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12 SETTLERS WAY - BUILDING INSPECTION (3) 1 ,. The Commonwealth of Massachusetts Department of Public Safety �V v ✓ \Ia.S,uhuselts State Building Code(780 CMR)Seventh Edition City of Salem Building Permit Application for any Building other than a 1- or 2-FamilV Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Ins a tor: SECTION 1: LOCATION(Please indicate Block# and Lot# for locations for w ch street ad res is not available) 2 e No. and Street Cin• /Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building Gd' Repair❑ Alteration Addition❑ Demolition Cl (Please fill out and submit Appendix 1) Cha nge of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as,part of this permit application? Yes ❑ No^� Is an Independent Structural Engmeerinl�,Peer Reviewr 7required? yes ❑ Nu, li Brief Description of Proposed Work: xi C�iAi /CfL»0✓A- l(ryi, rl/e Gl Cy b lrL � rl.�L mA/l ,, /rrn2rho —.12a10t ynr' cf11/2acf/ SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): p Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sq. ft.)and Total Heigh[(ft.) SECTTON 5:USE GROUP(Check as ap licable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto -F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile Cl R: Residential R-10 R-2❑ R-3❑ R-4❑ 5: Storage S-1 ❑ - S-2 O U: Utility O Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ 1160 IIIA ❑ 1116 ❑ IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside•Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentifv Zone: or, n Site>cstem ❑ required ❑or trench or.pecil%: permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: NIA I li,t;m,clan nu..i;m Itr,iom Pn,.•..; \ut Applicable ❑ la SlruCture mcnhin airport approach area' Is their review completed' .rt 6,11,ent In Bwld endowd ❑ Ye,❑ or No❑ YeS❑ \o ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of("'Lit'. Lne Groupl,l: Ic �c of Gnutniclion: �, . ) OCCLI lnt Lurid per Fluor: Dues the building;cuntaiman Sprinkler System': Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner o vV Dmu IC o rt\ M(` n, Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address City/Town State Zip to act on the pop pert owner's behalf, in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If building is less than 350)0 cu.tt.of enclosed space and/or not under Construction Control then check here O and skip Section 10 1) 10.1 Registered Professional Res onsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor DOG+Sono 1N r L �Pyj YurTUJS LL//C / pan,Nyribo C S 7JCSl�� ) � /<fc.Lpa rfl: t.�t_/rn YL j Name of Person Responsible for Construction !� License No. and Type if Applicable /53 rn/pni 2� yd- ) Street Address City/Town State Zip �7 -(711- 5.2a� ��-` 3 lo9/U ,11,�1, ��. C�'`rnnzll� C/incc��• Neff Telephone No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes❑ No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor t7 O Item and Materials) Total Construction Cost(from Item 6)_$ LY) 1. Building $ .3 Z S"7JU •�' Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ -06 , er0 appropriate municipal factor)=$ 3. Plumbing $ vq Note:Minimum fee=$ contact m nicipalily) 4. Mechanical (HVAC) $ 5. Mechanical (Other) I $ Enclose check payable to 6.Total Cost $ ,C)P.) (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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 y kno/"eand understanding. CJ7d--430-6q fO Please print and sign name Title Telephone No. Date 15: /6)&> Rai 11 /2t ' c, Y_)� nI& 1-1 titreet Address City/Town State Zip .Municipal Inspector to fill out this section upon application approval: Name Date CITY OF SALEM i PUBLIC PROPRERTY a' r'„ra/ DEPAKTMENT 5.\I I'\t,Nt.Ni.1l III it I - I'r1:978.74 9595 • 1°%X:978.740-9846 Construction Debris Disposal Affidavit (required fur all demolition mud 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 q is issued with the condition that the debris resulting front this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c t 11. S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name otZacillry) Geo rcro �Fo •, A-) — (address ut•tacility) xet applicant Signature date dc6n•,ii lane CITY OF S.U.E,`I, ,NLvLkSSACHL;SETTS BL'ILDLNIG DEPAlIMMIUNT /r 120 W.+,iHiNGTON STREET. 3'e FLooR r TEL (978) 74&9595 FAX(978) 740-9846 KI%joERIEY DRISCOLL MAYORNOKU ST.PMRM D IREcroa of F BLIC PROPERTY/gULDLVG CONMOSSION ER Workers' Compensation Insurance Allidavit: Builder$iContractoralElectrlciantilPlum ben Annlicant Information _ Please Print Legibly Nairle lausir 0rwtrs6on lndrvtdua1Y• _-k- LL-C Address. / $-3 AL_Lz . - 2_)) City/State/Zip. �3/flag rGa Mr. Dell rhonaN:_ '3 trey an empleyar?Cheek the appropriate boa: Typo of project(required): 113larnaemployinwith �al 4. ❑ 1 am a Rcncri l contractor and 1 employees(full and/or put-time).• have hired the sub,-coraractms 6. �❑,/New construction i.❑ I am a sole proprietor ar partner• listed on the acrechad sheet: 7. 1 tJ Remodeling :hip and have no employee These sub-contnewcs have a. ❑Demolition working for me in any capacity. Workers'Comp.inearsnoe. 9. ❑OuiWing addition (No worker'comp insurance S. ❑ We ate a corporation and its required.) otlieat have exercised disk 10.0 Electrical repairs or additiom 3.❑ 1 am a homeowner doing ail work right of exemption per MGL 11.