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23 SETTLERS WAY - BUILDING INSPECTION
4 tR I The Commonwealth of Massachusetts Department of 1 ublic Safety \Iassac h uscits State Budding Code(780 C MR) Building Permit Application for any Building other than aOne-or wo-F, weilit (I his Section For Official Use Only) Building Permit Number Date Applied: ------__--- Building Official: _ S ECNON l: LOCATION(Please indicate Mock N and Lot N fur locations for which a street add .s is not available) <3- c5e&5 4)Ay__- - c5glNo. and Street Cily ;fuwn /ip Code Name of Building(if applicable) SEC PION 2: PROPOSED WORK lidiliun of\I:\Stale Cidr uaal If Now Construction cluck here❑or check all That apple in the ttvu rut,:s below I \istinl; Buddinit Repair X Alteration ❑ Addition❑ Dvi n litioo C3 (Please fill tint and submit:\ppvndis 1) Chango of Use ❑ Change of Occupancy ❑ Other ❑ Specify:___.__ _ \re builJing plans and/or construction dtw'u rents being supplied as part of this permit application? Yes ❑ No J�Is Jo Indelmident Structural Eul;incering Peer Regiemyuina17 MQxKI Yes ❑ No (( Brief DeSC iption of Prupos- Wo k:._- - II O —h r We &p -- SECTION 3:CONIPLE"rE Tfits SL'Cr1ON IF EXISTING BUILDING UNDERGOING RENOVA"rION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CIMR 34) ❑ Existing Use Gruup(s): . _______ Proposed Use Gruup(s): .__ SECr1ON 4:BUILDING IIEIGIIT AND AREA Existing Proposed No. of Flours/Stories(include basement levels)dz Area Per Fluor(sq. It,) Total :\ma(sq. ft.)and Total ticight(it,) SECTION 5: USE GROUP(Check as applicable) A: Assembly A-I ❑ A-'_❑ Nightclub ❑ :\-3 ❑ A4 ❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ P_'❑ it: Ili h flaz.vd tl-F ❑ H-2❑ i1-3 ❑ li-4❑ I i-5❑ I: Institutional 1-1 p 1-2'❑ 1.3❑ 1-4 ❑ �IL,!cantile❑ It: Residential I1-10 It-2❑ R-3 ❑ R-d ❑ S: Storage S-I ❑ S-2❑ U: Utility❑ S ecial Use❑and ,leas•d •s ,• +• ,V t c c criN Ich w. Sprri,tl Use SF.CI-ION 6:CONS"I RUCTION 1-YPE (Check as applicable) IA IBO Il,\ ❑ IIBp III,\ ❑ IIIBp IV ❑ 1 VA VII ❑ SLC'rION 7: SITE INFORMATION(refer to 780 C�llt 111.0 for details on each item) Water SuPV Y I : Flood Lone Information: Sewage Disposal: french Permit: Debris Rcntuval: PUblic K C'herk it unhide I'I+hnl /one❑ Illdlaate Illtlitle ipol ❑ A french A,ill not be Lic1'os,'tl lalspo,,d Vitt/ ❑ I'm tit•❑ or indonlilyuroll sne gdoll ❑ rryuirt•d ❑or Ircnuh or spar ift - . pt'rtnit is ,it,losed ❑ Railroad right-4-way: Ilazards to Air Navigation: Neu .\ppllc.I blr�A Is vlrm limo+,Rhin mrport oppmat h .era' I Is their Tee It r,nuplotcd! . nr C o nwm to Iludd rn,lusrd ❑ )vs ❑ rr Vt' I l rs p No Cl SF(`I ION,4:('ON]L,V I'OF( FR I'Ir1C',\'1'I?OF OCCUPANCY I Jiw,n u 1,od" ( sr Gnnl Plsl. I\pr nt C,,lld rut non: c I,,a 11,1111 l rr.nl her lhn•t- -- L Ili r. Ihr builJinl�„'lu.11n.lu�lrinl,lrr tit drnl! �hrrlAl '4Il f•ul.11ion. 6l -7 r 1 'q C(_ — K�II�a-� SR IION 4: PROPM I OWN FR AU II IOI(I'ZA IION___ nuc .... css ul Priprrty Oo rm Icl1 .f.2i Perre._ oC_7EEF Coni> fls f riser+ i+rs ' a j5_ _Colitr ._(o'ue_C,ervlmvfw�.�s_. I/iv 01470 city/Town �iP Name(Print) No. and Street I'ropert) OwnerConta,t Information: 4W. -mm I'itle relcphone No. (business) Telephone No. (cell) c-mail address If applicable, the property owner hereby authorizes Name --- -- --Street Address -- -City/Town Slate Zip to act on the properly owner's bch,rlf. in all matters relative to work authorized b this building permit a „licatiun. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,0011 Ca ft of enclosed s,nee and or not under Cunstriction Control then check here O and ski,Section 10.1 IL1.1 Ite gistered Professional Responsible for Construction Control Name(Registrant) relephune No e-mad address -Registration Number Street Address City/Town Stale Zip Discipline Expiration Date 10.2 General Contractor Company Name - U girm,A 14aqqtYdr(15 ?i — Name of Person Responsible p Construction L' unse No. and Type If A' 'P K.bl m e 31 Teolii2r' dorb Strcat Address City/Town State Zip 1 -rlq__( - Tclo,hone No. business Telephone No. cell) a-mad address SECTION 11;to n,K P., r.:,'rt.All N:" V'\t It)\ I I11"AM�I Aj 1.11.'•'•�'l I M.G.L.e. 152. 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure it,provide this affidavit will result in the denial of the issuance of the building permit. Is a si•red Affidavit submitted with this application? YeAL No ❑ SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor OD Item and Materials) Tulal Construction Cost(from Item b) I. Building S L Building Permit Fec'Told Construction Cast x _(Insert here '. Electrical $ appropriate nnunicipal factor)'S 1. Plumbing $ COntact 4. Mechanical (HVAQ nuuniri ,slily S Note: Minimum (cc•'S_—( i ) 3. Mechanical Otter S Fnclose Clietk payable to r,. fowl Cost 5 (contact numiCipal ity')and write,lic,:k number here _----- —_— SECrION 13:SIGNATURE OF OUIL DI NG PERMIT APPLICANT Ity entering n» name below. I hereby attest under the pains and penalties of perjury that all of the information owtmllcd in this application is true.md act orate to Ilie best of my knots t •e nd understanding5VAAJ -XI AP.4666 . I'leaso print wrd .i-go n111v _ r._/� - frlephone�Nno�, �y LLuc it Vlrrcl .\dt4tj» r-aWC wT, _ itY� Iliwll /y; e. -iiiWryp I .Municipal Inspector to fill out this section upon application approval: _ _ .._-__._..___. __- Nome - 17o1r a BUILDING DEPAIKOLENT 120 WASHIINGTON STREET, 3'a FLOOA TEL (978) 745-9595 Rvt(97,3) 7.10.9844 KI.-,Il3ERLEY DRISCOLL THO%L"ST.PlERAS YL1YOR DIAECTOAOF PUBLIC PAOPEATY/BCI)DI\G C0`61ISSIUNEA Workers' Compensation (insurance All1davit: builders/ContractordElectrlcians/Plumbers %militant Inrormatinn Please Print Leff ft \ Nalnclllusitu, Org ttaiiamlGndividu�d)7: c �e/�J74�4_ t O. / ) r\ddress: /q�a�' CityiSratc/Zip: Ja&I'14 Ah oN5I PhuneM: Are you An employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with 4, lMl am a general contractor and I S. ❑Now,construction diliployces(NII and/or part-time).• have hired the sub-contractors 2.❑ 1 am a sole propric tar or partner- listed on the attached shec6 t 7• ❑ Remodeling .hip and have no employees These sub-contractors have g. ❑ Demolition working liar me in any capacity. workers'comp.insurance. 9. 0 building addition (No workers'.comp. insurance 3. ❑ We are a corporation and its required.( offlcen have exercised their 10.❑ Electrical repairs or addition: ).❑ 1 aim a homeowner doing all work right of exemption per MOC I LCI Plumbing repairs or Additions myself.(No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof n pain insurance requited.( t employees. (No workers' 4r��i comp.insurance required. I). Other ) t li •nay upphaant ttuf Omits boa rl muU a1w all uut thv rectioa below showing iA n air wake 'compensulun puby maaumution, '1 Lvncuwnne who•uhmit this attldavit iodieaing their ore doing ill writ and then him wilide eonimetats trial ruhndt an"antJavir indicting.ucle $'.mir+ctun thol ahaik this box muel anaahud an aJJtauruJ.hat,huwiny ilia nwna of the NtFeunl9eWle mJ tAelr wnrkm'mop,puliry In/afna0oq. l min an eurpluyer that le pruvlding worker:'cumpeuradoa Assurance for my employees Below is rite polley and job silo infurasudon. _ In,urmco Company Vame: CIS ��l��'�sUJ(1� 11C.� —_ Policy 4 or Selr.ins. Lio. t: + �y�fl n U/y/�lo:��/n Expiration Date:-- job - Sile Address: C c�PifllP /Uy r1�0�r 1717 CityiSmtrJ2ip: �iq /"1+' 0117/ �r .1,114cb A copy uT the workers' compensation polity declaration page(showing the policy number and expiration data). !9 h'ai lure to wicury coverage as required under.Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a rine up to i 1,54O.00 and/ur one-year imprisnnmcnq as Weil as civil penalties in the form of a STOP WORK ORDER and a lino or'up to 52M.00 J Jay against ilia violator. Ile advised that a copy of this,tammcnt may be iurwardcd to ilia Mica of Invc,ligatiuns of ilia DIA Far insuraoco coverngc vcriilcutiun. /du hereby cernfy under the paint msJ uh rs of prrjury/hat the infunnullun provided above i',t—l_ru/e'wind a'urrece Otlhiol use tmly. /)a not wite in this area, ti be cmapleted by city of lawn nfjh'ia2 Ciry nr I'u,vu: . I'crmiui lcctve 9 I„uia- Authurily (circio one): I. Ifuard ul IlvAth !. Iluildin.- Dcpartuical .1. ('ilyi Town Clerk 4. bacetrlcsl ln,pechtr i, Phimbint: Intpeetor 6. tiler ,- CITY OE S-V- Nrj N Liss.ICH(,'SETTS t3l'ILOLVC DEP.IRT(E\T I '0 l9.UHCVGTON srxssT, J'O accit I'M k978) 141-9595 1U�®F_RLfiY DItLSCOLL FAX(973) 740,98.44 .tiL1YO1! 1'}tG.�us ST.Ptz� DIatiCT04OPPl8t1CPROPff% Y/8t.'MOLYGC0U41SSIONEx Construction Debris Disposal Atfidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CabiR section 111.S Debris, and the provisions of,,tCL c 40, 3 54; Building Permit Atis issued with the condition that the debris resulting from Ihis work shell be disposed of in a properly licemed waste disposal facility as defined by ,NIGL c 111, 3 1 JOA. rho debris will be transported by: EEC. (n+ma ut'haular) The debris will be disposed of in : (n.m�o-IY) .. (lddrrn ae rl.,h,y) , �rt.mra clnt ;f;;" awl, '!tr SPS Your one-source solofien for property maintenance and improvements 179 Bear Hill Road • Waltham,MA 02451 •T 781.487.2500• F 781.487.2505 •www.spsinconline.com Brian M.Mangual Schernecker Property Services,Inc. 179 Bear Hill Road Waltham,Ma 02451 June 6,2012 City of Salem Inspectional Services Department Attention: Permitting Rep City of Salem Inspectional Services 120 Washington St., 3rd Floor Salem,MA 01970 Dear whomever it may concern: Evan Silberhom of SPS is authorized to file,pay, and request permits on behalf of Schernecker Property Services, Inc. and Brian M. Mangual • Please feel free to contact me if there are any questions or concerns. Sincerely, Brian M. Mangual Business Manager SPS,Inc. Office: 781-487-2537 Cell: 617-794-6759 Fax: 781-487-2555 • « kef@ � et� . � . . . : 2 :a$ d i.a .+ . . . . . a\y : � A aSuperviaor @" ! e" @ «m ©? » | AN 31 +#+#2 # 2 d w « - : - Expitaijaw, W2.5Az { < d Tr#: !a . Failure to possess:a current edition of the Massachusetts State Building Code is cause for revocation of this license. ;Refer.to: WWW.Mass:Gov/DPS i i i t s� • Office of Consumer Affairs and usiness Regulation 10 Park Plaza- Suite 5170 Boston, Massa setts 02116 Home Improvement for Registration Registration: 123616 Type: Private CorporffiWn _ Expiration: 3/142013 TM 2W158 Schernecker Property Services, In 1 • Fred Schernecker a - }9 179 BEAR HILL RD — WALTHAM, MA 02451 �w Update Address and return card Marie reason for change. El Address Ej Renewal El Employment Q Lost Card ovs-ass 0 50M0ee461e1216 - - Officensu� B3ein.44%'eg—� License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 23615 Type: Office of Consumer Affairs and Business Regulation Expiration: =13 Private Corporation 10 Park Plate-Suite 5170 ' - -------- Boston,MA 02116 qscmecakerPro �3 _ Fred Schemecke , = 179 BEAR HILL WALTHAM.MA 02 F4 ,,` .y� � 5�, Undersecretary 45::;��Not valid without signature • A�D® oa,EtrNroDlm� CERTIFICATE OF LIABILITY INSURANCE 12/27/2011 PRODUCER (617)723-0700 FAX: (617)723-7275 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION easy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Insurance, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Causeway Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Boston MA 02114-2155 INSURERS AFFORDING COVERAGE NAIC IT INSURED INSURERa(.`Ontlnental Western Insurance 10804 Schernecker Property Services, Inc. INSURERW.Union Insurance Company 25844 179 Bear Hill Road - WEURERQA (iia Insurance Company 313zs INSLKLEa o: Waltham MA 02451 INSUERRE 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. YPP OF INSURANCE INSR POUCYWNBER POLICY EFFECTIVE POLEYEXPWATION lIAM GENERAL LIABILITY EACH OCd1RRFl+(.E S 1,000,000 X COMMERCIAI-GENERALUABLLITY PREMISES Ea mnara S 300,000 A CLAIMS NAM ❑X OCCUR CPA 0183614-15 12/31/2011 12/31/2012 MED EXP AroY we E _ 5.000 PERSONAL 4 AIN INJURY E 1,000,000 GENERAL AGGREGATE S 2,000,000 GENL AGGREGATE LAIR APPLES PER: PRODUCTS-CONPIOP AGG S 2,000,000 i'OLICY X Fxg F1LoC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,006 ANYAUTO B ALL OWNED AUTOS KRA 0183615-15 12/31/2011 12/31/2012 BODILY INJURY E X SCHEDULED AUTOS (Per PO X HIRED AUTOS BODILY INJURY $ X NON4)WNEO AUTOS � ) PROPERTY DAMAGE E (Per acodenl) GARAGE LIABILITY AUTO ONLY-FA ACCIDENT S ANY AUTO OTHERTWW EA ACC E ALTO ONLY: AGO E EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE E $ 000 000 X OCCUR �CLANS LADE AGGREGATE E 5,000,000 E C DEDUCTIBLE Mh 0103616-15 12/31/2011 12/31/2012 S RETENTION $ $ WORKERS COMPENSATION WC STATlY O R AND EMPLOYERS'LJABILRY YIN ANY PROPRIETORIPARTNERIEXECUTNE❑ EL EACH ACCIDENT E OFFC�EXCLUDED? (Ma ye„s�tl�,Y me p0 E.L DISEASE-EA F]APID E B'ECn=w= n.Y E.L.DISEASE-POLICY LBBT S OTTER DESCRIPTi011 OF OPERATIONS I LOCARONSI VEHICLES I EXCUISIONS ADDED BY ENDORSEYBTISPECIALPROMMONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLNXES BE CANCELLED BEFORE THE E PRATION Schernecker Property Services, Inc- DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MALL 10 DAYS WRITTEN 179 Bear Hill Road NOTICE TO THE CERTRCATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL Waltham, MIL 02451 MWOSE NO OBLIGATION OR LIABILITY OF ANY AND UPON THE INSURER,RB AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Claire Boutilier/CT5 ACORD 25(2009101) 01988.2009 ACORD CORPORATION. All Lights reserved. INS025(20I9II) The ACORD name and logo are registered marks of ACORD OP ID: K3 CERTIFICATE OF LIABILITY INSURANCE °"0111`"m 12 1 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 I LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. PORTANT: N the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to terms and conditions of the policy,certain policies may require an endorsement 'A statement on this Certificate does not confer rights to the tificate holder in lieu of such endomement s.UCER 978-M-4667 COMAsurance,Inc.(MA) MOVE One Griffin Brook r Ste 100 978482-9037 xn Methuen,MA 01844-I M E41AIL Jennifer Monkiewicz 'CRESS' =0"VrER SCHER-2 AFFORDING COVERAGE MAIC# INSURED Schemecker Property Services INSURER A:ABC MA WC SELF-INSURED GROUP 179 Bear Hill Road INSURERS: Waltham, MA 02461 INSURER c: 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. LTR TYPE OF INSURANCE 11118. POLICY NUMBER MM�IO YEFF PMiDDIY Y OMITS GENERAL LIABAM EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES jEa ammerme $ CWMSMAOE 0 OCCUR MED EXP(Any one perms) $ PERSONAL$ADV INJURY $ GENERALAGGREGATE $ GENT AGGREGATE UMIT APPLIES PER. PRODUCTS-COMP/OP AGO $ POLICY D PRP Loc $ AUTOMOBILE LMIMU Y COMBINED SINGLE LIAR $ (En acdOanq ANY AUTO BODILY IOURY ffe perms) $ ALL OWNED AUTOS BODILY ILIURY(Pnr a emi S SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per arddenl) NONOWNED AUTOS $ � $ UrmRELLALWB OCCUR ... EACHOCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATLL TF4 AND EMPLOYERS'UABIUW IM A ANY PROPWETORPARTNEREXECUTIVEY IN I MIA BCMA12000112 12131111 01/01/13 EL EACH ACCIDENT $ 1,000,0 OFFICEILMEMBER EXCLUDED? FN (Mandatory In NH) - EL DISEASE-EA EMPLOYEE $ 1,000,000 I yam,desvibe ur ftn DESCRIPTION OF OPERATIONS beJnx E.L.DISEASE-POLICY LIMIT F$ 1,000,00 ProofMassachusetts�rMSIWorkers Co�mpensatr�'on Courage�y �ad�'I,,,o.naPa<n InrnanlreM CERTIFICATE HOLDER CANCELLATION FORINSU SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Insurance Purposes only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUn10RDED REPRESENTATIVE Jennifer Monkiewicz 9)1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD