25 SALTONSTALL PKWY - BUILDING INSPECTION (2) }
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7's edition ReOv s�ed aJa� EMary
{� Building Permit Application To Construct,Repair,Renovate Or Demolish a 1,2008
One-or Two-Famf Dwelling
Tffl Section F roffl$o Use Only
`41 Building Permit N mber: Applied: 31Z 7
Signature:
Building CornmisKinned lnspecto of Date
SEC :SITE INFORMATION
1.1 Property Ad//dress:1( 1.2 Assessors Map&Parcel Numbers
�-� `n /TOryes_s e./l doa,, 4.aw
L l a Is this an accepted street?yes�no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record.•
Name(Print) Address for Service: .
Stdature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑TExisting Building❑ Owner-Occupied ❑ Repairs(s) IR Alteration(s) ❑ Addition ❑
Demolition 67 I Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work: / I Y r tCyr
r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ ( 3 1 O U 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Co 3 m 6 multiplier x
3.Plumbing $ 2. Other Fees: $ r
4.Mechanical (IfVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ f 3 t10 O ❑Paid in Full ❑Outstanding Balance Due:
ob
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
�'/ Cl �793 3 O/O
6,e p h #
q e _ b e M,•d i 3 License Number Expiration Date
Name of CSL Holder
e �'d`. .L.w h 4 Yti/3. List CSL Type(see below) u
eAddres T Description
U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
78/-2s, Y`6 4) I RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIQ
G�LI, 10it ev, di/'
HIC Company Name or HIC Reg/iil�strant Name Registration Number
74 /'t. i c,A i H M.. /Y1iC• LVhh M/`/- //
Ad ure s^t.a
-6 Expiration Date
Signat elephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, -1 0 Al 2 .t C 4�;s+` N e [T t I iL-u"e,h as Owner of the subject property hereby
authorize r ep�q e ; h e .`i 1 ; to act on my behalf,in all matters
relative to work authorized by this building permit application.
X9, atu2e —
o� 3JIS1/O
f Owner - Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, .9. Pr P 11� 51 1 ,as Owner-or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. 'f� 4-,
n 1
�Y a 11 A 2
Print Nar e j�
l/S /1 0
Signature of @v ecor Authorized A ent Date
(Signed under the pains and penalties of
NOTES:
1. 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 not have access to the arbitration .
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
0e '�oyivnrxoxrcrrt�bl':c�✓�.000ucs�ertuQ2
Board of Building Replationa'and Standards '
Cor strttetlon Supervisor Mena
i
Lir _CS 89793':
EWr V13/2010 Trig 24722
R '� o i
j GEORGEH PIPE2�IDIS
X
�
as ECHANGE SI "t I
i LYNN,MA 01901 commission"
Office of Consumer Affairs&Business Regulation
C HOME IMPROVEMENT CONTRACTOR
Registration-
14148811
Explration z1 012 7/2 01 1 Tr# 291529
Type:i-.;L.Individual.-'
S t,`
GEORGE H.PIPEVIDIS :. '.
GEORGE PIPERIDISL
79 MICHIGAN AVE.,, W4
LYNN,MA 01902 Undersecretary
,S CITY OF SALEM
j PUBLIC PROPRERTY
DEPARTMENT
rat,S1.t.;.tt
I'rl:v7t.Ni:/jyS F%X:978•74'1846
Construction Debris Disposal Affidavit
(required Our all demolition and renovation work)
1n accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit li _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name ulTaclltty)
(aJt SA Ut•t•JCIIIIy) /fin
ry hcanl
vgnrt euFlxrmit PP
� ' 17 Il0
date
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ACORQ CERTIFICATE OF LIABILITY INSURANCE DATE(MNVDDIYY3/17/zolYoY)
0
PRODUCER (508)651-7700 FAX THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC - Main ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
233 Nest Central Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Natick, MA 01760
INSURERS AFFORDING COVERAGE NAIC#
INSURED George H Piperl is INSURER A'. Nautilus insurance Company
DBA: Olde Towne Construction INSURERS: Travelers Indemnity Co ZS658
85 Exchange Street #L1 INSURER C: -
Lynn, MA 01901 INSURER D:
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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. '.
INSR DD TYPE OF INSURANCE PODCY NUMBER POLICYEFFEDAM DCTIIVE POUCYEKPIRDATION LIMBS
GENERAL LIABILITY NC85525S 04/17/2009 04/17/2010 EACH OCCURRENCE $ 1,000,00
1( COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 10D,00
CLAIMSMADE OOCCUR MEDEXP(Any one person) $ S.
ON
A PERSONAL BADVINUURY $ 1 000
GENERAL AGGREGATE $ 21000,00
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS�OOMPIOP ASS $ 11000,00
POUCV PRO-
JECT LOC
AUTOMOBILE LIABILITY
COMBINED 5INGLELIMIT $
ANY AUTO (Ee ecddem)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per perwn)
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per ewidern)
PROPERTY DAMAGE $
(Per ewidem)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN
AUTO ONLY'. ADD $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR ❑CLAANS MADE AGGREGATE $
DEDUCTIBLE
$
RETENTION $ $
WORKERS COMPENSATION AND UB0485N68810 02/28/2010 02/28/2011 ORVT'M OT
EMPLOYERS'UABIUTY ER
B ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100,00
Rye, RIMEM,rrm LUDEDi E.L.DISEASE-EA EMPLOYE $ 100,00
P yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ S()0,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
e job: John & Christine Hiltunen 25 Saltenstall Pkwy Salem MA.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
0 -DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
City of Salem OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Salem , MA AUTHORIZED REPRESENTATIVE
Donald Uvanitte
ACORD25(2001lo8) FAX: (978)740-9846 ®ACORD CORPORATION 1988
2
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed.A statement
on this cerfficate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATI ON IS WAIVED, subject to the terms and conditi on 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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25(2001/08)