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45 SCHOOL ST - BUILDING INSPECTION 1 The Commonwealth of Massachusetts ' Board of Building Regulations and Standards CITY OF rt 1� Massachusetts State Building Code,780 CMR SALEM ry11 Revised Mar 2011 \QX) Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: - Date Applied: Building.Official(Print Name) Signature Date. SECTION 1:SITE INFORMATION 41 1.1 Property Address: 1.2 Assessors Map&Parce umbers -ram 5t l cal S�-. „l�LtU/U tQ 1.la Is this an accepted street?yes no Map Number Parcel Number 13 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?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP` 2.1 Owner'of Record: T'z n n i Name(Print) City,State,ZIP to ,} -'61�75- 6a 1� I ►OI�Xa�l�vteo. .Gl No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work z: F'"t4 V _SECTION 4:ESTIMATED CONSTRUCTION,COSTS Estimated Costs: - Item (Labor and Materials Official Use Only 1.Building $ D� 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ s ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ Jj /� X 4.Mechanical (I-IVAC) $ List: / " 5.Mechanical (Fire $ _ Suppression) Total All Fees:$ Check No. Check Amount:. Cash Amount: 6.Total Project Cost: - $ ❑Paid in Full ❑Outstanding Balance Due: c ♦ 1 � SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ix20 ,R�6 , { 4 kvT rcense Number Ex imt n Date Name of C L Holder q f 5,4Z60 List CSL Type(see below) No.and Street Description C��Q�..C-O-•7•? ��p� Unrestricted(Buildings u to 35,000 cu.ft. cJ 7/ 6 / R Restricted l&2 Family Dwelling 6ty/rown,State,ZIP M Masmiry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 78(- 6b8-3�// �b��gv5xo� r� L .Co I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC')) 7 3 DC F IV - TT e0&(!r ,dA�/ HIC Registration Number Expiration Date HIC Comp Name or HIC Re stmnt Name yg a5a{0� ��b 6aec65TZa7. G XAu . C6h� No.and Street 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.......... V No....-.....❑ SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT K I,as Owner of the subject property,hereby authorize d�)e/ AAKs / to act 00000`�tn my behalf,in all matters relative to work authorized by this building permit appli ac tion. Pnnt'Owner's Name(Electronic Signature) Due SECTION 7b:OWNEW 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. �22f?. 2r �iAkS7 6-$ Print owner's or Authorize Agent's Name(Electronic Signature) Date 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 can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basemendattics,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" CITY OF SaU.EN,4 AXSSACHUSETTS • BLUMMIG DEPART%W,-4T i 20 wAsHiNGToN 5TREET,Sm FLOOR TEL (978)745-9595 FAX(978)740-9846 KimBERI-EY DRISCOLL aW�YOR THONW ST.EiE,RIM DIRECTOR OF PI:BLIC PROPERTY/BL'ILDLNG COMMISSIONER Yorkers' Compensation Insurance Affidavit: Builders!Contractors/ElectricianslPlumbers AnAlicant Information Pisan Erint Legibly Name(Busimv:Organintionlindividuat):. Address: 7 !/ -5.4/ek City/State/Zip: o Phone#: 7S/- '--L 3 7� Are you an employer?Check the appropriate box: Type of project(r p egtllred): 1.( am a employer with 4. ® 1 am a general contraemr and 1 6. ❑New construction employees(full and/or part-time)." have hired the subcontractors 2_0 1 am a sole proprietor or parmar� fisted on the attached sheet: 7. ❑Remodeling ship and have no employees These sub-contractors have H. Demolition working for the in any capacity, workers'comp, insurance. 9. ❑ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions required.) officers have exercised their 3.© 1 am a homeowner doing all work right of exemption per MCL 11.❑PI Iling repairs or additions myself.[No workers comp, c. 152,$1(4),and we have no 12 . repairs insurance required.]t employees. [No workers' 13.