11 PYBURN AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF
f d Board of Building Regulations and Standards SALEM
I � Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwellin
; This Sect1on'For 0 se''Only =' 3
Butt ing Per iut Number at pphed ", a
�t
.: .:
Boil Official(PnntNante) Date -
�Ys
g
SECTION 1. SIT
Ll P o ert Address: 1.2 A ses rs Map&Parcel Numbers
I� 1�1��)e -R��
-� Ma umber Parcel Number
I.1 a Is this an accepted street?yes_ no_ p
1.3 Zoning Information: 1.4 Property Dimensions: so
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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"Z�: PROPERTY OWNERSHIP':,"'
2.1 �Ownertof cord: _ vo
N �J
ame�G1(Printt) City, Stale,ZIP
CIS 1139t
No. and Street Telephone Email Addres
SECTION 3sDESCRIPTI6N OFPROPOSED WORK (check alhfh it'apply)
New Construction❑ Existing Build mg ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units \ Other ❑ Specify:
Brief Description of Proposed Work':
Y k OO
q i a5t A-1-
SECTIO 4: ESTIMATED:CONSTRUCTION C STS
Item Estimated Costs: Official Use Only f
Labor and Materials . r s.,.._
1. Building $ 1 Bulldmg PermttFeex$ Indtcatehow`fee is detematned:,:
❑ Standard CitylTown Apphcatron Fee '.
2. Electrical $ `
q TotaltProlect Cost (Item 6)x multiplier x
3.Plumbing $ 2 Othgr Fees
Lrst EIS f
4. Mechanical (HVAC) $ - ---�
5. Mechanical (Fire s •
Suppression) $ Total All Fees $
Check:No. Check Amount Cash Amount
6. Total Project Cost: $ w - ❑'paid n Full ❑ Outstanding"Balance Due
r
SECTION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
:7_7_
f CSL Holde
List CSL Type(see below)
No. and Street Type Descrtpnoo
.. U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 FamilyDwelling
City/Town, State,ZIP M Mason
ry
RC RooSn Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tefe hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFH)AVIT(M.G:L, c. 152r§ 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 .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION;TO BE COMPLETED WH ,EN
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION-
By
name below, I hereby attest under the pains and penalties of perjury that all of the information
t is Iication is true and accurate to the best of my knowledge and understanding.
CLor horized Agent's Name(Electronic Signature) Date
NOTES:.
er who obtains a building permit todo his/her own work, or an owner who hires an unregistered contractor
stered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be found at
ss.crov:'oca Information on the Construction Supervisor License can be found at www.mass.gov dos
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. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half%baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
�e
CITY OF SM-E.M
PUBLIC PROPERTY
DEPART N, LENT
W OWar eu+vr L
VArae I'�i' .7d,rrlap•1�11>4�tAlA01l iiTt7 01 f'0
HOMEOWNER LICLNSR EXE.I�tPTIO,V
Piety l►rfat
Date
lob Loeados 11
Home Owner Address
Fromm Owmsr Telephone 1
Present Mailing Address Qs. nt o
the current exemption of-Homeowners"was extended to inehde owner-occupied
dwaftsm of two Unite at teats and to allow such homeowners to eegap an individual for
hire who does not Posse ad a Ifeenso provided that the owner acts U supervisor.
DERNMON O/HOMEOWNER
Pawn($) who owns a partial of Lod on which hdshe reddest or intends to redde. on
which there iq or is intended to bs,a one or two &mily dwelling attached or detached
atruculm accessory to such use and/or rarm structures. A person who constructs mars
than one home in a two year period shall not be considered a homeowner, Such
"homeowner"shall submit to the Building OQleiak on a form acceptable to the Building
Official, that hdshe be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliamee with the State
Building Code and other applicable by6laws and reyuladons,
The undenigted "homeownce certifies that hdshe understands the City of Salem
8tulding Department minimum inspection procedures and requirements and that hdshs
.vill comply with said procedures and r uir
HOMEOWNERS SIGNATLRB E'n^ QX`'
APPROVAL OF BU/LD1VG LYSPECTOR �c
See other side for state coda
ACORD" CSR: Cc
�.= INSURANCE BINDER DATE(MM/DD/YY
_
THIS 10/24/2012
BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO_T_HE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
COMPANY 9530
John J Walsh Ins Agency, Inc BINDERq
P O Box 4407 Commerce_Insurance Company
Salem, MA01970-5QD] DATE_ EFFECTIVE—TIME �TEXPIRATION TIME
John J. Walsh Ins.Agcy., Inc. X AM �_� IME AM
__ __ 10/23/12_�2:01 �_ PM 11/23/12 -NooN
PHONE - FAX 978-745-9557__— ---
_ Ext)_9]8_745-330D _L(AIC,Nof_ _ __ THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY
CODE: 947 SUB CODE__ PER EXPIRING POLICY#:TO BE ISSUED
AGENCY pETRR01 ---------CUSTOMER ID: DESCRIPTION OF OPERATIONSNEHICLES/PROPERTY(Including Location)
INsuRED Marie Petrucci 11 Pyburn Ave Salem MA 01970 Essex
52 Nahant Rd
Nahant MA 01908
COVERAGES
__ TYPE OF INSURANCE LIMITS
PROPERTY _ LOVERAGEIFORMS DEDUCTIBLE COINS A AMOUNT_
CAUSES of Loss A. Dwelling — _ _..
— BASIC D BROAD � SPEC B.Other Structures 270000
C. Personal Property
- -- F. Liability
500000
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAA TO—
RENTED PREMISES $ _
_-1 � CLAIMS MADE OCCUR ---
MED EXP(Any one person) g
'PERSONAL&ADV INJURY_ $
GENERAL AGGREGATE S
PETRO DATE FOR CLAIMS MADE. -- -- 1
AUTOMOBILE LIABILITY PRODUCTS-COMP/OP AGG $
ANY AUTO
COMBINED SINGLE LIMIT__I $
ALL OWNED AUTO 1
BODILY INJURY(Perperson) S
S -
BODILYINJURV(Peraccitlent)
SCHEDULED AUTOS
HIRED AUTOS PROPERTY DAMAGE
$
NON-OWNEDAUTOS MEDICAL PAYMENTS $
-
PERSONAL INJURY PROT S _
UNINSURED MOTORIST g
AUTO PHYSICAL DAMAGE $
DEDUCTIBLE J ALL VEHICLES SCHEDULED VEHICLES
— ACTUAL CASH VALUE
COLLISION:
OTHER THAN COL:
STATED AMOUNT S
GARAGE LIABILITY OTHER
AUTO ONLY ACCIDENT S
—_I ANY nuro
OTHER THAN AUTO ONLY
E___(CIDENT S
EXCESS LIABILITY AGGREGATE 3
UMBRELLA FORM EACH OCCURRENCE $
AGGREGATE
OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: S
SELF-INSURED RETENTION $
WORKER'S COMPENSATION WC STATUTORY LIMITS
AND E.L.EACH ACCIDENT EMPLOYER'S LIABILITY S 1
E.L.DISEASE-EA EMPLOYEE S
SPECIAL E.L.DISEASE-POLICY LIMIT $
CONDITIONS/ FEES
OTHER S
COVERAGES TAXES $
NAME&ADDRESS ESTIMATED TOTAL PREMIUM $
MORTGAGEE —I�ADDITIONAL INSURED
_ LOSS PAYEE
LOAN# —
AUTHORIZED REPRESENTATIVE)HN J.WALSH INSURANCE
John J. Walsh Ins. Agcy.,
\CORD 75(2004/09) NOTE: IMPORTANT STATE INFORMATION 0N REVERS IDE c ACt6 RDe0C0 PORATION 1993-2004