40 SABLE RD - BUILDING INSPECTION =� fhe C'unununsve;tl(h of Massachusclts _
Huard of 13ui ding Regulations and SLlttdards CITY OF
I' Massachusetts Slate Building Code. 780 CNIR S,\LI:\I
1uilding Permit I\ppliruion 'ro construct. Repair, Renovate Or Demolish s RrrA"'I thn.2011
"^I One-ur Tiro-Fwnil Dtrrllin•te
this Stctiun Fur O'licial Use Onl
Building Permit Number:
aeA
IhulJmy(Ahcial IPrmt Muriel
Signalu Uatt
I Pr s SECTION I:SITE INFORh 10
I. ouery C��„s �
1.1,1su3son,Hw Parcel Numbers
I.I a Is this an acce ted street? •es no \Lip Numhur I'urcel Nwnhe�
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning D�-"' 1'ropiueJ v4g
Lul Arca(sy lq Prontayt(ill 1.5 BuIldingSetbwcks(R)
From Yard Silt Yunls
Required Front
Required side
HRequiredHear Yard Provided
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Niblic❑ Private D Zone: — Outside Flood Zane?
Check T Municipd D On site disposal.)stem D
SECTION I: PROPERYOWNERSHIPt
1.1 O rt of a ord:
Nam (Print)
//r, Y�•/J J ('ity.Slutc.11P f !/ t•-"7/
Nu and Strnvl
Niephune t:mad Addrcsi'--
SECTION A. DESCRIPTION OF PROPOSED WORKS(chec all that apply)
Demolition New Construction❑ Existing Building❑ Osvner•Occupie . Repairsl ) Iterotlon(s) ❑ Addition D
❑ Accessory Bldg.❑ Number of Units
BriefDescriptionofProposed \Vork': Other D Specify:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labur;md.\Ltttrialsl Official Use Only
1. Building f Building Permit Fee: f Indicate how fee is dettnnined:
'. Electrical S ❑Standard CityrTo%m Application Fee
11'lun(hing S ❑Tutal Project Cost,(Item 6).x multiplier
_'. Other Fees: S - `--- -
J. \lechanic•d ill ACI S List:
5. Mechanical (Fire -
— -----
SitIIression) S Tatal .\Il Fees: S — -
t' TWA Prtject CnaC i :� �o0 Check No.
❑Paid in Full ❑Outstanding IIal;mce Duc:
sF.("PION S: ('ONSI-RU("PION SF.RVI('FS
Gs _
5.1 ('unstr ctiun Sullen lsur License IC I — I \piratlon D;nc
t I lnnsc Nunthcr
N;mtcal'l'Sl. 11tddef - _ _... IiiICSLI)pelsacl+clulN.__._____---
.Ls 111cicripliun
j ---1'---,yJ—� )I Iinrestrietcd till Jin�s lip lIII15,UIIU al. Il.l
NItstreet �/ —
K I(earieteJ I l?P,unil nticllin
('it ifalt n.5lale,LlP KC Kadin Cnvcrin
µS µ'indusr,mJSidin
SF solid fuel Iluming,\ppliunces
�xlG I Iniiludon
���,r.JC�� G D Dcnx)liliun ;
I'd
Ifmaii oJdrcsi )r '/ /
' hone
S.2 Re Istcr Ilu vemen(Cuntr ctor(HIC)
/
X �yyrti IIIC Rcgiil`Nlu�lh r I'spinuiun I ule
QP Q �
I IC' 'umpml Nam nr I II (cghlrum Nul � v 4(:moil aJJnsy
N d Street
Ci IT Sete,ZIP
fcic
SEC hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. I52. 23C(6))
Workes Compensation Insurance affidavit must be completed an ps submitted with this application. Failure to provide
this affidavit will result in the denial of the Issua a of the building
erallt-
Signed Affidavit Attached? Yes
No...........❑
1.
SECTION 7a:OWNE 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 mattes relative to work authorized by this building permit application.