�f Othrx camp.insurance required.] *Any appliwM[hat chucks bon et mug also nil out this saetiao Mow showing their worked compenrabun policy insinuation. _ - r I lomeownras who submit this affidavit ini cating they are doing all wogs and then hue outside contraction;must submit a now,aftldavil 6diming Mich =Cwura.:tats that duck this box most allotted an additional shot showing the most of the nNavmmctota and their workers'comp.policy intent ion. 1 not an employer that ft providing workers'compensation insurance far my emplayst% Below/it the pollty and jab site infermatlom InntllaneC COmpaay Vame: I.�LI7/^R/ J / ✓✓! t�r't[n f'(K/� .t/ J} — Policy 4 or Self-ins.Lie.M-W -2 _Ub 7la /0 1D Expiration Date: Q 07 Job Site Address: JCR 6GL ��f City/statt/Zip• ON 0 Attacb a copy of the worken'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 ofcriminal penahiea Ora fine up to S1,500.00 and/or one-year imprisonment,as well us civil penalties in the form oft STOP WORK ORDER and a tine of up to S250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the�tpolns and peaaldes ofperjury that rite informailon provided above Is true and rouser Si�ttte:_ & /V Okld use 0111y. Do not write in deft area to be completed by city or town Ofliciall City or Town: Permlt/I.icense Issuing Authority(circle one): 1. Board of Ileulth 2,Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Impettor 6.Other_ Contact Person: __ _ ------ Phone#: ,aco CERTIFICATE OF LIABILITY INSURANCE —DATE 6/8/20118/2011 PRODUCER (781) 581-6300 FAX: (781) 581-9070 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Quinn of Lynn Insurance Corp. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 152 Lynnway Suite 1D ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 789 Lynn MA 01903 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:EsseX Insurance Company 19046 DR FIX IT, LLC INSURER B:Liberty Mutual Fire Ins. Co. 16586 49 SALEM STREET #2 INSURER C: INSURER D: SWAMPSCOTT MA 01907 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 OFSUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLDATIEY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMSE$ Ea ocon-ante $ 50,000 A CLAIMS MADE 1XI OCCUR 3DE5955 10/01/2010 10/01/2011 MED EXP(Any one person) $ 1,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS - (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ S WORKERS COMPENSATION WC STATU- OTH- B AND EMPLOYERS'LIABILITY Yam$ _ER ANY PROPRIETORIPARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 11000,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) KC131S376761010 04/07/2011 04/07/2012 E.L.DISEASE-EA EMPLOYE $ 11000,000 If yes,describe under SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Salem DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 1 Salem Green NOTICE TO THE CERTIFICATE EjQiDER NAMEOTOTHE LEFT,BUT FAILURETO DO SO SHALL Salem, MA 01970 IMPOSE NO OBLIGATION IABI F- Y KIND UPON THE INSURER,ITS AGENTS OR REPRESENTA AUTHORIZ REPI NTA IVE ACORD 25(2009101) ©1 88.2609 A ORD CORPORATION. All rights reserved. INS025(200901) The ACORD name and logo are registered marks of ACORD Massachusetts- Department of Public S;tfety Board of Buildim, Regulations and Stand;u•ds V�V� Construction Supervisor License License: CS 85472 ROBERT A BAKST 49 SALEM ST SWAMPSCOTT, MA 01907 0 a-- "i_.G_ Expiration: 9/29/2012 . ('unniiissionrr Tr#: 5157 - OfTce0 oosumer A airs ae B��uess Regu ab HOME IMPROVEMENT CONTRACTOR ' Regisb,4on 126273 Type: " .Expiration S/10/2012 Individual ROBERL SAKSTI 49 SALEM ST. i r fff SWAMPSCOTT,tv1A 079Q7 - g Undersecretary ;; • \1 . 1 CITY OF S.EN4 -UNSSAC USETTS. BUILD=DEPARTMENT 120 W SHNGTON STREET, r FLOOR TEL (978)745-9595 PAX(978)740-9846 KLs,(BERL.SY DRISCOLL MAYOR `l HOMAS ST'.PTERRE D11tacrm OF PuBLiC PROPERTY/BuU mG COlL1mimiER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40,S 54, Building Permit# 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: DRrl>e- L , - ( Ci (name dfhauler) The debris will be disposed of in : Ndlt7`6�54�& CA0el,,416 (name of fact ityt ) �_... 164 (address signature of permit applicant .late •JcbriiuiT:kK: