15 ROCKDALE AVE - BUILDING INSPECTION 1 ;
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code. 780 CMR, 7°i edition NIUNICII':ALfll
a1 USE
Building Permit Application To Construct. Repair, Renovate Or Demolish a Rei iced Jatw�u_r
One- or Two-Family Duelling 1. 'tlu8
This Section For Official Use Only
Building Permit N ber: Date Applied:Signature: �.� ��� ob Buillt1iiig Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro e t lddress:
P y 1.2 Assessors "'up & Parcel Numbers
I.la Is this :[n accepted street'? yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Isq to Frontage (it)
LS Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. d0, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal ❑ On site disposal system ❑
2 T, SECTION 2: PROPERT,�Y�OWNERSHIP'
Name(Print) Address for Service:
970C — 2 /'/ — Fez
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Rep tads) ❑ Alteration(,) ❑ f\ddition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
(Labor and Materials) Y
fLn
L Building $ 49� 2G-° Oil I. Building Permit Fee: $ - Indicate how fee is determined:
2. Electrical $ Ntandard City/Town Application Fee
❑Total Project Cost}(Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. ��Check Amount: _Cash Anuxmt:
6. Total Project Cost: $ cad C�`*% %/ ❑ Paid in Full ❑ Outstanding Balance Due:
a
SECTION 5: CONSTRUCTION SERVICES r
5.1 Licensed Construction Supervisor(CSL)
License Number Fxpuanon Date
Name of CSL- Holder List CSL Type (.see below)
Type Description
Address U Unrestricted (Up to 35.000 Cu. Ft.)
R Restricted I&1 F:unil y Dwcllina
SIgnatllrC M Masonr Only
RC Residential Routine Covering
Telephone VVS Residential Window and Siding
SF Residential Solid Fuel 13ununp A l tliance Instulluuon
D Residential Demolition
5.,�tegiste ed,= Improvetne Contractor(HIC) /.2 Y�5^-,-
" �o C Registration Number
.HIC Compa Name or HIC Re nstrant Nam
S--6 , s•,T r� /�,avvf/�,f Y_ 3r d 9
was^% Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152.§ 2506))
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 ... ..
11
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I 6e /,C & ,e elite as Owner of the subject property hereby
// MC/J l' / «• x r to act on my behalf. in all matters
authorize
relative to work authorized by As building permit applica ion.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I U Oti u `/ n•as Owner Authorized ent hereby declare
that the statement and information on the fore ing application are true and accurate, tot a best of my knowledge and
be ' If.
J�Co/'� 411
�f/A
Prin Name /� g f /� J_/ y—O�
Signature of Owner or Authorized Agent Date
(Signed under the ains and enalties of er u )
NOTES:
]iRREW
er who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractoristered in the Home Improvement Contractor(HIC) Program), will nol have access to the arbitration or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program andction Supervisor Licensing (CSL)can be found in 780 CMR Regulations 110.R6 and 1 10.R5. respectively.ubstantial work is planned, provide the information below:area(Sq. Ft.) (including garage, finished basemenUattics, decks or porch)area (Sq. Ft.) Habimble room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of herring system Number of decks/ porches
Type of cooling system Enclosed Open —
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
ACORD� CERTIFICATE OF LIABILITY INSURANCE OP ID � DATEMIMAI O7
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dan Hurley Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Chestnut Green, Suite 24 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Seven Federal Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers MA 01923-3620
Phone: 978-777-9394 Fax:978-777-3306 INSURERS AFFORDING COVERAGE NAICS
INSURED NSURM A: preferred Mutual 15024
Kiley IRURERB. Granite State
BaarrtFiolometwtK�K�illey Construction
coon INSURERC
56 onanrs 2t�.S01923 INSURERn
INSURER 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 CONTRACTOR 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 BEEJ REDUCED BY PAID CLAIMS
LTR NW TYPE OF INSURANCE POLICY NUMBER WTUDIMMM DATE LIMITS
GENERAL LUU3HJry EACH OCCURRENCE s300000
A X COMMERCIAL GENERALuABILITY CPP0150564252 10/16/07 10/16/08 PREMISES(Eaomue ) $100000
CLAMS MADE X❑OCCUR MED EX ("are Perem) s5000 1
PERSONAL SADV INJURY s 300000
GENERAL AGGREGATE s 600000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO s 600000
X POLICY JECT
PR LOC
AUTOMOBILE LUURLNY COMBINED SINGLE LIMIT E
ANY AUTO (EA )
ALL OWNED AUTOS BODILY INJURY E
SCHEDULED AUTOS (I"I�)
HIREDAUTOS BODILY INJURY $
NON4)WNED AUTOS U
i
PROPERTY DAMAGE E
I
GARAGE LIABILITY AUTO ONLY-EAACCIDENT $
ANY AUTO OTHER THAN EA ACC E
AUTO ONLY: AGO E
EXCESSUMBRFIIA LMBILTTY EACH OCCURRENCE E
OCCUR CLAIMS MADE AGGREGATE E
E
DEDUCTIBLE E
RETENITON E E
WORILERS COMPENSATION AND X I UM TORY TAT% ER
B EMPLOYERS LMBRMTV WC2407407 06/20/07 06/20/08 EL EACH ACCIDENT $100000
ANY PROPRIETORIPARTNERIEJIFCUTIVE
OFyeFICERIMISMSEREXCLUDEm SEE ATTACHED HOTS EL DISEASE-EAEMPL0 $100000
Sscribs
PEaCELIAPPROOMSIONS b0aw EL DISEASE-POLICY LDGT $500000 `
DINER
DE3C.PoP770N of OPERIITONE/LOCATXINB/VExICLESI EXCLUSIONS ADDED BY ENDORSEMENT I SPSIW.PROVISIONS
Sole Proprietor excluded from workers compensation.
