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5 SHILLABER ST - BUILDING INSPECTION
,y The Commonwealth of Massachusetts CITY OF i Board of Building Regulations and Standards 4JA Massachusetts State Building Code, 780 CMR Sd Mar �c r 71 Revised rLtnr 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family avelling This Section For Of ci n Building Permit Number D'a he 'i, ' ' Date �� Building Official(Print Naine) SECTION I:SITE IN RINIATION 1.1 Property Addr 1.2 Assessors Map& Parcel Numbers SSHiLL..pg,g,e SeT 1 snte^- 1.l a Is this an accepted street'?yes_ no Map Number Parcel Number 1.3 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal 11 On site disposal system ❑ Check if yes❑ SECTION 1:' PROPERTY OWNERSHIPL 2.1 Owner'of Record:K�VAO AAas1aS1.A Sin Le^ MA O't` r?C7 Name(Print) /? City,State,ZIP - S S N ILL)j AA'R ST, &S7 2)V-1ot3/ No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF.PROPOSED WORW'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) 04 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work': R P PL j C-C TwV3 F? ' SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Officlal Use Only% Labor and Materials 1. Building ; 1. Building Permit Fee:S Indicate how fee is determined: �. F.Icctrical $ ❑aStandard,.City/Town Application Fee Total Pioject Cos?(Item.6)x multiplier x 3. Plumbing S 2. Other I. Mechanical (IfV:\C) S List: i. Jlech:wical (Piro S Ju > nessiun) 'l'0tal:Ul Fees: .S_ Check No. Check Amount: Cash 1in0unt �� -oject Cult S �6 L 0 d in Fidl 0 Outst ling tcc Du — — m � - -- - 1'ai Il ilu - - - - -- SEcrION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) q qs/l� — -- S PPS L D2 ML a 'L� License Number rxpiratiun Date Name utCSL Ilulder (J List CSL Type(see below) �—� y`\' fl✓W w"� TYVe g13 tion No. and Street �� U UnrestricMudding u to 35.000 cu. R. A-,CPF�� rr4A r 02Lh R Restrictewallin Cit /Tua ,Stat , " IP VI 'Masonr RC Rootin tV5 WindowSF Solid Fueiances Cgl 3S3-88 yb I Insulation "rely hone Email address D Demolition 5.2 Registered \Hone Improvement contractor(f11C) ) 7 L S 8 / P�U( ,� ')EeRVrh1Kt`(w-v HIC Registration Number E.xputttiunDate (I�)utf y . ,oukJ[l gistrnutN.une - No.and Street Email address NP D x ?S Li 13 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 .......... ❑ 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 PAS L Der Vur rf to act on my behalf, in all matters relative toto woorrkk authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION JByntering my name below, I hereby attest under the p ' s and penalties of perjury that all of the information ined in thisapplication is true an ccur e t the es of m Howl dge and understanding. � Vet s �l /3 Ownar's or Audwrimd:\;ent's NA nit!(Electrunic Signature) Date VOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut 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 m:u>.euv%oeu Information on the Construction Supervisor License can be found at tewvw.mass.,!ov'dL 2 When substantial work is planned,provide the information below: Total floor area(ml. It.) — __ _(including garage, finished basement/attics, decks or porch) Gro:; living;uea(sy. I1.1 — f fabi table room count Nlnnberoftirepinces,-.—_------_-- Numberofbedromns Number of bathrooms Number of ImItAmths _------ —_ — --- l'vpo Nwnher of dce s; porches I}pe 0f Canliny cydent F:uelused Upcn I'np.a iyu.ue Furst Ike" nl ry h� ,ub;ttnil_ I f,I I'mjccl .1+ n ,Y� 4K r1 y L✓H y CITY OF 8A'LE1%1,, ',aSSACHUSETTS BUILDWG DEPARTsi&NT • 120 WASHINGTON STREET,31D FLOOR TE r- (978)745-9595. F.A-x(978)740.9W KIMBERLEY DRISCOLL TFlpbtrlS ST.P3FJtRB \YOR DIRECTOR OF PUMIC PROPERTY/BUILDING CO:•LUISStONER Workers' Compensation Insurance Affidavit:Builders7C6ntraetors/Efectricians/Ptpmbers Applicant information Please Print Lepibiv Va1pC(F3usinessOrganiraioraindividual): Address: ? 1 �Kl ltDt.f` S l City/State/Zip: SwI-eM^d rA1A Phone#:�� —Sl3 ti 7 y Ar��,y"ou an employer°Check the appropriate box: Type of project(required): I.9 am a employer with, 4. ❑ 1 am a general contractor and 1 6. ❑New;construction employees(full and/or part-time).• have hired the sub-contractors ' listed on the attached sheet t, y ❑.Remodeling 2.El 1 am a sole proprietor or pnrtadre , ship and:have no employees > These sub-contractors have S. ❑.Demolition working for me in any capacity. workers',comp.inaurIimCe. 9. ❑Building addition No workers'comp. insurance S. ❑ We are a corporation and is (No 1 [ P•. 10.❑Electrical repairs or additions required.) y officers Have exercised[hair ,: .. r -. 3.❑ r qu r homeowner doing all work right of exemption per MGL I LEI 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 applicara that choxka box It must also fill out the sectim below showing their workers'compensation policy information; t l hwrnownen who submit this affidavit indicating they ors doing all work and then him outside contractors must submita new affidavit indicating such. �Contraetors that chock this box most aitached an additional shcat showing the name of this sub emaradors=it their workers'comp:policy infomution.. lam an employer char tr providing)porkers'coaipensadon hnsurance foe my employees, Below is the pollcy and job slle _ information: .