSL- Holder List CSL Type(see below)
T Description
Address U Unrestricted to to 35,000 Cu. F(.i
R Restricted 18t2 Frond Dss ellm
Signature M .Maori On]
RC Residential Roo(iu Cosenn
Telephone %1S Residential Wind.... ,rod Sidin
SF Residential Solid Fuel Uamme \i diani: Lni.d l�wm
D Re"dcuti at Dentuhuon
5.2 Reglstered 11, Irpper ement Cone�fV✓ (191�) I ^L' .�
r� I�r00`�'r C -l
HIC Comp Naine or HIC Registrars Name Regis(raoon Nwnbrr �7
Address — L bU,�(,L S F 1"R Expiration Dale
Signature Telephone
l
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 9 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure no provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... 0 No ........... 0
SECTION 7r: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I --�DCLV/\ e2 , as Owner of the subject property hereby
authorize N-1 ARSe"2�= to act on my behalf. in all matters
rela\ work authori y his building permit application. p
Si natui (Owner Date
SECTION 7b:
C OWNERtOR AUTHORIZED AGENT DECLARATION
I / 4ef-K
as Owner or Authorized Agent hlknowledge
that the statements and information on the foregoing application are true and accurate, to the best of my behalf.Print Marne � _ _ 1 ,-e'��� nZ. —cY6
Signature of Os er or Authorized Agent �•Y Date
(Signed under the 2ains and penalties of r'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 not 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 110.R6 and 110.R5, respecttsely.
2. When substantial work is planned, provide the information below:
Total floors 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 j
Number of bathrooms Number of half7ba(hs j
Type of healing system Number of decks/ porches
Type of cooling system Enclosed Open
3. 'Total Project Square Footage" maybe substituted for '-Total Project Cost'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
a,
19
Fsx: 9:'8 '4=-')84o
Workers' Compensation Insurance Affilda%it: Builders/Contractors/Electricians/Plumbers
\ f )hrant Information Please Print Lef_iblV
�;ll lle Ilitiancss Urg.uu�:n ian InJis l.lua l:
\ddrei,,: ) \ l CSW2 5
City,Stare.Zip: Phone
Pe w l �2Yr CS55` '
�:
.\re vt employer:' Check the appropriate box: -rope of project (required):
I. I ant a employer with_�__ 4. ❑ 1 :un a general contractor and I
�(J 6. ❑ New construction
employees(full and"ur part-time).' have hired the ached sheet. 7. ❑ Remodeling
❑ I :un a sole proprietor Or partner- listed on the attached sheet.
ship and have no emplovees
These sub-contractors have 8. ❑ Demolition
insurance.workers' comp. insurance. y. ❑ Building addition
working for me in any capacity.
j.No workers' comp. insurance 5. ❑ We are it corporation and its 10.0 Electrical repairs or additions
reyuired.l officers have exercised their
ri ht of exemption per MGL 1 1.❑ Plumbing repairs or additions
3.❑ I ❑m a homeowner doing all work b
myself. [No workers' comp. c. 152, §1(4), and we have no I?❑ Roof repairs
insurance required] employees. [No workers' 13.0 Other
comp. insurance required]
anon policy information.
•:\ny applicant that checks box 01 most also lilt out the section below showing their workers'campers
' I Io...eowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afhdavh indicating such.
CoatI t r that cheek this hox must anached an additional sheet showing the name of the sub-contractors-and their workers'comp. policy information.
l am its employer that is providing workers'caurpensation insurance for my employees. Below is the policy and job site
inJorIICCott.
Insurautce Comp;my Name: �L �/
policy k or Self-ins. Lie q:�( \) Mgc5 y 176/ Expiration Date: / — 5--o 7
Job Site Address: City/State/7_ip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
F;tihue to ccure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
title up to S I,5oo.00:nd/or one-year imprisonment, as well as civil penalties 1n the film of a STOP WORK ORDER and a tine
,it up to S25( 00 a day against the violator. BP advised that a copy of this statement may be forwarded to the Office of
III%Q,tivations of the DI:\ tar insurance ancrtge verification.
! du hereby e rt y a Jrr the pains and penalties ol'perjury that the in/itrmation provided above is true and nrrrect.
L-0 Date
--o//icial rise nnlY. Du not write in rhis area, to he rrn ipleted by city or rown official.
( in or Town: .
Is<uint; .\uthority Icircle ( ne):
I. Huard of Health 2. Building Department 3. Cih/Town Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
.q:---
Information and Instructions
\Ias.;Ic h u sous l icne rat Laws chapter I�' rrquuCS all emp lo%crs Ut pros ide workcn:+' compen.sanon for I lie ir employees.
PIHSU.Int to hits ,[ante„m rntplgree is Jawed as " c%ct person in tine set ice of another under anv anuract Of hire,
cypress or iinpIied. Oral or written.'
_A I etnphner is Ile 1ined ;IS "an ILoh ;dual. p,toncrship, association. corporation or other le,al entity. or any Iwo or more
,,I the foregoing engaged in a Joint enterprise. end including [he ]coal rcpresentatises of a deceased employer. or the
reecit cr or trust" Lot :in indic itl ua I. partnership. associm ion or other Ic_al entity, entplo%ing employees. IIowes er the
WA ter of a dwelling house hak ing w not In than lh m roe apartents and d ho resides therein. or the occupant of the
J%v ailing house of another who cmplovs persons to do maintenance, construction or repair work on such dwelling house
or on the __rounds ar huilding appurlcnall, d[ereto shall not bec:urse of such employ nte[It be Deemed Io be an employer."
\I(N. chapter I _', i2�C 10) also states that "C%ery 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, .%[(;L chapter 152. �25(:17) states "Neither the commonwealth nor any of its political ,ubdi%isions shall
enter into any contact for the performance of public work until acceptable e%idence of eumpliance with the insurance
requirements of [his 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) naute(s), addre.ss(cs) and phone numbers) 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 he sure to sign and date the affidavit. The affidavit should
be returned 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please he sure to fill in the permiv'license number which will be used as a reference number. In addition, an applicant
[hat must submit multiple pemti&license applications in any given year, need only submit one affidavit indicating current
policv information (if necessary) and under"Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidaJ it 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.c, a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The i ftficc of Investigations would like to thank you in ath'ance for your cooperation and should you have any questions,
picas do nor hesitate to give us a Call. _
I'hc Deparnncnt's address, [clephone and tax nuniher:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofilce of Investigations
600 Washington Street
Boston, MA 021 I I
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
lie%izeJ ,rt-us Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
`, i
PUBLIC PROPRERTY
} DEPARTMENT
'ri �,-U-'i;-�;ai • Fps: ;-i '+;.idu
Construction Debris Disposal Affidavit
(required Cur all demolition aid renovation work)
In accordance with the sixth edition of the State Building Code, "SO C`IR section 111,5
Debris, and the provisions ofNIGL c 40, S 54;
Ouilding Permit is issued with the condition that the debris resulting from
;leis work shall be disposed of in a properly Licensed waste disposal facility as defined by �1GL c
11. S 150A.
Vic debris will be transported by:
Inume of hauler)
I.e br,s will 'oe dis�oscd of in
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Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
-.� --
Registratin 5.: 326
'E�Cpirdfion 7/,2009
TWO e��"ud�ilementCard
ALPINE PROPERYixft& ,1"
RONERT WINTER§J` ,
11 WILSON STREET�'�':
SALEM,MA 01970 Administrator
it
IB FICA 155U A MA R OF I °
moOUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
H.1,Knight International imurance Agencies,Inc. VOIDER. THIS CERTIFICATE AFFORDED
DOER NOT AMEND,EXTEND OR
.500 Victory Road-Marina Bay
ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.
COMP FO OVERA
'North QOincy,MA 02121
co ArY Atlantic Charter insurance Co as VDAC
A
COMPANY
r
NSIden%tMA
Services Co.,Inc. s
Property DOMPu+Y
C
weet COMPANY
01970 p
T141V IS TO CERTIFY THAT THE POLICIES OF waURANCE UiTED BELOW HAVE BEEN gSUED TO THE NBURED NAMED ABOVE FOR THE POLJCT PERIOD _
DICATED.NDTWRH$TANDWO/WY RBOUDIEMEW,TERM OR COMMON OF ANY CONTRACT OR OTHER DOCUMENT Y REEPECT TO WHICH THIS
IN
C DicATEATE MAY BID ISSUED OR MAY PERTAIN,THE IN DURANCE AFFORDED BY THE POUCIEB DESCRIBED HEREW IS SUBJECT TO ALL THB TERMB.
