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22 SHORE AVE - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code,780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling '11�is,S.,ec�oa FQr+f> c�1 Lke Btiiidtag Potmit Number:. . Date Apphad: N SEMON l:SITE li`7T(1R11dATI0iV' 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1 ,)t Shore aV so Af — Lla Is this an accepted street?yes_ no Map Number Parcel Number 13 Zoning Information: 1A Property Dimensions: _! Zoning District Proposed Use Lot Area(sq ft) Frontage(fl) 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: Public Cl Private 0 Zone: _ Outside Flood Zone? Municipal 0 On she disposal system O Check if es0 wp SECTION2: PROPERTYOWNERS11W 2.1 iCflJlertoGO � ' p � F/ Y� �C// �� 220 Name(Print) City,State,ZIP AI- SyJorE aye No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New Construction 0 Existing Buildin Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition Accessory Bldg.0 Number of Units Other 0 Specify: Brief Descn ton of ProPq�ed World: �lltd ( � TC5 cavia (>�rvVl �nYI S SECTION 4:ES CONSTRUCTION COSTS Item Estimated Costs: Official Use.Only (Labor and Materials 1.Building $ d 1 Building Permit Fee.$ indkate howfee is determined 0 Standard City/town Application Fee 2.Electrical $ O Total Project cost'(item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List' 5.Mechanical (Fire $ Total All Fees:$ S ression Chedr No. Check Amount: Cash Amount:. 6.Total Project Cost: $ 0 Paid in Full. ❑Outstanding Balance Due: .. (NIL. Z7 '— VIZ sEClION 5: cONSTRIIGTIO N SERVICES 5.1 'Construction Supervisor License(CSL) ��s ��n�� O LicenseNum giber inuionDate N e of CSL Holder Ty ( ) —r-qrv� p�,/� List CSL T sce below I r \� Nl CSTTYP No.and Street U I Unrestricted(Buildings to 35,000 cu.ft. R Restricted 1&2 Family Dwe City own,State,ZIP I M RC I RoofingCoverin WS Window and Siding SF Solid Fuel Bumiug Applimces I Insulation Tel hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) )1� 7� �I � cJ�J 0�J ts.`L.r=C HIC Registration Number iranon Date HIC Company Name or HIC Registrant Name 120- T�� � ]�-��D(�u�hao L6M N .and Street 1 10— l��_) ' Jq Em s Ci wn State Telephone SECTIM&WORKERS'COhIPE]!ISATION RMIRANCE AFFIDAVIT @LG.L.,c.152.4.Z5Q4$)) 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...........❑ SECMN 7a OWNER Aftlib(RIZAMON Tf513E COWLETEDWECIN OWNER'S AGYNT OR RLAPPEW FOR HURPM PERAHT 1,as Owner of the subject property,hereby authorize to act my be f,in all matte ls relative to work authorized by this building permit application. q Print Owner's Name(FJ6ctronic Signature) D SECTION 7b-OWNER'OR AUTHORMM AGENT DECLARATION 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 my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) - D NOT Ea: 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 jnny mass. og vtoca Information on the Construction Supervisor License can be found at www.ntass.eov/dns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halUbaths Type of beating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPSS) Mass.Gov Home State Agencies ensee Details Demographic Informatiag FullName: OR MENDEZ Gender: Owner Name: dress: Address 2: City: Lynn State: MA ipcode: 01902 o nt : U 'ted tales natinn se icense o: 8 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: Issue Date: Expiration Date: 3/10/2019 License Status: Active Today's Date: 7/26/2016 Secondary License: Doing Business As: Status Change: Lic se Issuan requistW o Pre-requisite Information Discipline No Discipline Information ocumen um Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license_id=822765& 7/26/2016 CERTIFICATE OF LIABILITY INSURANCE DATE(Msconr IT 04/26/2016 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, the policypes) must be endorsed. If SUBROGATION IS WANED, subject to the tenns 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 endomement(s). PRODUCER Congress Auto Insurance Agency Inc PHP21ONE (781) 599 - 3400 (FAK aG NIF(781) 599 - 4114 131 Broad at AODREss: INSURER(S)AFFORDING COVERAGE MC# Lynn, a 01902 Iraw A: INSURED wsuREne: Hector Chilel Mendell INsuRERc: 150 Tiauson St INsura:RD: INM➢a:R E: Lynn, MA 01902 IMMURERF: 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 REOUIREMENT, 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 TYPEOFINSURANCE I,ySR yyyD POLICY NUMBER (MWDD)YYYY) (MMIDn=" LIMITS A GFAm+Yu.LIWmNTY y bma0O23664 04/27/16 04/27/17 EACH OCCURRENCE E 1000000 COMMERCLIL GENERAL LUIBILT' PREMISES(E»om^erm) E 100000 CLN S E ®OCCUR MEDEXP(A,..Paeon) E 10000 PERSONAL E AW IUURY E 1000000 GENERAL AGGREGATE E 2000000 GENL AGGREGATE UMIT APPLIES