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36 SCHOOL ST - BUILDING INSPECTION �17 Y d The Commonwealth of Massachusetts {. Board of Building Regulations and Standards CITY OF o Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2017 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Fancily Dwelling This Section For Official Use.GKIY Building Permit Number: Dore Appli : Building Official(Print Name) Signa a Date SECTION 1:SITE INFOR N 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 36 %ClAo0L- ST. 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1 4 Property Dimensions: ccSI EENriN— 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 g Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑ Check if yesltd SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert of Record ALIAS , LLc ( TmN WREN- h1A NEflb n � OI�1GS Name(Print) City,State,ZIP IS "l6GINS Kt, '1%1 - - ')3V No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building A Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work': VFPLp,'-C WN11OWS NEW IbWIS MTALL'ATt SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: - Official Use Only Labor and Materials) I. Building $ ` G p09 I. Building Permit Fee:$ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ �� 4.Mechanical (BVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ / Check No. Check Amount: Cash Amount: G.Total Project Cost: $ IO I O 0 0 ❑ Paid in Full ❑ Outstanding Balance Due: (�Ckl�vrc�i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) p g q p S t ToH Asz ��LINE License Number Ex tali n Date Name of CSL Holder List CSL Type(see below) U 1S- klG61NS Rh No.and SnectlI', Type Description HA Q ,�—k 6A n MR 0 I `7� U Unrestricted(Buildings u to 35,000 cu. ft.) 41 R Restricted I&2 Family Dwelling City/Town,State,ZIP M Mason ry RC Roofing Covering WS Window and Siding �� SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement gqContractor(HIC) Noyii CONS-PueN-19/v q LE`Mol1 coo,) y o HIC RegistrationNumber E HIC Cm any Nam e or F Registrant Name pira n Da[c hA! LtCWA� hA 0195' 'igi-7ZJ -132-7 Email address City/Town, State,ZIP Telephone 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 ..........A No ...........❑ 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 Owner's Name(Electronic Signature) Date SECTION 7h: 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 ace rate to the best of m knowledge and understanding. LoHfSZ �flgtfo �fiLifiS I L,LG� lti 6 Print Owner's or Authorized Agent's Name(INectionic Signature) 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 not 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 LLi .mass. oe v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns 2. When substantial work is planned,provide the information below: Total floor 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"may be substituted for"Total Project Cost" r 2( �� O(fice Well of consumer Atetry&Businessu�anoo ! HOME IMPROVEMENT CONTRACTOR t� Registration: 146850 Tye' Y Expiration: 5/2012013 Private Corporatto' r NjV7CCONSTRUCTION 8 REMODLEING, INC. TOMASZ WABNO 15 HIGGINS RD. - - MARBLEHEAD,MA 01945 _ Undersecretary License or registration valid for individul use only before the expiration date. If found return to: office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 -- Notva id w itutsre - - r \I:n�.ic huxtn - Uc p:rrtmrnt •rl Public �.drtt 1 Sna rJ 'd ituilditt, Kr,u Ltlinn� .uul �ctnJ:u'rls License: CS 89905 Restricted to: 00 3 TOMASZ A WABNO 15 HIGGINS RD {+ MARBLEHEAD, MA 01945 e--�— Expuation: 6/4/2012 r ••uuu �.••n.r Tr4'. 26405 Restricted to: 00 00- Unrestricted tG - 12 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Referto: WWW.Mass.Cmv/DPS CITY OF Sm EiNV I, N'LxsSACHL'SETTS • BUILDLNG DEPARTMENT • ' 120 WASHINGTON STREET, 3m FLOOR �.x o TW- (978) 745-9595 FAX(978)740-9W KLN(B Rt EY DRISCOLL MAYOR T HONtAS ST.PIERR6 DIRECTOR OF PUBLIC PROPERTY/BUMDLNG CO.