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6 QUADRANT RD - BUILDING INSPECTION (2) yy -Gz The Commionwralth of Massachusctts Board of Building Regulations and Standards Ft Ht ° \It NI( IP AIA I ) l Massachusetts Slate l3uilding Code, 7SO ('MR, 7 edition I.tiI: Bltildin', Permit Application To Cunstrurt. Repair. Renovate Or Dcntuli,h ;l Krr� rJhirl"'11 l One or Tntt-Fru)tih Durllrtt,q This Section For Official Use Only - Buildin_ Per ?lumber --- P _ / ✓d° Si_nalure: -- --- --- B Ili ine Cnuunieaoned I tec�ur of Buildings Dale _— SECTION 1: SITE INFORNIA FION LI op rerh .\dd 'ss: I? :\ssesurs MapiE ParCCI Number L la Is this an accepted sheet? yes _ nu \lap \'umber I'anrl \'wnher 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Isq 11) Fruntage Iit) 1.5 Building Setbacks (ft) j Front Yard Side Y aids Rear Y'aid Required Pruv ided Required Provided RCLIL; J Prue tdcd I 1.6 Water Supply: CM G L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone" Ntunici al ❑ On site disposal sy>icin ❑ Public❑ Pri%ale ❑ Check if ves❑ P SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner ofRecord: /' Name (Print) Address Ibr Service. Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) IL El _ ddition Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other AL Specifys)``'4J J _ Brief Ders�cripti In of Proposed Work': Terv—['�✓e�� +-� �6 ���'0"— !��' �Q•�% SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item (Labor and Materials) _ I. Buildin_ S I. Building Permit Fee: $ Indicate how fee is dcler turned: ❑ Standard City/Town :Application Fee 2. Electrical 5 ❑ Total Project Cost` (Item 6) x multiplier x t 3. Plumbing 5 '. Other Fees: .S 4. Mechanical IHVAC) .S I List: 5. Mechanical (Fire S T Su t ressiun) oral :All Fees: S Check No. Check .-Amount ('ash :Amuwtc - b_ Total Project Cost 5 3 S00 0 Paid m Full ❑ Outstanding BaLuxe Due: SECTION 5: CONSTRUCTION SERVICES 7r (A truction Supervisor (CSL) Lircn,e \'uinher I:Xnr:wnn Daly r5 `� , aLi,t CSLI\'pe I.ee hclo%c- '1\ c Description 1. l:nrrslnncd w p to ti.000 Cu. I:t_t R Restnaed I&_' Famth Dtt ellinc Sgi¢nat rrc `� ^7 �q Masonry Only RC Rea denttal R no title C ,\conc Telephone \\'S Readenull \1'mdwt .md Sidut_ SF Re,idvoual Solid Fuel litimim, V >plianrr I11,1,1 M-n D Rcadaulial Demolition i._ Re is ed 1lonie Im ro 'omen[ Co rat[ r (IIIC) /-5 FIIC�;,lmtpany Nam•or IIIC Registrant Name Rcetstr atiun Number f {ram .1 r"tA— OeTFO g/ZI �'� O O� Gxptrauun Date Stgm ore Telephone 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. F:ulure to pro,,idc this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached" Yes .......... O No .........elgr- SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, /�O�e - /� f CXg as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to wo :wtf 'ized by th=builgpplication. Signature of Owner Date fJ / SECTION 7b: O(W')NEW OR AUTHORIZED AGENT DECLARATION 1, j� (7 C y— �� O�� as Owner or Authorized Agent herchy decline that the statements and information on theO foregoing application are true and accurate, to the best of my knuwledoie and behalf. D� 1 Print .Name Sienaurre o(Ownrr or Authorized Agent Date (Si mcd under the _uins andpenalties of era ) NOTES: 1. An Owner who obtains a building permit to do his/her own work, or :In owner who hires an tmre�_istered contracwr (nut registered in the Home Improvement Contractor (FIIC) Program), will not have access a) the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC ProLr:nn and Construction Supervisor Licensing (CSL) can be found in 730 CNIR Regulations 110.R6 and 110.10, respectively. '. When substantial work is planned, provide the intirrmaion below fatal flours area(Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living urea (Sq. Ft.) Habitahle ruurn count Number of tireplaces Number of bedrranni, Number of hathroorns Number of halt/bath, _ -- fvpetit heating system _ Number tit decks/ porches Type of cooling systern Enclosed Upon 3. "Total R�tject Square Pootagt' may be substituted fur 'Total Project C'ust" CITY OF SALEM PUBLIC PROPRERTY �*�t DEPARTLIENT �Ft 978-TY 7=)i97 � I°�'1:978 7437d46 Construction Debris Disposal Affidavit (required Cur all demolition uid renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MCL c 40. S 54; Duilding Permit N.._ _ is issued with the condition that the debris resulting from (his work shall be disposed of in a properly licensed waste disposal facility as defined by VIGL c 111. S 150A. The debris will be transported by: (11J(ilC Jn haular) he debris will be disposed of in : CITY OF SALEM PUBLIC PROPRERTY 3 sl�ir DEPARTMENT - Vt.U::K I_'� �`:.AdllVlr�:�'S;itlPl ♦ b.AI i'V, fit.A��.At l(1 CI-I t, .l'/'� NN'orkers' Compensation Insurance Aflidacit: Builders/Contractors/Electricians/Plumbers t tlicant Information �J JJ I'lease Print Legibly �i allll t liusmc>: t h'g.tntiau�m InJn iJu.d 1: RID 6E eeP cj`cee rR 4 \.ILIre,S: 7 C'ity,State;Zip: � �� �,' a�970 Phone : 9 7� 3l .i,rc you an employer" Cheek the appropriate box: 'rope of project (required): I.❑ 1 aut a employer with 4. ❑ I :un a general contractor and ( 6 ❑ New construction employees (full and/or part-time).* hate hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship ;cod have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity workers' comp. insurance. q. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.0Electrical repairs or additions required.] officers have exercised their right of per N1GL 11.0 Plumbing repairs or additions i.❑ exemption 1 an a homeowner doing all work g Pon P' myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] r employees. [No workers' 13 ❑ Other comp. insurance required.] \uv applicant that che,;ks box.41 must also till out the section below showing their workers'compensation poi icy information. ' I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit anew affidavit indicating such. ('onvactors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'cutup. policy information. /urn an employer that is providing workers'compensation insurance for trey employees. Below is[he policy andjob .site information. Insurance Company dame: Policy # or Self-ins. Lira. #: Expiration Date: .Job Site Address: (o (QV,(r!1 lnnrF.C7— �`^e City/State/Zip: S`4 If'.F -" O/V 70 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 25A of�IGL c. 152 can lead to the imposition of criminal penalties of a tine up to S I.m.00 and/or one-near imprisonment. as well :Is civil penalties in the firm of a STOP WORK ORDER and a fine ,it up to 5250AM a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Ins c,tiu;u ions of the DI:\ for insurance cos crtge ceri ficano n. 1 du hereby re�unthr ant/penalties ofperjury that the injirrnrution prtrvitled above is true arts/correct-Date _ f�— 2t�'°s I1 c olliciul use only. Do not write in this area, to be congrleted by city or town official. Issuing .\uthority (circle one): CitylTuwn Clerk 4. Electrical Inspector 5. Plumbing Inspector I. Board of Ilealth 2. Building Department J. 0. other --- Phone #:_ Information and Instructions ,,I.i"a,husc Is (irncrtl LawS chapter I requires all cmplo%ers m provide cvorkers' compensation lix (heir employees' I'asu.ut to this >(atute, an ernpluIce is dcIl nerd as '._e%er% person in the Scrcice of:mot lie r under any contract of hire. cypress or implicJ, oral or %sri(tcn.'- \n emphol er is detined as "an indi� dual. parnership, association. corporation or other legal entity. or any MO or more of the foregoing engaged in a joint enterprise, and including (he legal reprcscntatit es of a deceased employer, or the rccei�cr or trustee of an individual, partnership, association or other Icgal cuti(y, employing cmployees. I lowecer the o��ncr of a dwelling house having not More than three apartments and tvho rcSidcs therein, or the occupant of the Ik%elling house of another who employs persons to do maintenance, cuns(ructiun Or repair work on Such dwelling house or on (he ,rounds or building Appurtenant I ereto shall not becAUSe of Such employ ment be dee(ned to be an employer." %1(IL, chapter I i2, §2 C'Ili) also states (hut "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, M6L chapter 152, §250 7) states "Neither (he cc)nunonwea I th nor any of is pal ideal subdivisions shall enter into any contract for the perfia-ntmuc Of public work until acceptable evidence of compliance with the insurance rcquirentens of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the bares that apply to your Situation and, if necessary, supply sub-contractors) name(s), address(es) and phone number(s) along with their certificates) 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 dues 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 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 (hat 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 till in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple perrttitilicense 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 (own)." 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.c, a dog license Or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give is a call. - I he D) paitmcnt's address, telephone and I:(.t number: The Commonwealth of Massachusetts Department of Industrial Accidents OfIIce of Investigations 600 Washington Street Boston, MA 0211 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE I(c�iSed �-_'o-US Fax # 617-727-7749 www.mass.gov/dia 4/14/2008 9:49 AM FROM: Fax Gerald T. McCarthy Insurance Agency, Inc. TO: 1-978-740-9846 PAGE: 002 OF 002 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE Odla20008 M. PROOUOER • Phone: (9e)7416433 F. (978)7443575 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION GERALD T MCCARTHY INSURANCE AGENCY,INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 92 NORTH ST HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P O BOX 839 At r R TRIP TF RIP QQUTiRArF SALEM MA 01970 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: SCOTTSDALE INS CO ROBERT RIDGE INSURERS DBA RIDGE REMODELING INSURER C: 6 CLARKE STREET SALEM MA 01970 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 REOUIREMEN". TERM OR CONDITION OF MY 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDT TYPE OF INSURANCE POLICY NUMBER POUCY EFFEOTNE poucv EXPIRATIONLiR INSRO DATE MMND/YY DATE IMNDrYY LIMITS GENERAL LIABILITY CLS1445400 10/20/07 10/20/08 EACH OCCURRENCE $ 1,000,000 [ COMMERCIAL GENERAL LIABILITY DAMAGE To RENTED $ 50,000 PREMISE$Ee...Yer" CLAIMS MODE O OCCUR MED.EXP(Any one person) $ 5,000 A PERSONAL 8 ADD INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTSCOMP/OP AGG. $ 2,000,000 POLICY JECCTT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Eaacddent $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA Acc $ AUTO ONLY'. AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND vm sTATLL GinER EMPLOYERS'LIABILITY mRv UMITS ANY PROPRIETOR R/E%ECIITIVE E L EACH ACCIDENT $ O FFIC ER/MEMB ER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ dbgdnbe under SPECULL PROVISIONS below EL.DISEASE-POLICY LIMIT $ OTHER: DESCRIPTION OF OPERATIONS/LOCA IONSIVEHICLES/EXCL SIONS ADDED BY NDORSEMENT/SPECIAL PROVISIONS CARPENTRY CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY HALL EXPIRATION DATE THEREOF, THE ISSUING INSURER WI ILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED To THE LEFT,BUT FAILURE TO SALEM,MA 01970 DO SO SHALL IMPOSE NO OBLIGATION OR LIABIL ITV OF MY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ,,��JJ����// //// Attention: /1Ude691 T rnKs`�iF ACORD 25(2001108) Certificate# 2871 ©ACORD CORPORATION 1988 / 330