❑Plumbing repairs or additions myself(No workers'comp. C. I52,41(4),and via have no 12.❑Roof repair insurance required.)It employees.(No workers, comp insurance required.) I3.0 Other, Any appueat Chia awcee boa et raw Start na tax tM artwa urloa deViaa dolt s olaw 'coopnari r your,irtAwasuloa. t hwruvnote who ailietir this aeldsvir indtadnp they as doing all work ad that him attaiee coarso e s"M atbma a new 3111drvil indtorip ado ('.rarsyos ther 11iRk this bar ttttw aaarhwd am adtatiwwl airs"showira do now dew arbartamsos ad their wwbna'comp.policy intern sawe 1 ate ate earlakyae that trPreriding rvorhers'rowpeamdea/eaarwetn jw my employ"& Qdene d rile pNhy ewI/sI slls inforaralloa, --r7 (� n Insurance Company.Name:_--IJe2_ G J�'tilr C! t h C . Policy Nor Self-ins.Lie. /(2 Expiration Date: Job$ir*Address: LU9 1A City/StawZip: Stlwyn- Mr. . .mach a copy of tbo wonders'compaasadow pat d—fth"lea pap(abowing the policy number and expiration daft L Pailum to secure covarap u required under Section 25A of MGL a 152 can lead to the.imposition of eriminal penalties of■ ' fine up to S1.500.00 andior one-year imprisonment.as well as civil penalties is 1M form of a STOP WORK ORDER and a 8w of up to S250.00 a day against the violator. Be advi.*W that a copy of this statement maybe rurwarded to the Offlce of Invca1iga6uns of ilia DIA for insurance coverage verification. /do hereby certify nadir the pia and yenahler of pei/uty that the infermodoo provided above is true and Correct, Phoned: ! -I --lp70 61a r 1 �3 CJ'W T I G OJflciol use dilly. Dona write is this arse,to be rotmpdtd by city or town d/flrial City or ru 1 - __ _ I Wn: PcrmiNl.lccnse e i Psuing Authority"circle tine): L Iluard of Ilrullh 2. Ruilding Department I. Clytrown Clerk t Electrical Inspector 5. Plumbing Inepeeto► 6. 01 her Luutaci Person: _ ._ _. Phone s• liIassachu..fits- Department of Public Safet% ' '&rrrd of Build inU Regulations and Stanilardoj Construction Supervisor Lic,Anse_ ` . Lic' se: CS '451187 - 4' Restricted td: 00 . RICHARD J OCONNELL 153 ALLEN RD BILLERICA, NIA 01821 o—i. iJ i3[jE Expiration: 12/2SW10 f'nnmisa•nrr Trn: 9133 •- _- HOME IMPROVEMENT CONTRACTOR Reglsfratlorn\I 54017 Expiratlail 1 12011 Trt 285600 r Ty Liability Corporation DOC 8 SONS GENERACONTRAGTORS I.I.C. RICHARD a NNF.IsC- �� v _ 153 ALLEN RD. �z BILLERICA,MA 01821 / Administrator' 1 4 ATA 'To: 19787409846 9787409846 ( 1 of 1 ) 01-27-2010 03:45 PM -0500 aco CERTIFICATE OF LIABILITY INSURANCE DATE(M/2010 �--� 1i272D1 PRODUCER (508)459-4700 FAX: (508)755-1724 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Wolpert Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1313 Belmont Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Brockton MA 02301 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A..National Grange Mutual Ins. 14768 D O C and Sons General Contractors, LLC INsuRER B.Quincy Mutual Insurance Co. 15067 153 Allen Road INSURER c,Hartford Underwriters Ins.Co. 80411 INSURER D. Billeri a MA 01821 INSURERS COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY RECUIREMENT,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'L POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD(YYYY DATE MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE PREMISES Ea occurrence $ 50,000 A CLAIMS MADE OCCUR SPO186L 12/8/2009 12/8/2010 RED EXP(My P,e Pelson) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPiOP AGG $ 2,000,000 X1 POLICY PRO- CT F7 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT AN $ 1,000,000 Y ALTO (Ee a.&nt) B ALL OVIN=_D AUTOS 205185 7/25/2009 7/25/2010 BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY $ X NON-0VVNED AUTOS (Per ecdtlenq PROPERTY DAMAGE (Perecddenl) $ GARAGELIABILUY AUTOONLY-EAACCIDENT $ AN Y AUTO OTHER THAN EA ACC $ AUTO ONLY. AGO $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION L. AND EMPLOYERS COMPENSATIONLILIABILITY VJC STATU- OTH- ANDEMPLOYERS'LIABILIN YIN X TORV IMI ER ANY WORM ETC RIPARTNERIEXECUD VE❑ E L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMMR EXCLUDEDP IMandarm In NH) S60UB-9934L24-2-10 1/15/2010 1/15/2011 EL.DISEASE-EA EMPLOYEE $ 1,000,000 1 yes,describe undo, SPECIAL PROVISIONS be. EL DISEASE-POLICY LIMIT $ 1 000 000 OTHER DESCRIPTION OF OPERATIONS)LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Subject to policy forms., tends and conditions. CERTIFICATE HOLDER CANCELLATION (978)74 0-9846 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 Building Inspection Services NOTICETOTHE CERTIFICATE HOLDER NAMED TOTHE LEFT,BU'FAILURETO DO SOSHALL 120 Washington street Salem, MA IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Robert Mucci/WATIVE p Robert Mucci/WOLP51 ACORD 25(2009101) ©1988.2009 ACORD CORPORATION. All rights reserved. INS025(s00001) The ACORD name and logo are registered marks of ACORD T ` S l COLLINS COVE CONDOMINIUM ASSOCIATION 37 Settlers Way, Salem, MA 01970-5269 Mr. & Mrs. George Danek January 27, 2010 12 Settlers Way Salem, MA 01970 Dear George and Carol Ann, The Collins Cove Condominium Association Board of Trustees has approved your plans to renovate the kitchen in your unit at 12 Settlers Way. Good luck with the work and we hope that the project goes smoothly and without too much disruption. Sincerely yours, Jeffrey W. Conley President Collins Cove Board of Trustees