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87 PROCTOR ST - BUILDING INSPECTION 2- Ll00 The Commonwealth of Massachusetts CITY OF ;�.. Board of Building Regulations and Standards SALEM 0Yi Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official-Use Only, Building Permit Number- DateApplied: -) f Building Official(Print Name). Signature me SECTION 1:SITE INFORMATION 1.1 Propert Address: L2 Assessors nVlap& Parcel Numbers fro 2R S Z- - I.1 a Is this an accepted street?yes f no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq tl) Frontage(11) 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'' 2.1 On rt of Record•w7p� 0 a N�ffl-e(Print) r�— City,State,ZIP g !�✓a�fo✓ Sf- �i32,V No.mid Str et Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building caner-Occupied epairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units ` Other ❑ Specify: . Brief Description of Proposed Work': Y.Ox tsx 1,J SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials 1. Building $ p O C�> 1. Building g Permit Fee:$ Indicate how fee is determined:. 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier xx 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (FIVAC) $ List: - 5. Mechanical (Fire $ t Su ression) Total All Fees:$ �y Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ V 6>� ❑paid in Full ❑Outstanding balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) IM l.-UZ Y� lP l,04 License Number E.xpi ation Date Name of CSL [folder —�T V List CSL'fype(see below) (A x �C) >x DL Type N Description. - ). and Street U Unrestricted(Buildings up to 35,000 cu. 11.) R Restricted 1&2 FamilyDwelling City fown,S a att n ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances (9f7��b l��f.� �j(cj/ /pc9rou �CO I Insulation Telephone Email addrrMs C014, D Demolition 5.2 Registered Home Improvement Contractor(HIC) // 2 9 2 S— HIC RegistrationNumber Expiration Date HI 'Company Ny,41n nr HIC Registrant Name / f •e v r-,C 3 °/�VObaetnixQ ouGt��/�1 �• t . Nip. , rd Street �� —' Em ' addr ss City/Town,State,ZIP 'rele hone 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 Wuance of building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN; OWNER'S AGENT OR CONTRACTOR R/APPLIES.FOR BUILDING PERMIT /I, as Owner of the subject property,hereby authorize mot Z tg4W! try act on my behalf,in all matters relative ''to__work authorize— d b—y this permit application. G� MR Owner's . n Electrons ignature) %-J t Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this. lica ' is true accurate to the best o y knowledge and understanding. Pri r Au{ho 'zed Agent's Name(�lecuo ' Si moire) Da e 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 can be found at www.mass.�>ov:'oca Information on the Construction Supervisor License can be found at wwsv.mass.eovAlps 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. R.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of healing system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 010i CITY OF S:U-E)m5 , L1SS:ICHUSETTS �LI1 BUIfG DEPARTNIEDIT 120 %YJASHLYGTON STREET, 3"'FLOOR TEL (978)743-9595 F.tr(978)740.9846 KINtBERLHY DRISCOLI THo:*wST.P[ERRz MAYOR DIRECTOR Of PUBLIC PROPERTY/13I:ILD4`1G COSL\fI5S10.iER Workers' Compensation insurance Affidavit: Builder&/Contractorv/Electr(c(ansiPlumbers Alflslicant In(ortnrtlon ,�Q Please Print Leeibly Name(0usii%s&organiratiorvlmlividual): � Ga r .1.P,(,I a Address: QV t)77 / e+-� City/Statc/Zip:��4Q1A_I• M o Z1'�� Phone#: ( ( 7 Are y9ei an employer?Check the appropriate box: Type of project(required): 1.C31 am a employer with Z 4• ❑ 6.I am a general contractor and 1 ❑Newconstruction employees(full and/or part-time)." have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheaL t 7• Remodeling ship and have no employees These sub-contractors have a. ❑ Demolition workingfur me in an capacity. workers'camp.insurance 9 . y p ry. ❑ 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.❑ i am a homeowner doing all work right of exemption per MGL I I.[]Plumbing repairs or additions myself.(No workers'comp. c. 152,41(4y,and we have no 12.❑ Roof repairs insurance required.]t employees.LNo workers' 13.0 Other comp:insurance required.] •Any applicant that checks boa el most otw rill out ilia waloo below showing their workers'camper a flon pulley iroo motlmr. 