0000 WASHINGTON SQUARE SOUTH - SALEM COMMON � _ �, - - --- I'he C'ununon�ecalth o1'M:usachusells - .
a Ilomd of Building Regulations and Standards CI I'V OF
Massachusetts State Building Code.'780 C NIR 5,\LI:�I
141'sholIfar=011
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Ttru-f amill Dive/thkv
This Section Fur 01' I Use Only
Building Permit Number: D e Applied:
_ � S�- 1 I t.e� I �
Building 011icial(Prim Mune) �y Signalurc Dulc
iVz
04 75, S C I: SITE INFORMATION
L 1 roperry Address: 1.2 Assessors asap S Parcel Numbers
I.la Is this an acre ted strew? es no wip Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
zoning District Proposed the Let Area(94 11) Frontage(11)
1.5 Building Setbacks(R)
Frunt Yard Side Yard$ Rcar Yard
Required Provided Reyuircd 1'ruvided Reyuirad Provided
1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Informations tMIansi
ewngo Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? cipol❑ On site disposal s)siem ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
' 2.1 Owners of Recardt
Mane(P — oily slaca.7fiP
No.and Street rdephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ E.risting Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteratlon(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bidi ❑ Number of Units_ I Other ❑ Spccily:
brief Description of Proposned Work':
SrnnQG r�--�yU�/o
I
SECTION 4: ESTIMATED CONSTRVCTION COSTS
Non Estimated Costs: Omclal Use Only
I Labur and.Materials)
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
:. F:Icelrical S
O Standard CityiTuwn Application Fee
❑Total Project Cast'(hem 6).v multiplier
1. I'lunihing S '. Other Fees: S_ —
J. \kehanical ill\ \('I S List: _
�u +ressiant S rota) .\Il Fccs: $_..-----
Cheek \'a. Cheek Amount: C'.uh \motmt:
n 1'uhul Project Cull: S g p0 -- _— _. _._..
J Sb, ❑ Paid in Full O Owstamdiog IlaLuice Due:
r ,
SECT ION S: ('ON5'1-RUCTION SF.RVI('FS ~
5.1 C'onslructiun Supcnisor License(CSI.I
I iccnee Numhcr I'yira wit Dole
Nalllo of l'.SI. I luldcr I Ist 01. I)lie(,cc hctuw l.
PC Description
No_.Ind Street (I I hnrcztricleJ l lLlilJin s ub u1 15,1100 aI. II.I
H I(c,tricted I.r? Fanlil I1%,elli'1
l'iNillno n,St.ue.LI I' ---. . . \I Mason
HC HIMItin l'o,crin -
__ 1 S window and Siding
SF SuliJ Fuel lLrrning:\ppliances
I Insululian
1'cic hone Flnuil address D Demolition
5.2 Re Istered I�/lome ImProvement Contractor(HIC)
,{ItZ e-)-e ro r— �t°u S IIIC Regisu;uiun Numhur I(cpirutiun Date
II Cum an) Nunes or I IIC I(`gistrwu Nanw
No. IJ S et 78 Emuil aJJress
9 hnne Sod
Ci !fawn,Stnt IP Tal-e hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L c. 152.1 2SC(6))
Workers Compensation Insurance affldavit must be completed and submitted with this application. Failure to provide
this atlidavit will result in the denial of the Issuance the building permit.
Signed Affldavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print U%wer's Nwne(Elcctrunic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering Iny name below. I hereby attest under the pains and penalties of perjury that all of the information
contained in this applicatioo true and accurate to the best of my knowledge and understanding.
r
Prim Dwnc or:\adloriivJ Al;cnl's Nano(lileclrunic Signature) ale
NOTES:
71hen—substantial
r who obtains a building permit to do his.her own work,or an owner who hires an unregistered cmuractur
(nuttered in the Hurtle Improvement Cuntractur i HICI Program!.will nu have access to the arbitration
r guar m) fund under M.G.L. c. la_'.A. Other important information on the HIC Program can be tiwnd at
. �+ • I Information on the Construction Supervisor License can be found at%%%," ni•n+stantial wurk is planned,provide the infurnlaliun below:
a l sy. Il.l _ ____,._I including garage. lmished basement attics.decks ur porch!
Cross li+ing area t sy. 11 l ..__._ Habimble round count _ _. ... .