Date
Prim Ussnut's Nwne(Eleetrunic Signuturc)
SECTION 7b:OWNERt OR AUTIIORIZED AGENT DECLARATION
eury that all of the
By entering lly name below,I here contained nithis application is true andtaccuratetest eto hr thee best of my kno vledgains and penalties ore and understanding.
information
nine
Prim l)tsnet s it \iahoriicd.\gent's Nanw I Ifleetrunic Siynaturc)
NOTES:
Improvement ion onthe la trntur
mh s ns
vltoI
i. 0\ nc % blmgroior(HICIProgrwill » have access to the arbitration
(not inheHue f m
al
program or guur i
ln)lnfo sunder on the Cunlstructio other
8 r fillip or License riant form in be found atC,Prugraln can be lt round at
iorl
neJ, p ids the infoI nlg?, o hen substantial twrk is plao including garage, linished basement attics,decks of porch)
rotai liour area I sy. K.I Habitable romp count
Uroislisingarea"el I'.l —_-- _... . -- Numberufbedruonls
\unl her ol fireplaces .-. _ \unlbero I'll alihathi
\lusher ofhalhnwnls , . \unthcrofdceks porches
1'\1)e Ill 11e.1f ng i1,IC111 Enclosed 11pd11
I
1 I)pc
1 t. 1a6d PfP�eet tillllllfl'I'oPla4e lint% he s11bslinded Iilr"fotal Prujecl Cui!"
I
CITY OF S,V-F.`i, AUSa1CHuSETTS
l31.'tLDLVG OEi.1AT1E,\t
I'0 WASHfNGTON STAFBT, 1'*F20C4
I*RL k978) 744.9591
41®F_Ar Y OIUSCOLL P.Vt(978) 7 984d
MAYOR MO.tW SLPtliif
011ECT04OFP1 HICPROPEA Y/1"nOICCO-%N133f0NEIt
Construction Debris Disposal At'tldavlt
(required for W demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 I I.J
Debris, and the provisions of MGL o 40, S J4;
Building Permit At is issued with the condition that the debris resulting from
This work shall be disposed of in a properly licensed waste dispose) facility as defined by&ICL e
1 11, S 1 JOA.
The debris will be transported by:
2P-s �s
(name ur'hauly)
The debris will be disposed of in :
(nAme of raclliiy)
f iddrm or rl.Il,iy)
u�o-irate of perm) lint
„'!Ip
ary OF siiiumll NWs.1CHL;SE'ITS
\.1J BL'ILDI\G DEP.4A"T\lE.\T
;�) ';�`1 ; '7�'•/ - 120 WASHLVGTON STREET, 31O FLOOR
TEL 978 745-9595
Rkx(978) 7 W-9844
j\taF nI FY DRISCOLL THO.%LkSST.P1ERM
�UYo.Z
DIAECTUA OF PL'9LIC PROPERTY/BCRDING COJNISSIUNEA
• )Yorkers' Compensation Insurance Affidavit: Builders/Contructorv/Electrlci•rn+/Plumbers
1 I dleant information Pfcaqe Print Leaihl
.Vllln,:Inueiil...yl7rgtmratiun.1/ndividu.d); / � Q ��°�.
Address: � 1J rl�`C L�
CilyiStatc/Zip: rti PhoneN: L
Are you an employer?Check the pproprfate boss Type of project(required):
� a employer with s, ❑ I am a general contractor and 1 6. (]Now construction
dulployces(full and/or part-time).• have hired the sub-contnctars
2.❑ lain a solo proprietor or partner• listed on the attached aheeL t 1. C]Remodeling
,hip and have no employees These subcontractor have R. ❑Demolition
working for me in any capacity. worker'comp.insurance. 9. Building addition
(No worker',comp,inwrance S. ❑ We are a corporation and its
officers have daarciscd their lo.❑ Electrical repairs or additions
3. required.]1 atn a homeowner doing oil work right of exemption per MOL I I. furnbirg rcpain or additions
myself.(\o worker'stump. c. 132, 410),and we have no Ropf rupair
insurance required.)r employees.(No workers'
cutup.insurance required.) I ,❑Other
,vuy upplls ud nW dhcclts but rt mug alas,all out this sedtiuo below,hawing chair roakm'compenmlun paltry mnumu la n,
'I1.nvuwnert wha,uhnlil thin atllAnvie Indicaing they an doing all work and then biro wtnide eantraeron tutu)mbmll n new m7ldnril indkoting such
$'omnwtun tMll rhak thie boa tuner auaehud an a llung.hst showing the nwnJ of tbd aYbiuntrrrtdre and thalr wnhm'wmp,pulley Intuematloa.
lain an rorpleyer rhuNi pruvldinR lvorkrn'cumpwuarlun lnturuncrjar my emp/uyrrr, Below is the polcy and fob War
irrjurnrutlnn.
In.Wmtice Cocitpany Valne: ___,
Policy 0 or Self-his. Lie. N: Expiration Date:
Job Site Address: City/State/zip:
\ttach a copy of the weaken'companeatloe policy deelarallan page(showing the policy number and expiration data).
Kiiluru to wcuru cuvdrage as required unddr.Scction 25\of 3tGL c. 152 can lead to the imposition of criminal penalties of a
rinc rip to il,500.00 und/ur one-year impri.aanment, is well as civil penalties in the farm of STOP WORK ORDER.arid d lino
Of up to S230.00 a Jay against the violamr. Ire sdvised that a copy of this m4tdmcm may bu I'urwardud to ilia 011icd of
Invcsligalions of Ihd OIA for insurance coverage veri licaliun.
/du Jrrrrby ce it Jrr that pubtr cord penalt .r a p u tlmrdtr Gtjunorulmr pruvidrJ ubuvr I:r rrtu',er/,,ur/d currrra
i .of,, t Data: G !�
et I:a r: 9 � j7
0114 iul rme may, Oa,tor ivrirr iris tln:a area, ru Sr rumpl ted by city us,town n/fkiai
City nr Ilnao:. -. .. .._ Permitif.lcense i
I ss uioy \uthurily (circla one):
1. liwird nl health !. Iluildlm; nrparlwcnl I l"i(pT, vn Clerk J. 1•:faetric.tl l,t,pcctnr i, Pluntbint; Inapeenv
G. Ihher
l, nl.icl I':ri... .._.___._.._..— Phone.lt
05-25-'12 16:41 FROM-Phil Richard Ins. 1-978-774-1318 T-923 P0001/0001 F-977
AC QR a" DgTEIMWDDNYYY)vr
__ter CERTIFICATE OF LIABILITY INSURANCE 05126/12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY 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), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polioy(ies) must be endorsed. If SUBROGATION IS WAIVED,Subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this Certificate does not confer rights to the
certificate holder in lieu Of Such endorselnen 5.
PRODUCER 978-774-4338 CONTACT
Phil Richard Insurance,Inc 97$-774-131$ PHONE
27 Garden Street Unit 18 Arc No Eat), PJC No:
Danvers,MA 01923 E6C
Cynthia Backe ADDRESS:PR u R OKEEF•1
G TOMERID#:
INSURERS AFFORDING COVERAGE NAIL#
INSURED O'Keefe Brothers Construction INSURERA:NGM Insurance Company 11066
397 Linebrook Rd INSURER B:Travelers Insurance
Ipswich,MA 01938 10647
INSURER c:Scottsdale insurance Company41297
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE L POLICYEFF PQUWEXP
POLICY NUMBER MWDDM MMIDDNYYYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,00
C X COMMERVALGENERALLUASILITY CPS1480676 03/07/12 03/07113 p n $ 50,00
CLAIMS-MADE OCCUR MEDEXP(Arydnepemen) $ 1,00
PERSONAL&ACV INJURY $ 11000,00
GENERAL AGGREGATE $ 21000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,00
X POLICY PRO LOC IS
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
A ANY AUTO M111363Z00 03103112 03l0&13
(Eaac ent) $ 1,000,00
BODILY INJURY(Per(Breen) S
ALL OWNED AUTO$ BODILY INJURY(Per Actidtnl) $
X SCHEDULED AUTOS PROPERTY DAMAGE
HIRED AUTOS (Per accident) $
NON-OWNEDAUTOS $
$
UMBRELLA Me OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIM$-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION 5
AND KERs EMPLOYERS NSATIONUAsIUT WC STATU- OTH-
ANDEMPLOYEPS'LIABILI7Y YIN - T
B AN'FIceRMRIETORIPWER ARTNE p1ECUTNE NIA
GS62UB-4530P19-0.11 04114112 04/14/13 E,L.EACHACGIDENT $ 11000,00
(Mandatory In NN) B.L.DISEASE•EAEMPLOYEE $ 1,OD0,00
If yes deswW Wder
Dts6mp osi OF OPERATIONS bebw E.L.OI5EASE•POLICV LIMIT $ 1,000,00
DESCRIPTION OP OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addltlonal Remarks Schedule,If rewe space Is required)
Evidence o£ insuraneO
CERTIFICATE HOLDER - CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE WITH THE POLICY PROVISION$-
40 Sable Rd
Salem,MA 01970 AUTHORIZED REPRE5ENTATME
� -31101-
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