'I hvneuwne,who submit this affidavit indicating they am doing all work and then hire outaidocontmctem meal submit a now arlldavit indicting such. !Conlruclun that chink this best most anachod an additional shoes showing the time or the oYb.contragom and their workers'camp.policy infamunon. lam an eurpluyer shut is pravfdlttg workers'eamptasatlon htsur ancefor my employees Below is the pulley and fob site %Ilfallll4lfatf. Insurance Company Name: Policy U or Self-ins.Lie. N: Expiration Dote: 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 23A of NIGL c. 152 can lead to the imposition of criminal penalties of a line up to SI.S00.00 and/or one-year imprisonmenq as well as civil penalties in the form of it STOP WORK ORDER and a line Of up to SM.00 a day against ilia violator. Ile advised that a copy Of this statement may be forwarded to the Office of Investigmiwty of ilia DIA for insurance coverage verification /doe horeby ctrt! It die t if f t Me ary that the hlf aelar provided above is true and ca"ect. I i'= )at P r 1 ( 2 C f7JJiciu! ae unfja Oa not write in dais urea,m be completed by city at town offlcluL I City or sown: PermitiLlceme4 ____ 6suing Aulliorily(circle one): I. Board of Health 1. Building Department 3.Cilyfrown Clerk 4. Electrical Llspector 5. Plumbing Inspector 6.0ther -- __—.- - i Contact Person: Phone th ( CITY OF SALEM, TNL-us kCHLSETTS BuiwetG DEPARTMENT 130 WASHINGTON STREET, 3iiO FLOOR T .L. (978) 745-9595 FAx(978) 740-9846 Kl,,iBE FY DRISCOLL T ,LiANYOR HOsw ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILDNG COSOQSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5 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 wilt be transported by: -e0 s a" Lt,nA (nhauler) The debris will be disposed of in ( me of facility) (address of facility) C 'ifmture of permit applicant � 3 d e Jcbri;al�:.l,k OP ID: LC s��oRo' CERTIFICATE OF LIABILITY INSURANCE DATE(M 10105112YY) 5/12 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 978-975-1300 CONTACT Segrevs&Hall Insur.Assoc.lnc PxDNE 305 North Main St 978-975-7596 AIC No Exl: AIO No: Andover,MA 01810 EMAIL ADDRESS: Lawrence J.Hall PRODUCER LEUNG-1 CUSTOMER,, INSURERS)AFFORDING COVERAGE NAICN INSURED SKY PHOENIX CONSTRUCTION iNSURERA:A LM. Mutual Ins.Co. MICHAEL LEUNG INSURERB:Arbella Protection Ins.CO. 41360 PO BOX 243 INSURERC:Zurich-American - BOSTON,MA 02127 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 -Da 9M TYPE OF INSURANCE POLICY NUMBER MWDDYEFF. MNOIIOOD E%P LIMITSLTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 B X COMMERCIAL GENERAL LIABILITY 8500054536 03/05112 03/051/3 PREMISES Ea occunenca $ 300,00 CLAIMS-MADE FXI OCCUR MED EXP(Any one Person) $ 5,00 PERSONALBADVINJURY S 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY X PRO jECTLOG S fB TOMOBILE LWBILITY COMBINED SINGLE LIMIT 8 1,000,00 03121/12 03/21/13 (Ea acaeenp ANY AUTO 6500054536 BODILY INJURY(Par Person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIREDAUTOS (Per accident) NON-OWNED AUTOS 8 $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,00 EXCESS UAB CLAIMS-MADE 4600054865 03/21112 03121/13 AGGREGATE $ 5,000,000 DEOUGTIBLE RETENTION 8 10,000 $ WORKERS COMPENSATION X TO S IMTIT OER AND EMPLOYERS'LIABILITY 05/06/12 05106/13 EL EACH ACCIDENT $ 100,00 B ANY PROPRIETORIPARTNERE ECUTIVEY� NIA 601439201 - OFRCERWEMBEREXCLUDED? El DISEASE-EA EMPLOYEE $ 100,00 (Mandatory in NH) If yes,eescdbe under E.L DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS below C Builders Risk ER70956443 uw21112 03/21/13 Building 300,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHO(JWED R \/E�PRESENTATIVE HO V t_ I4p� ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Massachusetts- j Public Saret Board or Buddinnd Standards Constructionicense License: CS 93609 —�^^ -.MICHAEL d+CEUNG-PO BOX 2 3.'�SO BOSTON, MA 0212n: 10/16/2013: 7783 Office o onsumer aas a mess egu anon _ HOME IMPROVEMENT CONTRACTOR Reg istrauon onya5112g Type: xpiration 9f25/2Q14 Individual U!Q 'LE EE EUNGy i ............. = lf MICHAEL LEUNG�`� 67 FEDERAL AVE. QUINCY,.MA 02169 � �'% Undersecretary