♦rnt her o I'll replaces .. _ _ \unlherol'hedra.nns
\rnlher of hathroullls \umber of hall haths
I',pe of heating s)Uenl \nnlhcr of decks porches
' I\peal COOhllg iKlelil
I!ncla,cd Open
t "I al.d I'roiect Slltiarc Foot.Iec- IIIl1) he sub,ioutcd Ihr"fatal Project Co,l"
C[-I'Y OF S:ILi [, N LISSAC H L:S ETTS
BUILDING DEP.kILT*,IF-\T
120 C(LISHLVGTON STREET, Ya FLOOIt
TEL (978) 745-9595
-9844
.1NIaERI-EY DRISCOtl
�rL�YO Z THO�LiS ST.Pt>raxs
DI:LECTGiIGP PUBLIC PROPERTY/SUMMING CO"NISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contructurv/Electric(ans/P(umbers
knpllcant Infnrmatinn Pease Print Le¢ibly
4
.N; n e: ll)usitxsUrgtmration Ind/ividua/l)': r /`61i Z"'J- /L1G�GGlWFL�
,UdresS: /9 v ! Q E-�-V/ / Yr C- 4-1
citylstatclizip:4i /v , D 970 lahune
Are yniefjn employer?Check the appropriate bon typo of prn)ect(required):
1, I am a employer with s. 0 I am a gcnd:ral contractor and I 6, ❑New construction
employees(fall and/or part-time).* have hired this sub-contractors -
2.0 I am a sole proprietor or partner. listed on the attached relied. t 7. ❑ Remodeling
.hip and have no employees These subcontractors have N. 0 Demolition
Workingfor me in an capacity. workers'comp.inseffanCe. y
Y ❑ Building addition
(No workers:comp.insurance J. 0 We are a corporation and its
requircd.1 officers have asereised their 11 10.0 Electrical repairs or additions
3.0 1 mn a homcuwnur doing all work right of esemplion per MOIL 11.0 Plumbing reptdrs or additions
myself.(No workers'comp, c. 152,11(4).and we have no 12.0 Roof repairs
insurance required.) t employees.(No workers'
comp, insuiancerequired.) 13.❑Other
-,vny appliuun duo chwks bat rI maul ahu All uul the wetiw hrlow ahowiny their vrorkm'eomptnurlun puety inanmelfon,
'I A.nuuwmnt who.uhmit nis attl&vit Initiating they are chine all work and that hire wleide earenctere mime ruhmit a raw affidavit inditetine wok
:v..nurtun dial chuck this bull mute aninh d an.Waulury l Otte chorine the mina at this rui►eumruWre and theft works ni comp.pul fry Intent on.
!wn un eurpluyrr rhut/s pruvbJlnX tvorAtn'cumprnredun bnrurunce�or my employers: Below is Jre pollty and job able
iujururutlan. f y-
In..umucu /
Policy t7 or Self-ius. Lief, N: �U �.�,�0 —1�— 7�,Jr—1� Expiration Date:[�[fi, --')//j //��
Jule Sile Address: X,r..�G � �,P LL l a i7"t S City/slatetzip: / P),,f • .y//r`T . 2,1
kilaeh a copy of the workers' compensailos polity declaration page(showing ilia policy numbor and expiration data).
Kiiluru to wcuru coverage as required under.Section 2JA )t'SfGL c. 152 can lead to the imposition of criminal penalties of a
tine up to il,I00.00 andfur one-year imprismmnent,as well as civil penalties in the form of is STOP WORK ORDER and a ime
Of op to 5230.00 a Jay against the violator. Ile advi.scd that a copy of ihis.,latement inay bur furwardcd tothe Milos of
lavcctiy,ttiuos of dm MA for insurance cowragc verilicaliun.
b du 1wreby veriijy uuJtr the pair alla ptntrR es ofiarrjury/but flu pro vidcul ab yr .iv iruie wt i comics
O//itiab ,It mdy. Oa nor writt in this area, to be cumplefed by oly ur lawn n,I/,iud
City or fwv)):_______ Iacrmitil.iccnte.i_._. .. . ...__ ....
hwia�,\othurily (circle one):
I. hoard of Ileallh !. lNifillnt 1)eli:is latent 1. ('ilyi fawn L'lerk J. b:leetrical fltg)cctor i, plumbing; hllpec/ar
6, Ulller
Phone d:__
11/01/2011 14:29 603-964-1484 ALLEGIANT MGMT CORP PACE 01
Acr' CERTIFICATE OF LIABILITY INSURANCE e;as,
TWiS CERTIPiCATE IS ISSUED AS A MATTER OF INFORMATgl4 ONLY AND CONFERS NO FWNTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR AL ETWEENC TW� UD GE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTTNTTE A CONTRACT
REPRESENTATWE Olt PRODUCER,AND THE CERTIFICATE HOLDER• __
IMPORTANT: 1f RN wrtmesta bolder Is an AODTIIONAL NTSURED,tbo pdit:y(les)m�t pe endor On Oft sed H ���nW 15 WegnW Igtrfa fe UIe
eft OleeRWas am or4tiol
holdcorantlomer bt Beu oPof the policy,such dorsarna 9pogoles may Tequlle m endmas9rlenL atatElrlerlt
MCO
P U 61 T23.7775 TAM rl.t(617)723S15S
Tan Ronan 00 Hays Compsmas of New England
133 Pederel SVaet
Second Floor B®La+ A1SY8818is covillAin &
Sceton,MA 02110 lam
asuRetA: Zudch-Amedmn Insuranoc Carla
NBURBB a:
Alleglant Management Corp. -
30D Lgiayade Rd. o: .