CERTIFICATE HOLDER CANCELLATION
DANVEIO
SHOULD ANY OF THE ABOVE DESCRIBED POLICes BE CANCELLED BEFORE THE EIPRATRON
DATETHEI90F,THE ISSUING INSURERWILLENDEAVORTOMAIL 10 DAYS WRITTEN
NOTICE 10 THE CERTMATE HOLDER NAMED TO THE LEFT,BUT FAMORE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABLLITY OF ANY HIND UPON THE INSURER,TIS AGENTS OR
REPRESMATNES
AUTHOR®REPRESENTATIVE
Daniel J Hurley
ACORD 26(2001M) 0 ACORD CORPORATION 1988
CITY OF SALEm
PUBLIC PROPRERTY
DEPARTMENT
\1�1. l3: 1.�9RV�:JMS1{✓<T �L�11.1L�VlH.`N*klbi.4
TO:~4&49M •F.%*I W461"
Construction Debris Disposat Affidavit
(requital ibr all damolition and smovatimt went)
Is modaws w i th Ilw sbttb eadm d dw stets&dwhv Coda,730 CUR soctim 111.S
OcW&and dw provisions of vtGL a 44! 54
3%iidtm3 Pon nniR it _ _ is ism"With the wnddm that the debris resuldcts bait
,his work shall be disposal or in a pcopacty licaneed ws"dlapoept ibeititr AS defined by.%WL a
I t t. 315OA.
The debris will be transported by:
Ino artvYl�
rho Jcbris will be disposed or in
u.rtw ui ixiAty)
.+.M:r,e. ai f'�►:Lty�
CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
i114LYatar,taYt%rLA.
1iL\tll� 12�:WASC%GVMISUW 0�tJt�h�A,Z1C7A>k111011TI.
Tta:t+J►7wvyq a F.\x:97114401ee6
workots' Compe"adee Insuraaa Afftevir swukryCoRtractsra/Eleetrldaawl%mbars
%palknot Informado■ Mean Met .tooter
Name IasvneWOtyaifat otVirkkvwhwn: �2YK�FitCS C.
Addt �
City/StsxJZip:
Are yea as er pbyer?Cheek the appropriate beset
L❑ 1 am a employer with ♦. ❑ 1 eat a usual caskaeter MW
cEttpl wcm(full swltar port-time).• have hired the sub•canractara 6 ❑Now construction
2.0�1 am a sale proprietor or partner- listed as the aaaehed shaat,t ?. ❑ Rame isliaR
ship sod bove no employ*= Thaa auk-oomoaoa haw Y. p Detonations
working for me is nay capacity. workan•Comp inwtsnoa. q• p Iluiktittg adiitiep
Ilia workers•camp. insurance IF. ❑ we an a eotporatim ow its
required) oAloas haw axercisw their 10.0 Electrical repairs or additions
1.❑ 1 am a homeowner doing all work right of examption per MOL 11.0 plumbing repairs or additions
myself.(No workers•camp. e. 152.f 1(4).and we have no 12•0 Ruof repair
insurance requind.) t :mployc"Met waken' 17.❑Otksf
comp' itnarsoce mVjrod)
�ro Wool s Per tttev♦w am at .eer air litl ng AVeee,lae cab.m.i s on in don ergrratL w DW�7 aarar,iaa
'11.1ea1eielrw vdr ueiwit n1Y anlrrsi b1Wa161a a1.y ale dilly rtl.erY W Etta Elbe aettfee aostnwrela eat sub"a new aR%dwO indenting rki
i,wraaln eta alma Ease as arat atadref r addllaeal.taw.briny tar nrae of s1e rskseapaeests W the r workan•map pulk7 wkrmaeoa
/uer no eraplo)er rhaf/r preeldlag workers.coarpeasaalan buaranri jew nay earployees endow k rhrpuAlay and Jot slq
iyfMrrsrelam
Insurance Company Vamr
POlicy a at Self-ins. Lie.
/ / � CC��
Eapiratton Dote: G "'.� U l'0�
lolf Site .�ddrese: 15- VC-C4 p ��Q�m Cay,Staw2,p: `J"sl,,r7 01-9 2 5
.attack a copy of the workers'compensation pulley doeleratloa page(showing the Polley number and expiration date),
Fai Tura w%xun coverage as required under Souioa 23A of.IGL c. 132 cas lead to the imposition ofcriminsl pensltias ors
rifle up as 31.500.00 Anwar one-year irnprisomncnc,ar wall am civil pcnaUi.m in the form ofa STOP WORK ORDER and a fine
,)(up to S350.00 a Jay againat Iho violator. Ile adviacd that a copy,ufthis stawawnt may be forwarded io the Office of
L,.:.na:luona vi dw DIA for lmurarcc c4)v:rj4u v:riftcauua.
