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15 SETTLERS WAY - BUILDING INSPECTION (5)
�5�} c� al�pesZs The Commonwealth of Massachusetts F O CITY u Board of Building Regulations and Standards C ITY Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2071 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling - This Section For OfficiAl Use Only Building Perriit•Numben Da Applied: _ 1 _ _ �A1 Building Official(Print Name) ` Signature - Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 15 SETTLERS WAY SALEM,MA 01970 42 42-0005-815 L l a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: CONDO 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: Zone: _ Outside Flood Zone? Public❑ Private[3Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP" - 2.1 Owner'of Record: KAREN O'BRIEN SALEM,MA 01970 Name(Print) City,State,ZIP 15 SETTLERS WAY 978-745-2056 No.and Street Telephone Email Address ,SEI9CION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building? Owner-Occupied lif I Repairs(s) If I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other Specify:Replacement Brief Description of Proposed Work": REPLACE 2 WINDOWS - NO STRUCTURAL CHANGE SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated(Labor and Materials) Official Use Only 1.Building $ 6,792.00 1, Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costs(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees; $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ion) Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 6,792.00 ❑Paid in Full ❑Outstanding Balance Due: ill1`k sl< ( Z SECTION$:. CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 90125 10-0 6-16 Jamie Moirn License Number Expiration Date Name of CSL Holder U 86 Gardiner St List CSL Type(see below) No.and Street Type Description Lynn, MA 01905 U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF I Solid Fuel Burning Appliances 508-351-2214 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 170810 12-2 3-17 Renewal b Andersen y HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 30 Forbes Rd No.and Street 508-351-2214 Email address Northborough, MA 01532 City/Town, State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 ..........iir No........... ❑ SECTION 7a:OWNERAUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR.CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Jamie Morin to act on my behalf,in all matters relative to work authorized by this building permit application. SEE CONTRACT Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, ereby hest under the pains and penalties of perjury that all of the information contained in this applicatio is true d acctuate to the best of my knowledge and understanding. JAIME MORIN Print Owner's or Authoi a gent's Name(Electronic Signature) Dale / 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.eov/oca Information on the Construction Supervisor License can be found at MMy.rnq&s.gov/dps 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" / CITY OF SM3 EbI, MASSACHUSETTS BUBM04G DEP.AmE YT 130 W ASIMGTON STREET,YD FLOOR TEL (978)745-9595 FAX(978)740-98" KIMBFIIr ff /t)RISCOLL MAYOR T HOMAS ST.PM= DIRECTOR OF PUKX PROPER'IYAUUMiNG CONOOSS10,2tER 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: Renewal by Andersen (name of hauler) The debris will be disposed of in : Renewal by Andersen (name of facility) 30 Forbes Rd, Northborough, MA 01532 (address of facility) tgaature of permit applicant i 7-ILt_t 6 date debrinfEdw Renewal Agreement Document and Payment Terms byArd,et5Et1 d6m Razes al l s.Sm&➢rem of awston Karim D'Mrkn t.estsi l{�me:Y•C+nY,adl hr Ard*sM LEl B setuerOyap 9T4864 541gR KAMM 3"Fi €talks p"Dad:l'Np10ho(mugh.liti;W5A `E'9973)715-2055 r TOF 5U 35.1-22001Fac 15rJ50 -7'OUi Ph.�BosiQnc7Agauon.�..ydt s2nrq�p,cnm Cuidinotetl,.s') Ninne: Karen,O'Brien Comtraet Due-05130/16 C-Et tnoter(s) StlLee,•Ydd is&15 Settlers WaY, Sale, MA 01910 1 l Psin y"OcphnLtat.E,, uCm T(91S) 'y�-2055 0 le F LLt1L'I:ICIf1nLL L��u13➢ISGr. �n;wv Emtad" kaMnTn0b,ree:ngF'hortl,ca$UMet. InR➢�tr)hnrt:ld" 0ax}to(31'heee€ryjohi y:sndses"cnKykyetstoputchaseeheprodur,Lcand/orxMosef',Rcnc-maLbydndees€uW--d&6Renei-A by x'9r)dtssct 1.ol:)9autam(Qrme➢arsne),in to3otdm"wiLk the eerins atwl eotidik6oxis dtSYrilLud ht ehls A;',teeffvtnr Mturituot aeid.1kayd"t Tiros,Nome of ciancellacton tmemn al Cha r N=ipr.Myrn mr,b Sala COw.SaAwp,Terms anal Coip Sit ons of'Uc,head-Safe Fbnv�, w4iser,,owner 4t Bwitdeti IMLne,ldrn:tge,and any mthtr dmcrtenemT attached to thiaftmmo enr Document,the mtrrms+af which are all apecd to bx'the Parties and imwaspvszted,hemim 6).re.FMEE ac le:m66 ottuelyx Ellis".r remuma" .Ilo)rer(s}1hr-re61v aprrr rID,s gn a minpletma .zlsmre afit Contracnmr hasr PkUd all work veld Ais Agmernent. 'l'ntt l gal:.11nainiat:. 56,792 's rtts°t.,'tbns agrermet+i.Yx^u aCk_rinoakrdg+:chat rhs 4h aaoc li�or- aE1fG t$-,,4nn.os<Tir OtpKWirfi lt.odxsi;d: sotar Fhtsrtd rnw I.e nIIAde Ly pe vAWC64 b aal_k,chedl,midis card,or,cxh- R'U LLlout: $6.792 Fp-Itiruaettil.Stan_ EstieiaeedCanipkdtow di➢nouoe.Flnalko:d: $6a792 8-1aiweeks 1-2'dLayrs Ltleshmd Of Papnew: fi11artmgj V*w—h1u1e idtsraltarions butd 6n the dax-e of rhLe:sipatd cmaujor and weadarifg on the lair in xx$LAL we onmplem the eacsniml mrnxnresmxretx The.it allateon date r:hau G!S 11211 113'S2264 �;air pmAding ar this time is only an estimate.We;silk communicate an Official sate Start of M'"Oh S2264 and t:met at 4later date.. Rain and cttMut w aeher att du raDit eametbon causes foo Sub. Comp, S2264 ,&1.,L ftyctW sgrfti and andcrua &dear ahh AgetmEe©t conxitucss the endic W-.d€, ,di:rtn berween the pules and rat there are rjc ,%v , imides€eandirtf;cleatt8,htS.ai MC d➢ftring any of the cent os r f ihis Ap ttniunt. No Arft etimnts to or dcviaairans fmsts Lbls Ayncanteme:%qB bt rrlid wishour she sign+A, wri:trmo nsenz Of both the&KVtx(s)amd C.,mnkuwtum R�.7w(s)hea*•wkmavaled shm"00 131 as rend''!ehis Ageo rot,tmderscan&the mxrms Of thls e�c,Tettncatq,aad has received a ctrmpkitd signrd, and lac M a€ Arrcetnenc„indmang, the MM mdrachea,iV"at[�affaatcellavmn.on the chn--fuss wrkmro al-r and 21+ Mally:informed mFRUYVs's Vt ta,sanM rhis dgrecntant. 11QDMCE,,1*0 OWNS lb➢amt sitipt d fW Weedate if 66nk You ate entitled ta➢a.civy of dw comma:a xt dne time ytw Ap. YOU,THE BUYER, MAYCANCEL,THIS TRANSAMON A37 i.ti Y TIM E NOT LATER THAN N1IDNii GH OF 0710512016 OR THE,TH(RA BUS kN Ur1'Y Aid l RTHE:EI�YIIi_`r.C1;f THIS TpJ%N i1CTk()kY, WHICHEVER DATE IS LITER. SEETHE ATTACHED NCXU`I'HC;E OF C&NCEI [—SMON F'C?MI FOR AN L,KP r'CMMON OF THM RIGHT. d5wko mlin-, 3i rnaflllace �,.� } • �_ TWMUte of sate, f{ rsun SiALMUI,r SIyC,tatutt Stave Palermo Kaien U'BOLmn Miski Nlame of Salta [♦tactic} Prieto i`iME Print Na rme Q'rwiOr16 'Pace 2 1 16 ReneWal. Itemized Order (Receipt "Adwen dl�R��+l h9'..Mfirwo of ewmu K�DSAnn. Reo3r rl4pare:' eairval hs•feiAc-r5FY1 LIC q,'y.;�nr5}vac � - tF0810 ^ytaa.r�,at974 �am®. .annr Mttdws ROW 1'Hmhhomu9h,.F AD157A F 07W?5-2050 ftm:5`+3351-22001I'm IWO 9a,W721CdW3�1anCPeznor�An�e�-,ertoiP.cam v y,� 77, 7777 .