Rye,NH 03870-000 Fder
COVERAGES CERTiFICATENUM®ER:11H"IW7DDf)96 - REVI310N NUlNBER: _
INDICATETF�CeD, NOTWTT}L4TANDMD ANY REDNRENI NT.TERM OR CQIARION OF'' ''kN LISTED BELOW HAVE ANY CONTRACT OR OTHER DOCUMENT YJrrH SPELT 7L HICFI MB,
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE asEURADICE AFFORDED BY THE POLICIES DESCRIBED HEREIN $USJECTr TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,UMR9 BtroWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. tLees
TYPE OF grBURAMDE SASH DCCURPE E S
GENML"PUT'/
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DOMMeAWL OENERA I mmD un wnl 8
CAIMe-MADE OCCIR iAL BAOY IN LW s
o AliaMOATE s
PRODWr8e ooNpmPA00 s
GENLADORaGATE LOAT APPME$PER S
PDMLY PRO.- LOC
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AVIOMOa9.8 LUBILIT' tRroILYRUURY(i9r Paw A1 ANY AUTO BODLY"wry Her w0dNYl S
ALL ED SCHEOdPO PRDPERTT OR E $
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IIINf$IA LIAR OCCUR A00EDAM s
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AND WPLPLayWLIABaRY TIH 1,101/2011 11f0112012 e' FJWIIACC@EM
ANY PAOPRRlTORRARnWW;rCIT`E❑ NIA WC SO.90-735-M E3.OP9EABE•FA EMPL S M1,DOD,OW
A (M In RMH)PXCL 1,000,000
EI aISEAEE-POLICY LAwT s
o°F° as a+w
Fppy; 11l01120,1 11101f-0012 CBeIO 821
ACORD 1Dt.AdIEaMB�Sttdul4aPveepaw M.eq,Aaq -
0E3CRIPnDNOP CPBRATTP�CA Rer cln �PwOfts Tor Rant
C&NA9e N Prrr4ded Tor 464 Lowell St
0*#awplovavaPeabody,MA 01880
leased to but not
wbcw&Bddrs at
CANOE TiON
CERTIFICATE HOLD
stIDIA.D ANY Os THE ABOtIH DSDCRIBBD POLICIES BE ClENGkI.t-ED BEPOrE
Honk shore Rental,Inc. THE w"ATWN PATE THEREOF, NOTICK WELL BE DELWLRED IN
dW-Everts for Rent ACCORDANCE IItTH THE POLICY PROY1610NS.
464 LMNNI St --
PBaDOdy,MA 01960 AtrTMpRRED RepMENTATNE
1988.9�RD CORPORATION. All rights reserved.
ACORD 25(2010.r05) The ACORD nAma and logo are repislered marks of ACORD
o �ns�n��n�l�n��ns�nu��n�n�ns�nrs�n��nrnn�ns�n�r- I M P O R T A N T DOCUMENT
5 -
5 5 -
S
(Certtfita�te of flame Rroi5tau.ee 55
D BY
REGISTERED ? Date of Manufacture
S APPLICATION 5 = Ro 03/07/00 S NUMBER NDUSTHIE5INC 5
5 , Order Number SOS EVANSVILLE, INDIANA 47711 5
SFI21.4 vs 311548 5
5 MANUFACTURERS OF THE FINISHED 5
TENT PRODUCTS DESCRIBED HEREIN 5
5 This is to certify that the materials described have been flame-retardant treated S
5 (or are inherently noninflammable) and were supplied to: 5
1101119 5
5
5 PAUL
LOWS RILSLO CO. #13528-8 S
5 PEABODY MA 01960 5
5 5
S Certification is hereby made that:
5 The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire S
5 Marshal Code, equal to exceeds NFPA 7010 CPAI 840 ULC 109. 5
5 The method of the FR chemical application is: 5
5 Serial #: 5
8106400(14) C
Description of item certified: r.C5,1
S TENT WAL L&S2 6-10 X 22 2/CA W
5 Flame Retardant Process Used Will Not Be Removed By 5
5 Washing And Is Effective For The Life Of The Fabric 5
5 .IOHN BOYLE STATESV(LLE NC Signed:
5 Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC.
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