/Jr hen•A)r.rn onei Aw pains urrd yrnu/rks v1per/ory that the!n/orssrllow prrrlded dAww is trw an/causes
iluu:c_a� n17� ' 77ri — O�f-S
UQlriad ase oe/p At eqf write AN this anal•to k evsep&atf jy coy ar town oQ4•hd
City of Tows _ PermiWJtease p
having Aulhurity (circle one):
I. 1141ard of ldeallb 1. Building Mpartmcnt J. City/roan Clerk J. Electrical Inspector S. Plumbing lospteto►
4. Other
Gndact Person: _ Phone q:
Information and Instructions
•husttoc General Laws ehspter l S2 requires ad a^PbYCM te provide workers' canpensatiat fora empbYaa
ntract*(bit%
Putsuanr to this at:atts.as ewlpbs e
is dsfirted tee'••away ptuaon is the service of another under any
e,Cpreta V unptied.„cal or writtta.
or two or mote
' any' se other lepl esory.
AA Art f�utegois wis"ens d� ��ensew aed�� gal reptesentadves of a deceased em~..�the
receiver or ttaetee of s individttal.parmesshtpr aeeoc+attan of ttbsr ie w entity,+mPbYiN °
rm bare haviat set sea*teen tbsae a WWAUb tad vrha teaidee tbeteitt,er dte eoeuPMe of the koues
owner*(a dwsdiat b do Mausa as sce.c��a"or repair work M such dweUiat +
dwe0a g bottle of another who ettaploya, dog net bs a ssae of arch enph pwa be dUsmW a be an employ..
of on the groutta or tsodins opptateaaet
,.iGL chapter 152.f=6)Woo saw t�'av�s�es,Ind Ueeaciat army dhd wi*MM tb ban OF
a epesate a budstass er a eoasteaet buildbp b the ee�eawsdth ter stay
ragwordappoew et a o law 0 permit evideaes of ceapUs sees with the its"nom coverage regalrN."
appYcaat who W ale ptredacd eat aqy of is Patical subdividene shad
Additirstslly.MOL chaplet 142.f ow acceptable evidence ofeaanpliaoee with the insurance
wo9teAase em asymtthscontract chaplet
have base presented to the cattracdnt au*witY
rcquinmetMe o!tlie Wpese
ApPlisa■te cocapicasly.by if
please IUl out the worhoos' compensate°affidavit
the bones that apply to your situation ea4
necessary.supply wd-estesa�s)naffs),addtees(es)and pboae numbar(a)along with their certtilkow(s)of
e i t(LLC)at Limited Liability partnerships(LLP)with no mtployea+other than this
mcutance. Limited Liability attpsa __. pencedom��, if as LLC or LLP does have
rrmploye or partners,ate aired. Be advised that thu affidavitsubmtted to the Depermumt of Industrial
COM
employees.•policy ra4 Ahto be sun to sip and dale the affidavit. The atYidavit should
Accidents for confirmed"Or of insurance the �'stbtt fbr dte permit at license is being requested.act the Department of
I n returned to the city h town that the a n ' rs the law w if you AN mquirod to obtain a workers'
1n.wetem titan policy,
��l the have p 1� gard"g companies should enter their
cotnpenastisn poHey. u the tttttaber lined below. SelRioattad
self-hteunna license number on the
City or To"OflMale
1< t The Dept Mmm has provided a speed at the bottot s-
Ptcaze be„ice that the to rU o is complete and printed g'b1Y:
of the affidavit far you to FiU out in the event the Office of Investigatioes has te contact you regortlint the applieara
t+l.:ase be sun to till in the permiUliceose number which will be used an a reference number. In Addition,an applicant
that must submit multiple Perm SIN appUptiSIN A any given year.
only write-all Iecations (cimit one affidavit indkadns ty Or
policy infonnation 1 if necessary)and under"Job Sits Addrea the applicant
rovrrl►."A copy of the affidavit that has been officially stamped or marked by the city a town may be provided to the
Applicant as proof that a valid at7idevit is on file for f6ture permits or licenses. A new affidavit must be filled out each
or citizen is o
year. Where a hart owner obtaining s license ter penult not related to any bu-W so or commercial venture
a dog license a permit to burn leaves ate.)said pawsisNOT required to complete thin atTldsvit.
Chc t)tii.e of Investi•� titans would fiat to thank you in advance for your cooperation and should you have any questions.
,�:cane do rwt hesitate to give us a uU.
The Department's address. telephone and fax number:
The Cotnmontvealth of Mmuhusen
Depsfemeat of InWWstrial Accidents
00a of Iavadpdew
600 WsaMaBoos Solve!
Bafte MA 02111
TeL Al617-7274900 en 406 or 1-877-MASSAFE
Fax 0 617-727-7749
a,vucd 1-26-05 WWW.MM.PV/"