%LNUSSIONF_R Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �O Please Print Legibly Name(BwitmsiOrganiration/Individmi): NOVA CoN51FUc-' loN Address: City/State/Zip: hAKg[ChWS MA ol9AS Phone #: Are you an employer?Check/'the appropriate box: Type of project(required): 1.V] I am a employer with 4 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity, workers'comp.insurance. 9. ❑Building addition workers'comp. insurance S. El area corporation and its required.] 10.❑Electrical repairs or additions raquireJ.) officers have exercised their P ' 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees. [No workers' 13.❑Other comp. insurance required.) •Any uppliaua that 4fiwim box a I must also fig out the section below showing their workers'compensation policy infumwtton 'Ihuneowtxns who submit this affidavit indicating they ate doing all work and then hire outside enum"m must submit a new affidavit indicating sueh :Conttucton that chalk this box must anached an mWitional short showing the name of the mb.eontractom and their wurken'wrap,policy information. I am an employer that Ls providing workers'compensation hesurance far my employees. Below is the policy and fob site information. Insurance Company Name: L 1 t:,,f t'� Policy#or Selr--ins.Lic. #: C I —3� S '-' b b© Expiration Date: Job Site Address: City/State/Zip: �AL 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 S 1,500.00 and/or one-year imprisonment,as wall 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 ol'thc DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. SL tLantre Date, 1/ 4 / it Phoned: Official use only. Do not write in this area,to be completed by city or town offlciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of aleallh 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other. Contact Person: Phone#: acoR& CERTIFICATE OF LIABILITY INSURANCE I.' 7/13/11 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 policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A stalement on this certificate does not confer rights to the certificate holder in lieu of such efdorsement(s). PRODUCER CONTACT NAME: Circle Business Ins. Agcy, Inc PHONE (978) 777-5619 FAX A NO (978) 777-4898 297 Newbury Street ADDIRRESS: PaulaHalas@CircleInsurance.net Danvers, MA 01923 PRODUCERr.IIqTOMFRI 9- 1061 INSURE S AFFORDING COVERAGE NAICN INSURED INSURER A:Northland Ins Company Nova Construction 6 Remodeling INSURER B:Travelers Insurance 15 Higgins Road INSURERC-Liberty Mutual Marblehead, MA 01945 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. INSR rypE OF INSURANCE ADDLSUBR POLICY EFF POLICY UP LTR POUCY NUMBER IMMIDDNYYY MM/DD'YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 OQQ QOO A. }( COMMERCIAL GENE RALLIABILITY WS073626 5/18/11 5/18/12 DAMAGE TO RENTED P E 1 otter $ 100 000 CI-AIMS-MADE Fx—I OCCUR ME UP(Arty one persm) $ 5,000 PERSONAL&ADVINJURY $ 1 000 000 GENERAL AGGREGATE $ 2 0D0 000 GENTAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG Ti.000,000 POLICY PH� LOC $ AUTOMOBILE LIABILITY CONE INED SINGLE LIMIT $ B ANYAUTO BA1427R926 5/18/11 5/18/12 (Eaaccidert) PLLOWPEO AUTOS BODILY INJURY(Per person) $ 100,000 X SCHEDULED AUTOS BODILY INJURY(PerxcidanQ $ 3-- ---- PROPERTY DAMAGE HIREDAUTOS IPeraccident) $ 100,000 X NON-OWMEDAUTOS $ $ UMBRELLA LIAB _ OCCUR EACHOCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X. WC STATU- OTH- AND EMPLOYERS'LIABILITY yI C ANY PROPRIETOR/PARTNERIEXECUTIME —YIN WCl-31S-366560- 5/18/11 5/1B/12 ELEACHAcaDEW $ 100,000 OFFICERMIEMBER EXCLLOED? ] NIA (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 100,000 If yes,deeabe under DESCRIPTIONOFOPERATIONSUebw E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (Attach ACORD 101,Additional Renerks Schedule,if more slaace IS MgUIMd) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE LIE SCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St. , 3rd Floor '. Salem, MA 01970 AUTHORIZED REPRESENTATIVE Paula Halas "".1"''=".'`o ° u -r ° ., �enn�is..d © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD