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5 QUADRANT - BUILDING INSPECTION
�1 The CommonwealthoFMassachusetts R CE(1( Board of Building Regulations and Standards INSPECTI 5NAL OF G Massachusetts State Building Code, 780 CMR SEE$ +5(' TT�� qq -RevisedlMo-2011 Building permit Application To Construct, Repair, Renovate Or DerrhS1�91n�P —3 P 5 One-or Tivo-Fancily Dwelling This Section For Offici2nse Only Building Permit Number: Date pplied: Building Official(Print Name) Signature Date SECTION I:SITE INFORMATION 1.1 Procter Address: 1.2 Assessors Map& Parcel Numbers S 1.1 a Is this an accepted street'1 yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arca(sq Il) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Sidc 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 disposed system ❑ Cheek iryes❑ SECTION 2: PROPERTY OWNERSIIIPt 2.1 Own 'of Record: Name( nnt) City.; 1 — No.mtitY;trwt I'eleplmo, Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work'-:_ _ '�D( �;, _ ' SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official U Only Labor and Materials) Use n Y 1. Building $ 1. Building Permit Fee: S Indicate how fee is determined: 2. Electrical $ ❑Standard City/town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: 4. I'vlechmtical (I IVAC) $ List: ryL U 5. Mechanical (Fire Su ression) S Total All Fees: Check No. Check Amount:_ Cash Amount: 6. Total Project Cost $ (, ❑ Pahl in Full ❑Outstanding Balance Due: — I'. UDC. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSC) - L / Fr > _ �tiww License Nuntbcr Ezpiratwn Dute Name of CSL Holder List CSL'Type(see below) r Ne.and S reet� Type Description Al /' Unrestricted(Buildings u l0 35,000 cu. ft.) r' I '� I R Restricted I&.2 Family Dwelling Cityffown,9tate,ZIP / M Mason ry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances II Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Regis ration-Number Expira ion Date HI ' yoLm an N1me�'r�II I I C Registrant Na ne (/ / �y y�'q No.an\SI.�F( �� v J ��.tj 69 Y'(�S�fL/z�l�i/! Email address City/Town,State,ZIP le phone SECTION 6:WORKERS'CONIPENSATION 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 Issuance of the building permit. Signed Affidavit Attached? Yes ........ No........... ❑ + SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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: OWNEW 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 application is true�and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Dr tc 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 FIIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.kov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. If.) (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 halt/baths Type of heating system Number of(leeks/porches Type ofcooling system Enclosed _Open 3. "Total Project Square Footage may be substituted for"Total Project Cost' Q-1-Y OF Siu2m ANSSACHUSE1TrS BL:IL DtNG DEPARTMENT 3 4 fIl SI 120 WASHLNGTON STREET, 391 FLOOR TEL (978) 745-9595 F.kX(978) 740-9846 KlNiBERL F-Y DRISCOLL "StALYOR T HOxLxs ST.PIF—Vz DIRECTOR OF PL'OLIC PROPERTY/BUILDING CO-,[MISSION ER Workers' Compensation insurance Affidavit: Builders/Contractor.v/Electrlcians/Plumbers A a ilicant Information / Please Print Le ibl Natlle (ilufinessOrgani¢atiom�lndividual): kif �(/ 'e f r Address: IQD �A 82ti676,1 S7- City/State/Zip: Phone #: r Arc you on employer!Check the appropriate box: F10.0 roject(required): I. 1 am a employer with. 4. ❑ 1 am a general contractor and 1 employees(full and/or patt-timo).' have hired the sub-contractors construction i 2.❑ lain a sole proprietor or partner- listed on the attechcd sheet. t odeling .hip and have no employees These sub-contractors have olition working for me in any capacity. workers'comp, insurance. ding addition [No workers'camp. insurance 5. ❑ We are a corporation mid its required.) officers have exercised their «ical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repuirs or additions myself. (No workers'sump. C. 152, §1(4),and we have no 12.❑ Raof repairs insurance required.) t employees. (No workers' 13.0 Other cutup.insurance required.) •,Any arilltw ad that checks boa AI must also NI out the ecution below showing their worker'cumpenaariun put icy inllannatiun. 'I lommtwncn+rho wlnuil this a lilwir indicating they arc doing all work and then hire uunido eentracton muct auhmit a new antdavil indicating such. :r'emmcturs thal check this box most anachw can adduiunal eh.1 showing Ilse mane of oho subruntneton and their worken'camp.pulley infurmalian. l ant an employer that is providing Ivorkers'compeaxailon insurance for my empluyeer. Qeluly is oho policy sadjob she llrfarat Allan. "�� / f Insurance Company Name:,_4� (�,� Pulic 4 car Self-ins. Lie. 0: t Y "'E.�p Ira ion Date, Jub Silt Address: City/State/zip: Attach a copy of the workers'compensation policy declaration page(showing the pulley number and expiration date). Failure to secure coverrge as required under Scclion 2SA of MGL c. 152 can lead to the imposition ofcriniinal penalties of a tine up to S 1,500.00 and/or Oise-year imprisonment,as well as civil penalties in the term of a STOP WORK ORDER and aline of up to 525000 a day against the violator. 13e advised that a copy of this sralemcnt may Ix: I'unvardcd to the Office of I it vc;l i gal iun.v cal the 0IA for insurance co vcrige vcri tical ion. 7 /do hereby certify under the pubis and penulties of perjury that the infuratutlon provided above iv rrue card correct 011h iul use Only. Du not wrile in lhir area, tube completed by city ur town a/jicla2 City nr Town: ____ ___ Permitll.lcenac,Y !suing Aulhurily(circle one): —_ -- _-- -- I 1. Board of Ileallh 2. Building Departutcia 1.Citylrnau Clerk t, rieetrical luspcctur S. Plumbing luspeetur 6. Other Cis nl act I'c nun: Phone lt: CITY OF SALEM, MASSACHUSETTS �� BUILDING DEPARTMENT 120 WASHINGTON STREET,311D FLOOR TEL. (978) 745-9595 KIMBERLEY DRISCOLL FAX(978) 740-9846 MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: k2-(( �t (name of hauler) The debris will be disposed of in: Y42 a 124(d2 40 yC� (name of facility) (address of facility) Signa ure f pplicant G D e _. V/LB lOM)IiOLMt(I/C(!�[1t:O�Vl��A1(RC�L!(JCGC- Oftice of Consumer Affairs&Business Regulation 9- ME IMPROVEMENT CONTRACTOR gistration: ,123553 Type: xpiration 3/6/2015� DBA Preserve Painting Ei Sean O'Connor ', " 203 WASHINGTON ST-#256-,,'• SALEM,MA 01970 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Constructions, sor License' CS004Q3 AIIII SEAM OCONNOR= 26 CHESTNUT ST SALEMMA 01990 Expiration jy3112015 .. Commissioner 1 1 A008Du CERTIFICATE OF LIABILITY INSURANCE DATE(M1iM DD/YYVY 08/07/2014 PRODUCER (978) 745-6469 THIS CERTIFICATE IS ISSUED A5 A MATTER OF INFORMATION Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 66 Lorin Avenue HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR g P.O. Box 958 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC 4 INSURED INSURERA:WESTEELN WORLD INSURANCE C Kyron Inc. dba Preserve Services, INsuaeR B.Hartford 203 Washington Street #256 INSURER c,Travelers INSURER D.Great American Salem MA 01970- INVJRERE. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOP,THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR A00'L POLICY EFPF_CilVc POLICY IXPIRATION LTR INSRD TYPE OF INSURANCE POLICYNUMBER DATE(,MMIDDAN) DATE(MM1VODIYY) LIMITS A GENERAL LIABILITY NPPS236095 05/22/2014 05/22/2015 EACHOCCURRENCE IS 1000000 X COMMERCIAL GENERAL LIABILITY GAMAGETORENTED 100000 CWMS MADE ❑OCCUR / , / / MED IEXP(Any ene C=erson) S 5000 PERSONAL S ACV INJURY $ 1000000 GENERALAGGREGATE $ 2000000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOPAGG 6 2000000 X POLICY MOT I LOc I , , / C AUTOMOBILE LWBILIT Y 46BC85787 06/05/2014 06/05/2015 1 COMBINED SINGLELIMT ANY AUTO (Ea eccdw) $ 1000000 ALL OWNFD ALTOS , , / , BODILYINJURY SCHEDULED ALROS (Per persm) S X HIRED ALTOS f , , BODILY INJURY X NONAWNED AU I'OS (Pereccweno S PROPERTY DAMAGE (PeraccNent) S GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO , , , , OTHER THAN EA ACC $ ALTO ONLY: AGO 5 D ERCESSIUMBRELLA LIABILITY ZES0040350 06/01/2014 06/01/2015 EACHOCCURRENCE 5 2000000 OCCUR OCUIMS MADE- AGGREGATE S 2000000 DEDUCTIBLE RETENTION S 5 $ WORKEMPLOYERS' SCOMPBILITY NAND 6S60U30523NO0914 05/20/2014 05/20/2015 $ WC STATU- OTH- ANYPR ERI LIABILITY TOR Y LIMITS ER OFFICER EMUFREXCLUDR�XECUTIVE EL EACH ACCIDENT S 500000 OFFIGERRNEMBER EXCLUDED' E.L DISEASE- ES EA EMPLOYE 500000 If Yes,describe under � � � � SPECIAL PROVISIONS beb E.L.DISEASE-POUCYLIIIIT IS 500000 OTHER DESCRIPTION OF OPERA7ION540CATIONSIVEFIICLES/ERCWSIONS ARCED BY ENDORSHIENT1SPCCIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION — SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THC ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Mr. Paul Martin FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 6 Irving Street INSURER,ITS AGENTS OR REPRESENTATIVES. Brookline, 1,M AUTHORIZED REPRESENTATIVF-) I AcoRD zs(2001/09) ©ACORD CORPORAnON T9s6 INS026(0)LW),II6 Page i of 2