� sal GvM!s%�' 101 ( ning ItAndow:Casement-Triple: Casement, 1:1A,Vented, E1 crime, EXTERIQR milrfle.INTERIOR Affille, 06fd:Sash All;high Performance SmartSun Glass, No Pattern, llardriwarec White. S een: Ttukene viith,tnleanar Color k1a.tcfr, Grille Style: Grilles Between Graz fG13G), Grille Pattern:Sash Afl- Colonial 2w x Sh, Misc. Casing Exterior- Maintenance Free, Caning Exterior- Mal ntenancL—Pie 102 Bathroom t[Lf dow::Casement- Single. Casement, Left, El Frame, F9tTER17R While, INFIFEWOR White, Gja$5: Sash All, Mogh Performance Smartiu:n Glass, No Pattern,. hardware:White, Screen, TruSeene voth kiterlar Color(.latch, Grille Style; No Grilles, Misc; Non WINDOWS!2 PATIOIDOORS,0 SPECIALTIt_0 MISS:0 TQTPJ- $6,792 UPDATED: 46130116 "`''''"� 1trroRr4wC bjA+rdivartn es rsaKrrerr�}ra eras tettre�rra'rafrti dF " rgneplyimg u-hb s!w m&Y and at rJ nr7Y mrr6 +rerrirrr{pr,rfivJ r br CPA- oar;=mr 7t Fame 4 r I Renewa- byAndersem� WINDOW @k!PLACt MieNT ��Aee�sArn4arn�a� CONVOMENIUM PERMISSQ,N ? C M ,}',Q+jy"fo 'r►ir &".d,�r•uiN4,v k&r! ""Czpv�Ap,&tt� +�S+ 'l,' o++u�kwis• Woq 4,L r1C;At a-&k %or-2rzr ?epre4e4uhq� "&f Fd'ow&rev"i e-tiulA,w f' Z#ltfw+n¢ f&- `rl' ✓I�e !+R#.�LY`1�1CdL+R �F{r+'L�'k6"I'1�- 3fF tR�q� G%`4',�PL�:L2l' !%t�1'C''E S` '{1 ffkR @640.VY��'GMih1`fid'.&¢f�+4,},ry�i', E.tr4N-Lj:;+tESYU.•. der l &r L+the'.PT&P&S'e&w5fc. 0 rf - s-- Sknn.utfju.r€. �^'e - .t2�yt�y��w've'�t,�,w}+.a� .•�f �dn LAtA-Of 3,iJY ih d t 5€ g fj—rp&K.+ w v E—',pd"f Co"4jo a w� M.Farkas Rd Vmllhmrou&.MA OL332 J'6uw.l5 kq1.].351.2241 Fae(508)% -7072 Wasik!u•wYn_mr�.3alLti�vxl¢_'n,�irn.. e The Commonmealtk of.Massackilamis DepaMlimin ofIndrshral:leddem's D,('&,e t?f*m'estige diotrs 600 ,avitingfon:Weer Boston,MA 02111 a rvmcmamgos,1d1e °h%oR-kers' tompensaUon insu'•arce At Adavit- BuiY.det s/Coctractoi-s/r;eetriciers/1?lumf,,)etrs An_nticaln'Infformatren Please t'ts-t %imMy Nam RENEWAL BY ANDERSEN Address: 30 FORBES ROAD City/State'Tip',NORTHBORO,MA 01532 _ __ phptle #: 508-351-2200T Are/�'ou an employer" ec. Chk!hc a-wtproprate boa i ciion �� ~� 't3'Pe of project(required):f.� 1 am a employer with_-30_ 1• C1 1 am a gmeml contractor and I �New t� eroployees(ftW and;'orpa:Mime).* have hired the>nMconlracv s 2.El I am a sole proprietor or pm mer- listdd on the attached shert.% I V-1/Renodaling ship and have no employees Am sub-couttatuns have S. Q Demoiitiom working, for me in any capacity. workers'comp.insurawe. c- 0 Building addition [No workers'comp.inxoranee 5. d lVe area corporation.and it- required.) L fihxtrieal repairs ,r additie ns required.) officets'have mmi6 i their 3.[j 7 am a homeowner doing all work right of a:;iiption pet NIG1. -1 1:1 Plumbing repahs or additions myself.1-No,workera comp, c. 152,1i 1(4L and we have at 12 D Roof mpairs insurance royukd j a ctuployees, [NO workers' 13,[J Other atimp.insmancemqutre3[ '.1ov apO:cann thm civ.&N tm,a:must atw fdl•cot thew,,M_ ocean slim$iheir W-_A ":�M;r sau;M puiWy mah man r; ?,i bmeuurexa w1w.::3rnit trio affidavit indicalmg t a:�.d hey om}ail c ne ork find titeii iue nfi. �umraU:cc mua su9ma a w affidavit.mdi,;Wag vwh wtaxaors talc Cited this ta)t mat majod Al addit:rmw%heet;.ta w;mt me nm ie of the mbrwpra.•nv,and than workat 'comp policy mto.mxian z, —,.. ... -act.-. .. lam an employer tkat is provkl W workers'cempensudon insarance or J' loft•employees llelor.