26 SHILLABER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Buildingg Regulations and Standards CITY
Massachusetts State Building Code, 180 CMR, 7u edition OFSALEM
r Revised Junuun,
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a
(� One-or Two-Fumdv Dwelling
This Section For Official Use Only
Building Permit N mb r: Date Applied:
Signature: 2� )�
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map di Parcel Numbers
A(, S l, i 5r
I.I a Is this an accepted street?ycs .,---�no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
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 Zom?
Public❑ Private O Check if esO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 caner'of Recnrd• S
U�'I CD _+{ e � 5�1`,11�C��-r
No a(Print) Address for Service:
g? 7- - 7Yl - 7b l 7
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied ❑ Repairs(s) O 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': kj4a� -,N5— 61ow g c¢l L4
Kt:. SkQ.l loot / No O•. vl (CaplaLc,.er F C Ja As Lou r�A pn-yam
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
I. Building S 1. building Permit Fee:S Indicate how fee is Determined: . 1
? Electrical ❑Standard City/Town Application Fee YJ
. S
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S v
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S �Q�D 007 O Paid in Full 0 Outstanding Balance Due:
1 '
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
/, � ) �� ( ✓j// License Number Expiration Date
Name uit�'C'S1.•,I I�dJer' S _I List C'SL Type Isee below) 2-
6 T De Description
Address U Unrestricted(up to 33.DOO Cu.Ft.
��� R Restricted IR2 FamilyDwelling
Signau£i .?Yq—Vl{� M M Only
%% �� RC Residential Routing Covering
Niephonc WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Horrla Improvement Contractor IH C) `C�� A S 9
A F ran ! c U 200 -Ltn i 7
HIC Company Name r IIIC Registrant Name Registration Number
� I �
Address /J
g7� ) YY-fr(`(3 Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. f 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 -building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT
1, 6r-1 (/ &0 R 2 as Owner of the subject property hereby
authorize eEj:r r <.s to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of ner Date
SECTION 7b:O /WNER'OR AUTHORIZED AGENT DECLARATION
W - &( --I ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name _
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
I. 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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I l0.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/anics,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"
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F ailum to secure coverage a required under Section 25A of MGL s 152 can Ipd to the imposition ofcriminal ponald"of s
f ne up to S 1.300.00 antY«one-year imprisonment as well ea Civil peneltioa is the form of a STOP WORK ORDER and a flos
of up to S230.00 a Jay iwifist the violator. Ila adviwd that a copy u(this Itstams. may be forwarded to the 0171ee of
I nvc.tl nations ol'ilie MA for itisuranco coverage writica suit
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City or ruwn: YrrmiNl.leena/__, _.
tuuint.\uthontY (Circle unol.
I. Iluard u(Ileallb 1. nudt11n0 Uvpartmenf 1. City/fawn Clerk 1. flectrical Inspector 3. I'lumbint Inspector
h. tllher _
'Phone e:
�A CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Ia:���+111.\1.:��V SrMtl'r 15.�I1\I, fit.\+i.0 III +I I ,.:I9'_
fF1 471-74{-•699 I AX:%7Y•74S'I:IM
Construction Debris Disposal Affidavit
(required lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 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 from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
t name ul'luuler)
The debris will be disposed of in :
(nartxul aci rty
taddrea�ul'1'�cilily)
N411amre of Immit applicant
G/�1 /d
hate
EIG Fax Server 4/6/2010 3 : 15 : 24 PM PAGE 2/003 Fax Server
DATE NWDDtY'YYY)
CO CERTIFICATE OF LIABILITY INSURANCE 04/06/2 10
PRODUCER (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
233 West Central Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Natick, NA 01760
INSURERS AFFORDING COVERAGE NAIC9
INSURED Atlantic Weat erizatlon LLC INSURERA Arbella Protection Ins. Co. 41360
61 Rear 3efferson Avenue INSURERS: Arbella Indemnity Ins Co. 10017
Salem, NA 01970 INSURER C.
INSURER 0:
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 OF SUCH
POLICIES.AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DD' TYPE OF INSURANCE POLICY NUMBER POUCYEFFECTIVE POUCYEXPIRATIOIYYIN LIMBS
GENERA-LIABILITY 8500042816 03/20/2010 03/2O/2011 EACH OCCURRENCE b 1,000,00
X COMMERCIAL GENERAL LIABILITY DMAAGE TO RENTED $ 50,00
CLAIMSMADE FX OCCUR MED EXP(Any me person) $ 5,000
A PERSONAL&ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000.00
GENL AGGREGATELIMIT APPLIES PER: PRODUCTS-COMP/OP ASS $ 2,000,000
POLICY X JEGT LOC
AUTOMOBILE UABILRY 93927400003 03/20/2010 03/20/2011 COMBINED SINGLELIMIT
(Ea ecddeM) b
MY AUTO 1 OOO,OO
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person) $
B X HIRED AUTOS BODILY INJURY $
X NON-OWNED AUTOS (Per aa:ItleM)
PROPERTY DAMAGE $
(Per..Idert)
GARAGELIASIUTY AUTO ONLY-EA ACCIDENT S
MY AUTO OTHER THAN EA ACC $
AUTO ONLY: ASS $
EXCESSAIMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR FJ CLAIMSMADE AGGREGATE $
E
DEDUCTIBLE $
RETENTION S $
WORKERS COMPENSATION AND 9111820309 03/20/2010 03/20/2011 X I `,vC STAru- OTH-
EMPLOYERS'UABILRY E.L.EACH ACCIDENT $ 500,00
A ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMSER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 500,00
I yes,tlesaibe antler E.L.DISEASE-POLICY LIMIT $ 500,000
SPECIAL PROVISIONS belay
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
CITY OF SALEM BVTFAIWRETOMAILSUCHNOTICESIHALL IMPOSE NO OBLIGATION OR LIABILITY
120 WASHINGTON STREET OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
SALEM, MA AUTHORIZED REPRESENTATIVE
Rosemary Fulham/PMA
ACORD 25(2001108) ®ACORD CORPORATION 1988
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 87977
Restricted to: 00
ERIC W PALM
3 HILTON ST
SALEM, MA 01910
Expiration: 4/23/2012
('ommixsioner Tr#: 22214
-.: _✓�Jee >�000ur;u+a�a�eu� o��/�l¢macr�iireEf£d
e141'raeof.Geasumes.f�+pha&BasihmsamAw1'an
tfOME 1 - cimmmi 69R
Re9JSb*G 9 - -
Expira{� — _ 12 Trill 29@Mz7,4
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ATLANTIC WE — L .C. _.
retie PALM
• L` 1;>M�-tl�4970 �-� t<Imleesar<meCasg
i,
ATLANTIC WLATHERIZATION, LLC
61 R JEFFERSON AVENUE
SALEM, MA 01970
May 14, 2010
To Whom It May Concern:
I, Eric Palm, owner of Atlantic Weatherization, LLC authorize my employee,
Damian Anketell, to pull permits for my company.
Sincerely,
i `"-'q
Eric Palm
Atlantic Weatherization, LLC