0000 WASHINGTON SQUARE SOUTH SALEM COMMON BPA-12-213 \� - - ---- l'lle C'onunonwe:dth of Massachusetts
Board of Building Regulations and Standards CI'I'1'OF
Massachusetts State Building Code, 780 C NIR SALEAI
Building Permit Application To Construct, Repair, Renovate Or Denn>li- a
One-or Tttvt-hirmill Una
This Section For O' cial Use Out
Building Permit Number: ate
//AJJp��plied:
Building ffilmal(Print N;une) Signatu Dale
SECTION I:SITE INFORMATION
I Property Address: 1.1 Assessors Map& Par Numben
_S�iPn'1 CO rnws O1V
I,la Is this an accepted street?yes no M1lap Numher Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/on DiDistrict Pr—op..e UUsa Lot Arca by It) Fromage(tl)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Reyuircd Provided Required Provided
1.6 Water Supply:(M.G.1.c.qa,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici el ❑ On site disposals)
Check fif es❑ P stem ❑
SECTION 2: PROPERTY OWNERSHIP'
I Owners of Re ord:
O�r
Name(Fein ) Lily.Statc,!.I P
No.and Street Telephone &nail AJdmss
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction I!] Esistittg Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ .Specify:
/ Brief Description of Proposed Work': tZ ez- a•• p e rVT
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and .Nlaterials) Ofllcial Use Only
I. Building S 1, Building Permit Fee: E Indicate how fee is determined:
'. Electrical S ❑Standard City/Tosvn Application Fee
i, Plumbing S
❑ i Total Project Cost'(Item r
p 6)s multiplier __ -_.----
_. Other Fees: S
q. Nlxhanical t11\':\('1 S LisC
15. Mechanical iFirc ----
Su t tressionl S Taral .All Fees: S - .------ ---_..----- -
/ Total Project Cnst: S Check No. ---Check:\mown: - _Cash ash \mouse -
f ❑Paid in FuII ❑Outstanding Balance Due:
SECTION 5: CONSTRUCriON SERVICES
5.1 Construction Supervisor License(CSL)
License Numhcr I:cpiratuw Date
N.une of l'SI. I luldcr
List CSI.1)pc)sec hcluw') —
S� .1.tPe Description
No. .aid Street /
l I InratriclnJ Iliuildin+s ti to 35,1100 cu. It.l
��/fC (J/� •/I F}" _ R lic,lricted I&'_ITamil ' MwIlinil
Cilyifown,.State./I1, ---- N1 N111sonry
RC' R+wlin C'overin
-_-- WS Window,md Siding
SF .Solid Fuel Burning Appliances
Insulation
'I'cic hone IimaiI address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Numlx:r lispiroliun Dute
IIIC C'nmpan) Name or I IIC Itegislrunt Name
No, and Street Email address
City/Town,State,ZIP 'relc hone
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 .......... ❑ No........... I]
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
ct on my behalf, in all matters relative to work authorized by this building permit application,
P 'n,Owner's Name(Electronic Signature) Dale
SECTION 71b:OWNER' 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 and accurate to the best of my knowledge and understanding.
Print Owner's or AuthorircJ,\gcnt's Nano I :1cetrunic Sigmuurc) Date
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 Lig)j have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
tt Asa v.n. !t. , �,I Information on the Construction Supervisor License can be found at Jp,
2 When substantial work is planned, provide the information below:
Total floor area(5q. R.) _ ___(including garage, finished basement attics,decks or porch)
Gross living area tsq. Il.l --- _--_--_-- -- Habitable room count
\umber of fireplaces ..._ Number of bedrooms
Numberolbathroouts .\umberofhalfhadts
I\pc ofhc:uingi)Stcm -- .. . - -- Number ofdecks, porches - - . _ .- ...
Enclosed
t. "I mal Project Square Foomgc"ma) he SnbStltnted for''fotal Project Cost-
08/1'Y/2011 12:59 978-744-7225 SaLE14 C(JIJNC ON AC,TJG PAGE 01/03`
rug. 10, zv, t 1:vrrm 5v$- Z33- �tSS No. 4050 P. 1
Criy oF SALEm,.MASSAGHIJSETTS
PARK,IM- EA770N&COMMUNUY SERVICES:
5 B OAD S2RT rT,POST CIMCRBOX 465
SALk`M;MASSACHUSL+M 01970
xinrfSPA_ 40L1: TEL(078);744-0180Ox(978)74�44924
MAYOR F.+X(978)7447225
bR07dPNS�SAtyat,GDN
DOUO[ASJ.80U13N
DnUK, 'OR
APMJCAnM,PTO USE MUM coMt�1[Qx
Ta ms 1Mrlr;Rc�uoo�eo�.,fh ee, nteeNaar�moo;
we,die UWWiWrr���dp//% f�/y'Wlrapaq$m ue.ute sekm a As& a
RAMEOFPERSM.- lldam /Y ,U k=6ilee
oteaAfverArrox t'-/.4 Amto� tt _a-lazw
ADDRM,, eSO (�.ara S; s," iF»S�— IIA &7S.7 .
TUXPff0MW;MBEFL_.s-a 1� o 3a 6 711/4
SST42DATM /0 .F6Prgja//aftEAx_oowNDA=;,/o Ssarap/J
Tltmc iomor3
ATTENMUCE: APrMD70A"}EMAWAOF PBDPlE fiL. .
TYM CIF UU REQUE.4TED CHEM ONE
Wedd c4ft naiw
RCI9giousEvem. Specifies
CMA Fair—Number of vendm
Rued Pa=Val&-t-"—map of route muRt a of igiMdan
C4v Event-Each in�vidval aleaclon musf be listod ofercvcrse'
Qfthis page hwhimag bmn by hwr bfak&wa of
Evot.
Masiw_ Type OfMWe
Nuoiberofisk�
Amp}ifim(vas or no)'
Other(pieasc:eapiain)
Fill out beam of#As pagawitb specific iafforms imt md`sr wwa ofpa wd
rmrs-ALL CONCE ITS MUST BE IN FULLCOMPLW=WnWTEM
SALEM:NOISE ORi7'9VANCE'(ENC )
r
i
08/W/2011 , 12:59 978 744-7225 SALEM COUNC ON AGNG Np, QQSa PPAGE 02/03
CMCRCt/FFAUOFLdtNGl�
.TRE 78A,TPERrAINT0Y0mEt'EtV'P
✓ _ '—L�npmYxa SYrn'
/APPNare*aaEmdiCYq) ar1cT�naC9?8745-000 tp
�t�LiStmrmfor decomiad a�vme
f" TapecEBotapdfeme� '
aaattactdfa"mUite�rl�etc, sdvEasat tr744-0}$e
TOOs Airactor'sRieEdesFzs� +am�erte�salloaad
Fae►ear Applicant' akoea 4l�ftePoe mtt978-74-'7MtjrttpwmEbm
u Fa16kSm�imryF p(mi�l 'd& `ol.W'�
'Q' :
AppftaNareomaatdteEteepll'Aapm'heanCffi.979-745-9;4aA5rgSsoiteyFad'li
Reelekl>wmtmffit*a@�dro'Pnic,t#natsatim�CipOooeanf��avVnxs D�a trpmt eo.
deoeemrme saigbla
Loeeuonfbr>�i�m.
Foot-tom■4 dte�pela3is fa yao rircoC
com'dus
ApDlieardamst oaomct maF -A +®t 978 745A59S;75ttDs9Td•745+??77
Lieeasing Ao�d97B-'fAS9S95;8ntaddkimiai vLie�,Food 7mm�imd�e
Vmdasl9ak otCoed�Ma `�—tint kereo 6e soid
AppJitant mmt Igoe Aaomtin4BostYsa47E-T459SRf ldc�tdicg vmdOrli
OdmcAWvfd s—WallcPoa we&a "voinbehm,aspnorywc m
AppliegM is tes�aionadfa -q�e Saldn PdicaDept�918244D171e�d127
RCP'ft$the new*ofs Pon o bowl*ow#yalt
Applicant ea aieo MOM&to cwdwt Bee Salem Pollee DainwQmeK Taft Divisi
At 978-?44AI71,caR 137;n�arg ha$ie issaas
Appliedamsa ASot aWROMot hShM Ambulat w at97$744-1349 rep*g
0msit0 a0mgoWscm!0--
Fe um to oomeettk 8etam Dgmft entshaU be Vpmo4 fbr eovo*Wm of pemtk.
I
f
0811.?f2011 1.2:59 1 .978-744-7225 SALEM COUW ON "AGNG PAGE 03/03
No. 4050 P. 3
CrrY OF SATXK MASSACHUSEM
PARK; REG'REAmoN&coAw JNrrysmv7cm
SBROAD MfMT,,POST OMCB BOX 465
SALBM,MASSACIifJS�TIS;Qf970
CRtSCOt L TEL(478)74"180 OR iP78)744 0924
huyOR PAX(970)744-7223
DRMI1t *ALSKWM
DOUGLASJUOUMN
DMECTOR
A CAA LIST SALE1►! COMMQN
8ippattrte of
d DaectnrSippmmcofApprova(
RecommondetloaofParkaadRectuda► Appm�ed 7J�ed
comrnem tic 7_. . ¢. , t '� Cl qme c
iap®rthe gppvatwn,phw rows W.