EACLUSIOHB AND CONDITIONS OF SUCH POUCIEM WERE SHORN MAY HAVE BEEN REDUCED BY PAM C W MB.EFFECVVE UMRb
DO TYPE OF INSURANCE POLICY NUImER DATE(mwom T) DATE IMMODNYIN on mewem)
LTR
BODILY INJURY OCC f
GENERAL LMBILRY -
BODILYINJURYA00 f
OOMPREHENSNE FORM
PROPERTY DAMAGE OCC {
PREMWEyopmATIDNS
PROPERTY nAMAGE AGG i
VNDEMROLND
BI6 PD OOMBWED DCC i
E1PlOB101J A ODLUPSE HATARO
PRODUCTIPOOMPLETED OPFA BIBPC COMBINED A00 i
PERSONAL INJURY AGG {
CONTRACTUAL
INDEPENDENT CONTRACTORS
BROAD FORM PROPERTY OAMAGE
PERSONA INJURY
BODILY INURY
AUTOMOBA!LIABILITY
(Per person) i
ANY 4UT0
fl N Peas) BODILY INJURY
ALL OWNED AUT03(P j
rywAaaenU i
OWNED Auras
(DPgr BPR PAvab PauageO
HIREDAUTOS _ pROPETOY pAM4GE i
NONOWNED AUTOS BODILT IWURY A
PTtOPETfIT 0.aAKGE
GARAGE LIABILITY
COMBINED i
FACH OCOURRENCE f
"CM LIABILITY
AGGREGATE i
UMBRELLA POW
S
OTXPR THAN UMBRELLA FORM
YnmlMwcOasl MNA11D WCV00754901 1/5/200$ 1/5/2009 8*"T"T°"Y`WITs
DN 0L 4LDPILITY PAOH ADDIDENT f 500,000
DDTEASE-POLIOY LIMIT i 500,000
w6wa-EACHEMPLOYEE i 500.000
OTHER
DEb MON OF OPERATIONVLOOAnDNCYEM0LF31bPBOAL I 3
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
12 DAYS WRITTEN NOME TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
BUT FAILURE TO MAIL SUCH NOTICE SHALL IM PSE NO OBLIGATION OR LIABILITY
COMPANY,OF ANY KIND UPON THE CONY,ITS'AG -OR REPRESENTATIVES.
' AuanoRvsDR®wEaF�Gr°TIYE :.: r:: :�.
I
• IL
ACORD CERTIFICATE OF LIABILITY INSURANCE 7�`mND01yYYY) \
PRODUCER PFRN (TIONTL IN U (81T)857d112 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
KNIGHT INTERNATIONAL INSURANCE GROUP ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
MA VICTORY ROAD HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
MARINA BAY .ALTER THECOVERAGE AFFORDED BY THEPOLICIES BELOW.
- QUINCY MA 02171
( INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: FIRST MERCURY INSURANCE CO.
ALPINE PROPERTY SERVICES CO.,INC. INSURER B; -SAFETY INSURANCE _
11 WILSON STREET INSURER C:SALEM MA 01970
INSURER D:
INSURER E- •
COVERAGES
THE POLICIES E INSURANCE LISTED BROW HAVE BEEN ISSUED TO HE INSURED NANIED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REgUO2EMENT,TERM OR CONORION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PFRTNN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LRAITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAN&
wR TYPE OF INSURANCE T POLICY NUMBER P cv ERECTME POLICY IMPIRATION DMIT$
DATE MMN
GENERAL UABILJTY PMMA00186 06/14/07 06114/08 EACHOC URRENCE $ _ 1,000,000
X COMMERCIAL GENERAL LIABILITY OM1P[iETO RENTED $ 50,000
See(Fs mmrpmal
CLAIMS MAOE� OCCUR (A,MED.EW(A one Person) $ 1.000
PERSONAL 8ADV 01JURY S _ 1,000,0130
GENERAL AGGREGATE S 2,000,000
GENL AGGREGATE LBAIT APPLIES PER
PRODUCTS-COMPJOPAGG. s 11000,000
POLICY X JECT LOC
AUTOMOBILE LIABILITY 2702661COMOO 01/09/08 01/09/09
ANY AUTO COMBINED SINGLE LILnIT
(ED aeaDen) S 1,000,000
ALL OWNED AUTOS
BODILY INJURY
B SCHEDULED AUTO$ (➢tr pmsml) $ i
X HIRED AUTOS
X NON-0WNEDAUTOS BODILY INJURY $
(PxlsoDenq T .
PROPERTYOANWGE IS
IPee mddml)
GARAGS LIABILITY
IY S AUrooNLr-EAncC1DENT
ANY AUTO ,. -
OTHERTHlW FA ACC $
' AUTO ONLY: AGG 7
EXCESS I UMBRELLA LIABILITY CUMA000117 06/14107 06/14/08 EACHDCCURRENCE S 6,ODO,OGO
X OCCUR ❑CLAIM$MApE AGGREGATE S 6,00D,000
A � PJ( DEDUCTIBLE
$
RETENTION S 10.ODO $, S
IWORKERSCOMPENSATIONAND I WC STAN. OTDEA -
EMPLOYERS UAIMU" rDRvuwTP
ANYPRODryE1pRryARTNFItID{EIVTIVE E.L EACH ACCIDENT $
OFFI('ERIMEMDEREXCLDDEDa
uy..,Pasclmcl,nsu G.L.DISEASEFJ FJDPIOVEE S '
ePEPML AROVRIOM9 mbar
E.L DISEA$B•PGLKrY LIMIT S
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSIVE:HICLESI"CLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
_ EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVORTO MAIL 10 GAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE
TO 00$0 SHALL IMPOSE NO OBLIGATION OR LIABR ITY OF ANY MND UPON THE INSURER
IITS AGENTS OR REPRESENTATNES.
AUTHORIZED REPRESENTATIVE ,/(.��C��'���/'��
C--~� Haroltl�nighf V
ACORD 25(2001108) CerlMc$te III _ O ACORD CORPORATION 1988