•iv eke pulley aNd jib acre Wermadom Insurance Company Name. OLD REPUBLIC INS. CO. Puliac f of Self-ins. Lic. : hgy {tQ37Q0 —._ lixpi^anon Ueto: 10-01116- �^ Job Site Address: 15 SETTLERS WAYSlatc�Lip: SALEM, MA 01970 Attach a copy-of the workers'compensation pope)-deciaratfon page(shoring the policy numbei MR]expiration dete). Failure to secure coverage as required under Section'-5A of I!vtGL c: 15'can lead to the imposition of criminal pc/talti•a of a fine up to$1,%0.00 andlor ena-year imprisonment,as well as cavil penaltie.:in the form of a ST<)P 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 fimvardad to the Office of Investigations of the DMA for insurance cov;-rage veriiieation, t du kereb c ,y under eke pains axdpenalttas ofperjugy.tbatthe infin mWtm protdrkd ubm-o iv true and cornet 44,4 phcme.6: 508-351-2200 O/Jicial uie only. Do not write is ikk area,lobe completed by cip,or town o,(/lc.W -- _ City or i own: Permit/Liceme tr Issuing Antho:fty(circle one): 1.Board of Health 2.Building Department 3.Cityfrowo Clerk 4.Electrical Inspector.S.Plumbing inspector 6.Other Contact Person; Pbode#: ANDECOR-01 YADAVYO CERTIFICATE OF LIABILITY INSURANCE D 1 0/1 12 01 5Yn 10l1/2015 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,fhe 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 statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NaMEACT Willis Certificate Center Willis of Minnesota Inc. PxoNE F Wo 28 Century Blv() Arc N ,(877)945-7378 a/c No, 888)467-2376 P.O.Box 305191 nuko ,Certificates llis.com Nashville,TN 37230-5191 INSURE S AFFORDING COVERAGE NAIC4 M3URERA:OId Republic Insurance Company 24147 INSURED INSURER B: Renewal by Andaman LLC INSURER C: 30 Forbes Road I INSURER D: NorBlborough,MA 01532 INauRER 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 TYPE OF INSURANCE LTR I SD VW POLICY NUMBER Pi0—L1D MO-IDD�P DNnB A rX COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,00 CLAIMS4AADE �OCCUR MWZY 305440 10/01/2016 10/01/2015 -OR $ PREMISES Ea occumance $ 500,000 MED EXP(Any one pemon) $ 10,000 PERSONAL&ADV INJURY § 1,000,00 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 4,000,000 X POLICY❑JECT LOC PRODUCTS-COMP/OP AGG $ 4.000,OOC OTHER: $ AUTOMOBILE LIABILITY` COT LE LIMIT $ 5,000,00 A X ANY AUTO MWTB 305438 '10101/20'15 10/01/2016 BODILY INJURY(Per pwsw) $ ALL OWNED SCHEDULED AUTOS AUTOS MDEN INJURY(Per aceidard) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS nt S § UMBRELLA UAB OCCUR URRENCE $ EXCESS LIAO CLAIMS-MADE E $ LIED RETENTION$ $WORKERS COMPENSATION _AND EMPLOYERS'LIABILITY YIN TE ERA ANY PROPRIETOR/PARTNER/EXECUTIVE MWC30543700 10/01/2015 10/01/2016 ACCIDENTOFFICERIMEMBER EXCLUDED? NIA § 1,000,00(Mandatory In NH) SE-EA EMPLOYE § 1,000,00 It yea desonbe under DE SCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be axached If mom apace! mqulmd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATIVE Evidence of Insurance " "4- k,'- 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD tom! Maumachucette-Department of Pubes Sa" . / Sward of Building Regulation.and Standards Construction Snpen7sor '_icamw ' a .a�.£s�LP:14�i'tIFT - r4 1 i irl s� +„l ` At to�' Expiration Culmnluionaa 10108f2O7fi COL �Oom:anonvlea�i a��''.4aaafc"b'6 i. _ we of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Reglstration::'E7ili!'t0 Type: Explr44eJ5.._;4 3 tT, Supplement Card RENEWAL BY AND41l l:k'.C�. JAIME MORIN �`.'.''» 30 FORBES RD -,.--�<�•a, --- NORTHBOROUGH,MA 01532 Undersecretary • I : . � Oa nd rmnare mS9nd mda lnapea0oa Ban mL4 tarlulgai�4amo� '.; g urta Renewal byAn&,sm • - - vuva� aaueoea vJisnrf.pq. AND-N-1O2 j Pmdu@Typs Cwwnaft - • ERMWY PEiPORMKNCE pKnNW I - . 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