C*,Ocsabm
Park, itareaat&Caemro[ty Setvkeit
3iBroad shod
Saeat,MA M"
Seeatraehadibr Raw Fam.
MOD DMNPdMVAObebMwd�liapeodoaby Pak mod Ns"dgy
! �Sae3'beeceiflU�demegetefo�t.
_O fie&Pak Rmcm&mtG RYSWW=Dhc=v71walmdedsmmanaaa'
of wakas her taeb;event.
All tash saw be pined inpkodcbego'aedpinetin vnqmdm ordWpmWdw
rorCitypi ck uT-
Plane aiga appllca�oASAPoCmyau:A�,
i
f
lee Ile• 1e ee 1e19 I • It lee 1e ee It Be• lee It Y e• lee It
® ®® ®® • 1e0 !go Formation to be 3 x 100
, lee ae• fee
Flag rpole o
:� o0
o'
wAi iL
.J Fl W,'R
gel same come OGG" ego" gone gemie
lute
II i
Annex C Troop Formation
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
= tr Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): vl
Address: M O L0 X-d v% S
City/State/Zip: ZfW45(w OI Phone #: Gi-7&--$St—'20oZ
Are you an employer? Check the appropriate box: Type of project(required):
1.L.7 I am a employer with I'�_ 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P Y• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.'
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: s t WL,
Policy # or Self-ins. Lich. #: �.[�U �Cf�9"I yy 9 Expiration Date: I 3f - 20 1 Z.-
Job Site Address: S W(h [_�1 OVA M clN City/State/Zip: 1 GQ VX^ A
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under t e p ins and penalties ofperjuiy that the information provided aboveis true and correct.
Signatue: y PG r r^o Date:
Phone#: V`-1 p —0 S l -2,0 07i
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License 4
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Dq IC jMMIV Un I i �I
ACORD.- CERTIFICATE OF LIABILITY INSURANCE 04M9/2011
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 ADDITIO NS RED,the policy es)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 endorsement(s).
PRODUCER NAME:
US[ Rental Specialties PH N 800 854-3298 ac,Na: 949790922�
NC N Eat:
P.O. Box 53310 ADDRESS: ------
Irvine, CA 92619 CUSTOMRS ID s,
800 854-3298 INSURER IS)AFFORDING COVERAGE NAIO r _
INSURER A:St Paul Fire& Marine Insurance 24767
INSURED 25682
Baystate Electronics Inc. INSURERS.Travelers Indemnity Co of CT
DBA: Baystate Tent& Party INSURER C:
150 Lorum Street INSURER D: --
Tewksbury, MA 01876 INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER:NSUR REVISION NUMBER:
T THE POLICIES OF IANCE LISTED BELOW HAVE BEEN ISSUED 10 .....THE INSURED
THIS IS TO CERTIFY THA NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER l>OCUMENT WITH RESPECT 70 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.
LIMITS
TYPE OF INSURANCE POLICY NUMBER M DO MID
A GENERAL LIABILITY CK00223544 4/01/2011 04/01/201 M7C
RENCE E$ O
0
occ r-Ace X COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE a OCCUR one peson)ADV INJURY 0REGATE 000MP/OP AGG 0
GENL AGGREGATE LIMIT APPLIES PER:
X POLICY PRO- LOC SINGLE
COMBINED SILE LIMIT S
AUTOMOBILE UABILITY (Es accident)
ANY AUTO BODILY INJURY(Per person) $
rI ALL OWNED AUTOS BODILY INJURY(Per accident $
SCHEDULEDAUTOS - PROPERTY DAMAGE $ ---
LAGIGREGAATE
accident)HIRED AUTOS $
�j NON-OWNED AUTOS $
5
UYBRELLAUAB OCCUR
I,—{I EXCESS UAB CLAIMS�AADE $
$
DEDUCTIBLE $
RETENTION OTH-
B Wow S COMPENSATION XNUB5899Y49711 1/31/2011 01/31/201 —
AND EMPLOYERS'UABILRY YIN E.L.EACH ACCIDENT $1,000,000
ANY PROPRIETO"ARTNERIEXECUTIVE WA
OFFICER/MEMSER EXCLUDED? a E.L.DISEASE EA EMPLOYEE 51,000 OOO
(Mandatory In NMI
II es.descndeunder E.L.DISEASE.POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATION Eabw
DESCRIPTION OF OPERATIONS I LOCATIONSI VEHICLES(Attach ACORD 101,AddlUomil Ramar6a StniKIU a,If more........
This certificate is issued as a matter of proof only.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
01988.2009 ACORD CORPORATION. All rights reserved
ACORD 25(2009109) 1 of 1 The ACORD name and logo are registered marks of ACORD AXLJG
AS557809SIM5578096