6 RAYMOND AVE - BUILDING INSPECTION a The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 C MR, 7'"edition Revised Ju umry
I I Building Permit Application To Construct,Repair, Renovate Or Demolish a /• 10014
I V� One-o Ttvo-Family Dwelling
(yn r is Section For Official Use Only
FJ Building Permit Number: ate A lied: 2i
Signature: - 11
3/7i1�I
Building Commissioner Inspecio o ulld Date
',SE TION 1:SITE INFORMATION
1.1 Prope Address: 1.2 Assessors Map 8r Parcel Numbers
I.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard - Side Yards Rear Yard
Required Provided Required Provided Required Provide)
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ p Po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 9wnerr,pf Record: /�d 4 e y �,�.
//4fl4Ir iV�///t r-�l� 7 � �_�j
Name(Print) Address for Service:
22-2 2
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check ali that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑' ReQairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMcial Use Only
Labor and Materials
I. Building S 7�d0 0 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) s List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ���. 0 13 Paid in Full O Outstanding Balance Due:
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 1"8177 `L�'2 / Z
k/e w � /�n y/I/ 3' License Number Expiration Uate�
Name of CSL-I I older �++�4-�
D dlc/ / n /et List CSL type(see below)
Addressr' Description
/ U Unrestricted(up to 35,000 Cu.Ft.
R Restricted IB2 Family Dwelling
Signat M Masonry Only
RC Residential Rouring Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin A liance Installation
D Residential Demolition
5.2 MereQ,Harr �emeot Contractor(HIC) 3
�� C-1`i/urcH C Rn is egivration Number
f IIC pan M
Address
S^3 s���Nj6 Expiration Date
Sigmu Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .........'-U—' No...........O
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.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
e11eexaA ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signalurc ner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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_W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/anics,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
1. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SM-E.`I, NLkSSACHUSETTS
BLMIMIG DEP.\RTSI&r r
"a 1_0 W.\SNL-IGTON STIM. !'a FLOOR
TEL (978)745.9595
FAx(978) 1i498U
KIN(HEAZY ORI5COlL THOAW ST.Pl21:RRs
MAYOR DIRECTOR OF PL BLIC pROPERTY/eVI DLNG COMMSSIONER
Workers' Compensation Insurance,%Mdavit: Builders/ContractorslElectrlclanslPlumben
a / Ileant Infnrmatloa Please Print Ledbll
Vatte ItluaorwvaOr�ativatiolrlotJtvodual): �
Address: U 9!�, i; 2 r
City/State/Zil 4C2 F PhoneN:
\re yoe as rain 9 Check Ike appropriate boss Type of project(required):
1. am s employer with e. Q 1 am a general contractor and 1 6 ❑New construction
employe"(lldl and/or pat-time)•• have hired the sub-eauaetor
2.ClI am a Soleproprietorpartner-du partner- listed an the ansehad chew : 7. Q Remodeling
+hip and love no crnployeea Then sub-contactors have s. Q Demolition
working for me in any capacity. worker'comp.insolence. 9. Q Building addition
(No workers'comp, insurance S. Q We are a corporation and is 10.❑Electrical repairs or additionsrequ quital l ofters have exercised their
),Q I ■hoe"toner doing all work rigbe of exemption per MOL I I.Q Plumbing repairs are additions
myself.(No worker'comp to 1 S2,'1(4) and we have no 12.❑Roof repairs
insduance requird.J( empbyosa(IN*workers, 13.[]Otba
comp,insurance required.)
-Any appana oho dwe4 ba et mom odors as cal dha soeria Solar Ibowids dhdr awsea'taonpaaadm podky ika
't hww orpwa she subwir olds aradwb indloadoa Oe y as Jose 90 wadi and dots him oartds eeauatsrm no oodtmb•ow anbYvil Wdicainn ark
:C'MI -Wo dhoi cl ook ow box mow waehod as 3"tw ul show rhowiss Jot soar afar Alb samonwa ado dtak woAan'rardp.policy ialamooaa
/moan eaployer'her b providlas workers'cos rewinds lwanreweejor my tarpleyaat edew a lM pN/q awd Jot rgtr
inferlwallaw,
Insurance Company Name: /
policy N or Self-ins. Lit.N: 60C 7 � ` �U Expiration Duo- 3- jV-A9
Job Site Address: 4 /Qd4&1Jw'� kD City/Statrailic (�/ /Z_VY -
,\tack a copy of the workers'compemetloa poltyy deelarallen pap(abowing the polity number and espirsllon daft}
Failure to secure coverage a.required under Section 23A of MGL C. 152 can lad to the imposition of criminal penalties of a
fine up to s1,500.00 and/or one-year imprisonment.as wall as civil penalties in the form of a STOP WORK ORDER and a Ron
of up to S250.00 a day against Iha violator. Il iw e.advpl that a copy ul this siatemcne may tot rurwartled to the OIT1ce of
Invv,uyatiunaul'thaDlA for instrranea eragavuirtcatioa.
l de hereby errtift un/rr tba pains nd ptnal'ler ojper/u/y that the infornatlea providd above is true on11 a d carree
P''oore a• .� 3
0/J7rld sae OII/yt DO 1109 W/III/w/b(r Y/rI.to be�alnp/erd by airy or taws olJ(t•ial
I
City orrur.n: prrmiN.lcensee__ _. __
Ivsuing.\uihuriiy (tircle nne):
I. Iluard u(Ilvallh 1. Ruddlny Department 5. City/town Clerk S. Electrical Impactor S. Plumbing Inipeelor
6. other
l,,,M act Person: . _ ... Phone n:
ACORD CERTIFICATE OF LIABILITY INSURANCE DATEI"9/20 0
03/1 /2010
PRODUCER 781.438.S000 FAX 781.438.SO28 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
New England Heritage Insurance Agency Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
335 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Stoneham, MA 02180
INSURERS AFFORDING COVERAGE NAIC#
INSURED A. B. Carnes, Inc. INSURERA Essex Insurance Co.
30 Arrowhead Farm Rd. INSURERS: TRAVELERS INSURANCE 0038
Boxford, MA 01921 INSURERc: AIG AMERICAN INTERNL GROUP INC
INSURER D:
NSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR ICY TYPE OF INSURANCE POL NUMBER ATE MEMFNDrfY"CTIVE DATE MIDD TIOM UMITS
GENERAL LIABILITY 3CZ1798 03/18/2010 03/18/2011 EACH OCCURRENCE $ 1.000.00(
X COMMERCML GENERAL LIABILITY PREMISES Ee ocwrtence $ SO,DD
CLAIMS MADE O OCCUR MED EXP(Any one PNwn) $ EXCLUDE
A PERSONAL S ADV INJURY $ 1,000,00(
GENERAL AGGREGATE $ 2,000,00
GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/GPAGG $ 1,000 00
POLICY JET LOC
AUTOMOBILEUAe1Lm BA 6919MB06 09/29/2009 00/29/2010 WMBINED SINGLE LIMIT
ANY AUTO (Ea=ident) $ 1,000 00
ALL OW NED AUTOS
BODILY INJURY $
B X SCHEDULEDAUTOS (%rPm"I)
X HIRED AUTOS. BODILY INJURY $
X NO"WNEDAUTOS IN,acaOeM)
PROPERTY DAMAGE $
(Peres dent)
GARAGE LIABILITY AUTOONLY-EAACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS 1 UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION WC 742 62 18 03/31/2009 03/31/2010 TORY LIMITS ER
AND EMPLOYERS'LIABILITY
C OFMEWMEMBER EXCLUDED?ECUTIVEr1 EL.EACH ACCIDENT E 1,000,00
("MMa In NH) �J E.L.DISEASE-EA EMPLOYE $ 1,000,000
ff ya
SPEC LIROd-08VISIONSE 1. E.L.DISEASE-POLICY LIMIT $ 1 000 00
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENTI SPECIAL PROVISIONS
ontractor
Subject to terms, conditions, endorsements and exclusions on the policy.
This will serve as evidence of insurance only.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF T1IE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
n t AUTHORIZED REPRESENTATIVE
PROOF OF INSURANCE COVERAGE ONLY'
"SPECIMEN COPY ONLY" William Kell AM
ACORD 25(2009/01) 01988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
'A CITY OF SALEM
• PUBLIC PROPRERTY
WDEPARTMENT
.IVI? MIf1 ' Nly '•I I
\I u 'N 11C�•.i+Ill.\b:+!V 51'NlrT 0 SA I M,S1A+i.%t III 4 1
I'M 471-745.9399 •1:.%,(:979-743.9M46
Construction Debris Disposal Affldavit
(required I'ur 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 c 40, S 54;
Building Permit q is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
0� I (11am of a
s
IaddT
rm of Iarilily)
ignature ofl3k3mit applicant
date
%�aar f cnue{�al�i.
R ;(;'�3 I�r Board olt✓�uildmg Regulat ons and S�tanc�ards
One Ashburton Place - Room t301
a
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Reqistration: 100733
TVpe: Private Corporation
Expiration: 6123/2010 TrA 267195
A. B. CARNES, INC. --
Barry Carnes - -
30 Arrowhead Farm Rd.
Boxford, MA 01921
Update.Address and return card.Mark reason for chaa0e.
Address , Renewal Emplugntent Lost Card
nrscdt :} sonlrrw.rcx<sn
Ma'sachnsetts- Ocpartntcnl or Public�afrry
Board or Nuildin" Rc-Mation,and tituntlarda
Constructton supervisor License
License: CS 68139
Restricted to;. 00
KENNETH R CARNES
8 DORIS ST
GROVEIAND, MA01834 �^„s'