�� //.�,�,, [[ . .. Insurance Company Name:yrnn'1✓f'I erS - Policy 4 or Self--ins.Lie.M I ` 0 6 US,1J.t Expiration Date: L k l job Site Address: 1lC S Ell C t A R i4 If sy- City/Slat e/Zipi -C�Acp-- /r A- 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 S1,500.00 and/or one-year imprisonmenq as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250A0 a day against the violator. i3e advised that a copy of this statement may be forwarded to the Office of investigationspr the DIA for insurance covcrageyeriticalion.% l do hereby cerdj under the pains and enaldes of perjury that the informadon provided above is true and correct 24 c .gt¢,vi�l S dC:PLt.��651L.- Date• Phone d- Ojjiciui use only. Da Isar write in this area,rit be completed by city or town of it!114L City or Town: Permit/l.lcense# Issuing Authority(circle one): - 1. Board ufllealth 2.Building Department 3.Cityrrmvn Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: .. —_ Phone th aAf°t!p .s ie",1 GLIIMAES CONSTRUCTION IL!\ 1 21 BALCOMB STREET .'n SALEM MA 01970 FONE: 978-836-7279 To: Anastasia Revao QUOTE: 01 k . 5 Shillaber St DATE: May 21, 2013 Salem MA 01970 ,1"wr W _ k Quantity Description Rate Amount y {:` 5' Remove the old tub % In,lall new iub Scrape the old Floor Install cement board new tile floor Install medicine cabinet A � Install one window Paint Nvall and ceilim, if r s�µ ' O 0 ® Total Price includes, permit lahoc and material $ 3 3 C;cj U 1 Quotation prepared by: Rodrigo Guimaraes Signature of Rodrigo , y GUIMARAES 50%down and the other 50% due when job is completed CONSTRUCTION To accept this quotation, sign here and return: 21 BALCOM13 STREET Complete Name of person signing this quote: SALEM MA 01970 FONE: 978-836-7279 Date:�S/ / 3 To. sy® 'I oP2 20'13-OS-2'1 "I 5:'19:20 (GMT) Laura n:ane Insur'a nce Agency Fr'em. Larry Laurbnisno ACORQ, CERTIFICATE OF LIABILITY INSURANCE DATE(mMIDDnwv) 05/21/2013 PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Lauranzano Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Beverly D1A 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A.Western World Rodrigo Guimaraes INSURER B Travelers Guimaraes Construction INSURER C 21 Balcomb Street INSURER D: Salem HA 01970- INSURERS. 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, Ti4E 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 ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MI DATE(MMIDDM') LIMITS A GENERAL LIABILITY NPP8113915 10/22/2012 10/22/2013 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occur*ante $ 100,000 CLAIMS MADE OOCCUR / / / / MED EXP(Any one person) 5 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS COI AGO 5 2,000,000 X POLICY JECT LOG / / / / SOWND AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANYAUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED AUTOS (Perperson) 5 HIRED AUTOS / / / / BODILY INJURY NONOWNED AUTOS (Peraccident) $ PROPERTYDAMAGE (Peraccident) 5 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ 0 AUTO ONLY. AGO $ EXCESSIUMBRELLALIABILITY / / / / EACH OCCURRENCE s OCCUR CLAIMS MADE AGGREGATE 5 5 DEDUCTIBLE / / / / $ RETENTION E $ B WORKERS COMPENSATION AND 7PJUB-5059P86 02/28/2013 02/28/2014 X WC7ATITs °E� EMPLOYERS'LIABILITY ANY PROP RIETORIP ARTNERIEXEOUTIV E E.L.EACH ACCIDENT $ 100,000 y OFFICERIMEMBER EXCLUDED? / / / / EL_DISEASE-EA EMPLOYEE $ 3.00,000 Ifyos describeunder SPECIAL PROVISIONS below EL_DISEASE POLIOYLIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ( ) — (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE One Salem Green INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Salem VIA 01970- �,%•( / .a'-�' ....- ACORD 25 (2001108) ©ACORD CORPORATION 1988 n,-INS025(otos)os ELECTRONIC LASER FORMS,INC.-(800)327-0545 Page I of'_ < CITY OF S.UZNf, LtiL1S&; CHUSETi'S rl`t} It�'�� ') 1 ©l.'[L.O4YG DEP.1AT1lE.�iT I10W- �,,, WNCVGTON STREET, .3 FLOOR 3.� TFL (979) 743-9595 ;<IJCOE.RL.SY D(tISCO[1. F.Lx(973) 7•10-9344 bUYO,i T IOAU SrAEAAB DuECTOR OF PL OUC PROPERTY/B(;tLDLVG C0\pt155t0.V EA Construction Debris Disposal At'tIdavit (required for all damolition and renovation work) In accordance with the sixth edition of the State Building Coda, 730 CAjR section 111.5 Dcbris, and the provisions of tbiGL c 40, S 54; Building Permit J# 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 NMI% e I 11, S 15OA. The debris will be transported by: (name ut'hauler) The debris will be disposed of in _SaucuS PVti-r 1 (name of facility) o Nadress uict taaility) III siynamre ufpermit a lica pp nt I