8 RED JACKET LN - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
�i Board of Building Regulations and Standards CITY OF
�J �( Massachusetts State Building Code,780 CMR SALEM
Building Permit Application To Co Revised Mm 2011
nstruct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
Tt
' ' -: T1iis Secdwt F.or;Official Use t�nly u .
'��#! •>�! ��"57..{.��:�;� t�iT r r r�l}ram �,..-- cPY�'7_ry rz ..� .;.���.+��-,�.
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igniittQe�r�;^�
rSECTION'1c STIE INI+O'RMi?T
1.1 ProJONi.perty Address: 1.2 Assessors Map&Pareel Numbers
8 Red Jacket Lane Salem MA 01970
Us Is this en accepted street?yeses_ no Map Number
Peril Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning DbWct Proposed Use Lot Ares(sq fi) Frontage(8)
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 Die
Public O Private o
Zone: Outside Flood Zone? Disposal System:
Check Cap Municipal❑ On she disposal system o
Nancy Gallagher Salem MA 01970
Name(Pnnt) City,State,ZIP
_8 Rad IarkaT I ana 7R1_9dd-919R n
No.and Street - --- - - — Telephone an.�ll1!7rnm act n t
' a - Email Address
L� ON 3 DESCRIPTION OF PROPOSED YVOR�I{.(c(kekaB tkat apply k,,i
New Construction O Existing Building Owner-Otxupied III Repairs(s) Yd Aherati
Demolition O A Bl on(s) O Addition ❑
csed Work :
O Numbea of Units_ Other Specify;Replacement
Brief Description of Proposed Work:
Replacing 6 windows, no structural changes
ESTIMATEDCONS'TRUCTIONJCOSTS
Item Estimated Costs:
0 and Materialsi,` ` r tit >DCIq�Use Only _ t` r;a
1.Building $9 567 �1Bmldih;Permit'Fea�1$ htdicate}tow fce is determined tl
2.Electrical
$ DityllowmApplicafio'nFee ti' ; ` n
Total`, act C' .. w'A F7 teZ—_
>'i'oJ (Iteer 6)x m
3.Plumbing $
2 d OtherFees $ `�Jt - �- «+rr Ir� ,o.•-�,„a _
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $ > r
Suppress on That All Four$ 72_ _
6.Total Protect Cost: $ 9 567 Che&No r' Check Arno& Cash Ai oim't 't " _-
❑Pahl n Full ` t'_zD Outstanding Balaitce'Due:'!r
„� ,. ray= •. r �`7-`; -Try �e�SECfdOPT?S ff +NBTRUCTION`31;R,,\'ICES '+, ` ."�.y,'�,`•,
5.1 Construction Supervisor License(CSL) 90125
Jamie M 10-06-18
L License Number Expiration Date
Name of CSL Holder
86 Gardiner St List CSL Type(ace below) U
No.and Street 1 °C'YPc, 0. -. . �Deacrtph ''
Lynn, MA 01905 U Unrestricted undin to 35 ODO cu.lt.
City/Town,State,ZIP 1t Restricted IA2 Farok Dwelling
M Maso
RC Roo Coven
wS window and Siding
SF 508-351-2214 Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Rome Improvement Contractor(HIC) 170810 12-2 3-17
Renewal by Andersen
RIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
30 Forbes Rd
No.and Street
Northborough, MA 01532 508-351-2214 Email address
C' /To S ZIP Tel oar
_ SECTION*W2$I JE S COMPENSATION D CE'AFFIDAVIT
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 per! ._
Signed Affidavit Attached? Yes.......... No...........O
`SECTION'7a_OWNER AUTHO]tiZ'A. ION TO'BE CAMP D r'
VVNER'SAGEIT�OR• NflRAC�1bRAPPLS:FOItBUII;DINGpIrRl4II�, u.r
I,as Owner of the subject property,hereby authorize Jamie Morin
to act on my behalf;in all matters relative to work authorized by this building permit application.
SEE CONTRACT
10/97/901 R
Print Owner's Name(Eledmnic Signature) Date ,
"� '__ SECTION„96 O,W1VElt�£OR AUTHORIZED AGENT DELI ARATION ;: jp s T 1
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.
JAIME MORIN 10/97/7016
` Print Owner's or Authorized Agent's Name(Electronic Signature) Date
I. An Owner who obtains a building permit to do his/her own wary,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 gumudy fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mess.gov/oca Information on the Construction Supervisor License can be found at vNML ss eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.fL) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.1) 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”maybe substituted for"Total Project Cost"
CITY OF SALE14 MASSACHUSEM
BUILD=DE1PAaTmeNT
120 W-WWGTON STRM,r KOO&
TEL(978)745-9595
1CISf8cn*m+DBISCOLL PAX(978)740-98"
MAYOR THOMAS ST.PM=
61xECro1 of PUBLIC PROPFAW/eCMI)ING COADRSSIONEI
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,780 OM section 111.5
Debris,and the provisions of MGL c 40,S 54;
Building permit N is issued with the condition that the debris resulting from
this work shall be disposed of-Fin a properly licensed waste disposal facility as defined by MGL c
111,S 150A.
The debris will be transported by;
Renewal by Andersen
(name of healer)
The debris will be disposed of in
Renewal by Andersen
(name of facility)
30 Forbes Rd, Northborough, MA 01532
(address of facility)
signaprre of permit applicant
data
debrirarEdoc
The Commanwe M ofArassachuse&
DgwMm atofLm&sbfatAceldvn&
tfitce of impudgadona
600 Waddnrm s*m
Bovlb%MA 02111
www.maw,gvWdIa
Workers' Compensation Insurance Affidavit:HoBders/Conhwtora/EkeWetauMumben
Auvhemt Information N a Loidbly
Name ): RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
City/statelzip: NORTHBORO,MA 01532 phone 0 5DB-351 2214
Are you an am~Cheek the app oprlate bm-
1.K] I am a employer with 30 4. ❑I am a geawal conlracmr and I T�Pe of Project(requhv ):
areployeas(fall mdlor p dmo).• have hired the sub contractom 6. ❑Now construction
2.❑ I am a solo proprietor orperirm- listed on the attached sheet 7. g]Remodeling
ship and have no cmployaw These atb conhactae have & ❑Demolition
working for me in any capacity. emPloymm and have workers'
[No worker,camp.insurance comp.insurmoe t 9. ❑Building adftm
required.] 5. ❑ We aro a corporation and its 10.❑Ek*ical mpeas or additions
3.[3 I an a homwwner doing ell work offmans have weercised them
myself[lie wado ms'amp. right of memptimpm MOL 11.❑Plumbing;ropaire or athliticm
insamote roquhed]t a 152,¢I(4),and we bow no 12.❑Roof rrpdm
rmployees.[No workers' 13.❑Oder
comp.insmmm ra pared.]
•Aq eyparaatad Checks boot eI coma den ton aotamemtbm bdow dswbg adr wodmr' Infimmolm
t Hameowosawtto submaab emd"k mduaBmgAw medit dlwmk@add=boa� UWmbmn aaar
:Omtmdme addw*d&bm must anwhad w eddWond&M dwwbp aesemaafeer mt.mmromm and ddewlm w��hm
empbyaea Sae u b mammu hm cmPbrtm,aeymadpravide tbeh v mkm'aoaP.pdb mmbw,
law u aapdeyer Am blauwift work=,ooapama egea t for ap Avoyem Below h depeaq mtdfob S&
nl mmadmL
hourance Company Name: OLD REPUBLIC INSURANCE COMPANY
Policy#or SW-ins.Lie.#: MWC30823100 10I01/2017
Expiation Date
lob SiteAddrear 8 Red Jacket Lane aty�soatn2;p;�alem_ MA 01970
Attach a ropy of the twttoeea'compensation policy deehtrad=page(a wvft the pogey number and emgdra&n date
Paihue to secure as required under Section 25A ofMOL a 152 can iced to don impo®tiom of orimiaai pities of a
fmo up to$1 M00 and/or one-year imp to®mt,as well as civil penalties m the form of a STOP WORK ORDER and a fine
crop to Z250.�a day against the 8000 co Be advised abet a copy of"statement may be B r%wded 10 tine Ofte of
for inemanca covamage verification,
1 do pdaa sad pesam�olPa auu dke irymnmmionprerfdtdeiova 6 Orase and aN
10/27/2016
8-351-2214
t7,Bidal mar sm* Do not wwdtr in dims ava,to be soar led by OW or tans offimW
City or Town: PanmiuLbmm#
haft Anther/ty(Nrds me):
L Board�of Health 2.Bspdiog Departateat 3.Cltyfrawn Clerk 4.Elertrierl Deter S.Plmrbiog hnpeetar
Contact Pasco Phma#:
ANDECOR-01 SALWAIIIN
GATE NMO
CERTIFICATE w nYY+T
OF LIABILIT
Y INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY 9/30T201B
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),AUTHORRED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: N the ;wti holder Is an ADDITIONAL INSURED,BEa Polk Ami must be endorsed. N SUBROGATION IS WAIVED,subj—
the terms and COndltle o of the policy,certain policies may require an endorsement. A statement on this cenfifil s doss not Roller rights a to the Certificate holder In lieu of such andorseme s
PROD of NAME: Willis Toarere Watson Certlfleate Cellar
WillisCONTACT
26 Cs;pWpMy Blvd 1 E 877 945.797E
PA,11RNL 305191 N. 888 467.2378
Nashville.TN 37230-5191 'NIwm UbLoom
are s ANvoRDlNoewaRAce Noce
INSURED
INSURELA:Old Re ublic Insurance Com an _ 24147
INSURER a:
Renewal by Andersen msuRER C:
30 Forbes Road deuReR o:
Northborough,MA 01832
NNIRERE:
INSURER P:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS B TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICTED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CX7NTRACT OR OTHER DOCUMENT WITH RESPECT TO WFIICH THIS
CXCLIRGTE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORD® BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,
IX(D.USION.4 AND C ONDRIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTN MF OF INSURANCE POLICY NUMBER • l.aaTa
A X carveRcw cExeeALLIABwrr
cLaMs-wwE X❑cc" WZY 808234 110101T2016 10/01T2017 EACH�RRENCE s 1,000,00
S 500,00
are 1 a 10,00
PERSOMgL B AOV INJURY S 1,000,000
DENvaaoPI[DATe LIMIT APPLIES PER '
X POLICY❑JIBLoc GENERAL a 4,000,00
RTrHr9 I I TS.COMMOPADS S 4,000,00
AUTOMOMMLL& ULI S
C�rtRNED sINOLEimr $ 5-000,00 A X ANYAU O ATM 309232 r'
nOWNED 1N01/2078 1W01T2017 BODILY IWURY(Ptr ANNULI E
TOS AUTOSSCHEDULED
eoRLrlwuRr(P«eouUsn) a
HIR®Al1TOB AUTOS
LTMWZUALBB OCCUR a
EXCESS UAB ClNM6-MN]E I I I fACM OIXXNRRENOE S
DED RETENTIONS AGOREOATE $
YRIRXEn COYPEI mm S
AND EMPLAYFRB LUIDIUTY I I X m TUIE ER
A ANYPROPMMErOR,PARTMER1FJECurNE YNx OP C30829f00 10l0712016 10T012017 FCERa�RERP7.CLIJDEDT N NNA El EAMACQpgRr a 1,OOD,9 WyyoamAa,Mms In 00
MCI
OFaE:IiIPT 'IOH OF ppFRATIW♦B beW I I EL DISEASE.EA ISMS 1,000,00D
ELDREAEE.PDuCyuw S 11000100
I
DESCRWTWNOPOPERATIONa IL.00ATMMIVEIaCIES PICORD 101.Adtlltlene R•nsNo 8chamb,my YMeRMEImae sprw4,egWNe)
CERTIFICATE HOLDER CANCELLATION
I
THOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED SEPM
E EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY pROVImON&
AmxoRJZEp REPREBEI-DTI-!
roofotimEsu Ce $0,-,f. br�
ACORD 25 2014Po7 01088.2014 ACORD CORPORATION. All rights reserved.
( ) The ACORD name and logo are registered marks of ACORD
Massachusetts Department of Public Safety
Board of BuNding Regulations and Standards
License: CS.090125
Construction Supervisor ,
JAME L MORIN ti
Be QAROwwR ST '
LYNNMA 01906
W
t-" zw CA— Expiration:
Cofrmmissioner18
Construction Supervisor
Restricted to:
Unrestricted-Buildings of any use ggroup which contain
less than 35,000 cubic feet(901 cutxc metros)of
enclosed space.
s
P
i ` I
Failure to possess a sweat editias of the ♦Massachusetts
ate It""Code Is cause for ravocallon of this Iteoase.
OPS Lloeaahrg WOM1490o visit:WWW.MA6LQO WS
i f
�ile�/d4 y�H�aaaad&me!!a i
#Of Coasamer Affairs&Badness Regaiados
ME IMPROVEfAENT CONTRACTOR
Rogkhatl ,Tye.
FxPi _ Supplement Card
RENEWAL BY AND _ .- r-.L 1l
JAIME MORIN
30 FORBES RD
NORTHBOROUGH,MA 01532 Uaderxcrctery
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