3 RIVER ST - BUILDING INSPECTION � 2g c-Krs �
fhe Commonwealth ofNlassachus"PEC ZONAL SERY CES CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 1 ,N
�OIIAR I5 P 2� ►�'isedor201
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Avo-Family Dwelling
gThis Section ForOfficial Use Only
Building Permit Number: Date.Applied,
building Otticial(Print Name). Signature; Da e
L SECTION 1:SITE INFORNIAT10PF
I— 1.1 Property Address: 1.2 Assessors Map Parcel Numbers
3 t;%yu S�' Sale.-t U
L I a Is this an accented street9 yes_ no Map Number -Parcel Number
1.3 Zoning information: 1.4 Property Dimensions:
Zoning District =^.c Propose)Use -- Lot Area(sq R) - Frontage(11)
1.5 Building Setbacks(ft) .
Front Yard . .Side Yprds - Rear Yana .
Required - Provided Required Provided: .. . Rcquired Provided
1.6 Water Supply:(M.O.L c.40,§54) t.7 Flood Zone Information: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal Cl On site disposal system O
Public❑ Private❑ Check If yesCl
SECT[ON2: PROPERTY6WNER9HW-
2.1 OwnertofRecord:
l Chuck �fnn (�lunS S
xl7'rme(Print) City,State,ZIP
3 fLi.><i �oC• 9 18 510614� on16c c(�)ar,A 1•Co"+
No.and Street.
Telephone Emm Ado •sg
SECTION 3:DESCRIPTION OF PROPOSED WORWI(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 A)teration(s) O Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other O Specify:
Brief Description of Proposed War
SECTION 4:ESTIMATED CONSTRUCTION COSTS
ItemMd
Estimated Costs: Official Use Only
Labor and Materials
I. Bui $ I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. EleS p Total Project Costs(Item 6)x multiplierJ. PluS 2 Qlher Fees: S 4.�\Ic ;\C) S Lisc5.Mere 5 'total All Fees:S
Su rCheck No. Check r\mount Cash AmountCost: :S . ❑Paid in Fall ❑Outstanding Balance Due:
14030
t ,SECTION5: CONSTRUCTION SERVICES
5.1 Coustruction Supervisor License(CSL) I n hon'l o,9AdrL1
<f-SSL- ' A'66o09] License Number Explrutioh Date
Name of CSL holder 1 \
List CS (see below)
Type Description .
No. wmd Street
U Unrestricteg'Buildings tip-to 35,000 cu. 11.
R Restricted 184
2 Family Dwelling
City/Town,State,ZIP M Masomy
RC Root Covering
Sk r1A VS Window and SiJ in
SF - Solid Fuel Burning Appliances
9S"(1svS 4J-tO.n\•�"__ I Insulation
Telephone a ss 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'CONIPENSATION INSURANCE AFFIDAVIT(M.G,L:F.IiL§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........... O
SECTION 7a:OWNER AUTHORIZATION TO BE,COMPLETED WHEN
OWNER'S AGENT OR CONTItACT Olt APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matte elntive vork authorized by this building permit application. ((__
p --�
e(E �
Print Own 's Nam Ironic Signature) Date
SECTION 7b:OWNERt 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 nd accu to to the best of my knowledge and understanding.
XPrint Owner's or oho 'zed, gent's Name(Elecuonic Signmunre) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not roistered in the Home improvement Contractor(HIC)Program),will no have access to the arbitration
program or guaranty fund under M.G.L.c. I d2A.Other lmportant mii5mFdtion on the HIC-Program can be—tott�nt at
www m:nss.cov:'oet Information on the Construction Supervisor License can be found at www.mass.^ov.!dns
2. When substantial work is planned,provide the information below:
"total floor area(sq. R.) N (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 half/bnths
Type of heating system Number of decks/porches
'rypeof cooling system Enclosed Open
3. `Total Project Square Foolage"may be substituted tar"Total Project Cost"
CITY OF SALEg AfissAcHm m
BumDmDEPAR7 zw
120 WAgmgcmS7REET,31ORx R
UL(978)745-9595.
PAX(978)740.9846
KIIv18ERiEYDRISaDLL
MAYOR MCMAS ST.PIERRE
DmEcwa orPuBucFAaPFRTr/sl LDm ocmmomR
Construction Debris Disposa/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 coo, 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:
ccc-
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature--of applicant
"A0c ,�
Date
Z
i
}� usetts p
Board of Building- ep urtment of Public at-
Safefy
`; +' CnmteyCtin°Supi Rey rlSPo,s and Standards
1 License: CSSL- '101"09
CLAIMCARy CLA `t- I r,
58 DER-By STREET
SaleB
n4 MA 01970=
i"�•
commissioner Ea`Piration
0aib1iz0n
HAPFRE I commelr%flur^AM
J NS&R A m c E- Direct Bill
ContractoSAusiness Owners Policy Renewal Certificate
BGGYRC Individual
THE COMMERCE INSURANCE COMPANY
--�M'9105112/15
From 05/12/15 to 05/12/16 70X
Individual
1-ndi
GARY CLARK ALDEN C. GOODNOW, aR.INS.AGCY.INC.
5 5 Y S 1 P
8 DERBY STREET 16:6 PARK STREET
W
SALEM, MA 01970-5606 DANVERS, MA 01923
777-77777
In return for the payment of the premium and subject to all terms of this policy, we agree with you to provide the insurance as
stated in this policy.
Loc# Bld # Street city ST Zip-Code
1 1 58 DERBY ST SALEM MA 01970
In H,
Buildingfersonal Property Deductible: $500 1 Optional Coverage/Glass Deductible: $500
I Buildina Auto Incr I Personal Property Valuation Bus Inc Premium
1 storage 4* $5 1 1000 RC INCL $90
Except for Damage for Damage Rented To You, each paid claim for the following coverages reduces the amount of
insurance we provide during the applicable annual period. Please refer to Section 11, Paragraph D.4. of the
us ssow rs Covers
a Form.
B ine ne era egFt
Businessowners Coveraq
Coverage Limits of Insurance Premium
Liability and Medical Expenses $1,000.,000 Per occurrence (INCL.)
Medical Expenses $5,000 Per Person (INCL.)
Damage to Premises Rented to You $100,000 Any One Premises
Contractor Class: 97447 Rate: $20.07 Payroll: $29,000 $640
Property Damage Deductible:
��;w'Ul� 7-
"Advanced Annual Premium: $730 -turn Premium:
Authorized:Representative:
04/02/I5 Page I
Insured Copy
The Commerce Insurance Company
211 Main Street Webster, MA 01570 1508-943-9000 1 www.commerceinsurance.com
NOTICE z NOTICE
TO TO
e
a
EMPLOYEES 4 � EMPLOYEES
zr,� ve
O,9M SV6
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 &30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
ZURICH-AMERICAN INSURANCE GROUP
NAME OF INSURANCE COMPANY
P .O. BOX 1450
MIDDLEBORO, MA 02344-1450 _
ADDRESS OF INSURANCE COMPANY
(GZZUB-OG01929-9-15) 05-11 -15 TO 05-11 -16
POLICY NUMBER EFFECTIVE DATES
ALDEN C GOODNOW JR INS 16 PARK ST
�= DANVERS MA 01923
NAME OF INSURANCE AGENT ADDRESS PHONE #
CLARK, GARY 58 DERBY STREET
SALEM
MA 01970
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS h
TO BE POSTED BY EMPLOYER
023662 W20PIG02