PER: - PRODUCTS-COMP/OPAGG $ 2000000 POLICY JET LOC E ALITOM aU.E LIABILITY ecaaen0 E ANYAUTO BODILY IWURY(Pm person) E AUTOS AUTOS O SCHEDULED AU BODILY IWURY(Per e¢imee S S HIREDALMOS AUTO ED E (PiQPER Y E UMBRELLA LIAR —UR EACH OCCURRENCE E EXCESS UAB CIAISMADE AGGREGATE E DED RETENTION E 1 E g �COMPENSATION Y 6MM2E88946915 04/28/16 04/28/17 AND EMPLOYERS'LIABILITY YIN TORV UMITS ER ANY PROPPoETORIPAWNEWEXECIRIVE EL EACH ACCIDENT S 1DWOOD OFRCF1bMEMSER EXCLUDEW Y❑ NIA - - E.L DISEASE-EA EMPLOYEE E 500000 DESCRIPTION OF OPERATIONS IxIow EL DISEASE-POLICY LIMIT E lOOOOO DESCRIPTION OF OPERAPONSI LOCATION81 VEpCLES(AroN AfARp Tel,Addtlwl RNmYb SrIIeB^N,H mole epeoe V requlre� ALL ASPECTS OF CARPENTRY 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. AURiOA�D REAIESENTATNE ' 01988-2010 ACORD CORPORATION. All rights reservetl. ACORD 25(2010/05) ,. The ACORD.name and logo are registered marks of ACORID Estimate get�hLueensed 6lnsureit "The Nght hand for the JOV Date Estimate# m.n 7/1/2016 56513 271 Western Ave Suit#211 D Lynn MA 01905 Name/Address Project Address Paul Cote 22 Shore Ave. Salem MA 01970 Description Total The following Estimate for the property located at above address. The following paragraphs explain the work that Mendez Contractor will carry out. SCOPE OF WORK:BUILD A DECK New Deck Build a deck 1.Remove old existing deck 2. Dig Holes for the footers 12" Wide 4'down 3. lay Mortar mix 4.Install Galvanized base 5.Build frame 2"X 10"joist, galvanized hangers,and 6"x6"PT posts 6.Install 1"X 6"PT decking 7. Install new PT baluster,railings and install new composite round columns 8.Install new pine prime 1"x10"fascia around the first floor decking TOTAL FOR LABOR AND MATERIAL 8,475.00 Payment terms: 6 $ 4,000.00 down payment n $ 3,075.00 upon the job is in progress $ 1,400.00 upon the job is completed i rcm . ome Owner nager www.me 11 n NOTE: Any alte Lion will be approve by all parties before is done Total these may result an extra charge. C 17 Y OF SALEA MASSA(HIBETP BruZEWDBrAMExr IM WwemaXrwSMWv32DADCa 7�L�78)7�5.9595. BII�ERIBYDIRL�. FAX 740-M" MAYORDnmcmncppulucppxnmylBumnmcommmcmm 7}a sST.P�tte Construction Debris Disposa/AfflAw t (required forall demolition and,.renovation work) In accordance with the sixth edition of the State Building Cie, 780 CMR, Section 111.5 Debris, and the provisions of MGL 00,S 54; Building Permit B is issued with the condition that the debris resulting from this work sha0 be disposed of in a properly!tensed waste deposit facility as defined by MGL c 111,S isoA The debris will be transported by. (name of hauler) The debris will be disposed of in: (name of fadlity) -- (address of facility) Signature of applicant Date a JQGD rumEr axe' e � r � P:5 , CC6 C-f -- _ _ _ - - _ - __ _ _II The Commonweakh ofMassachusetts Department oflndustri ,4ceidents 1 Congress Street,Suite 100 Boston,MA 02114-2077 wwwmassgovIl is Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE MED WJTH THE PERNIIITMG AUTHORITY. Applicant Information Please Print Leefbh Naine(Bosiness/Orgammtionandividuai): �S t (ll�cil Al L L .. Address:_IL a�tl M snn s j Ar City/State/Zip: Phone M CMe� LWem as empbyerY Check the appropriate box: a employer with T ype prrojeM(required): �eagtbyee(tun and/mpart-time).• ew construction a sole psopaierm or partnership and bave no anpbym worliog forme m capacity.[No workers'comp.tnstsance regrmed) emodeling a homeowner doing an work myself.[No workers' mohtion �P.imunmce requtred]t a homeownv and will be hiring contractors to conduct an work on my properly. 1 will ilding addition re Wert all contractors either have workers'compensation entrance m are sole ctrical repairs Or additions rietors with on employees. mbing repairs or additions a geceml eoonacrer and I have hired the aubmbaetnrstintedontheaaaehea sheet.e subruntmclms have employees and have workers'cep,iu memt ofrepairs a corporation and is ot5ars have exercised then right of exemption par MGL c = 61(4),and we have no employees.[No workers'camp.marxaoce regtmed.) -Any applicant that r]uxlra box#1 must also all out the section below showing their workers'wmpeosation policy mfmmstion. Homeuwriars who submit this affidavit indicating any se,doing an work and than hire outside conaamms must submit a new,affiduvit indicating such lContraetors that check this box mutt attached an additional shot showing the name ofthe sub ins and slate whether or not thme entities have employee. Hthe mbtootractors have employees,they must provide their workm'comp.policy number. I am an employer,that is providing workers'compeeesimon insurance for my employees. Below is thepahry andjob site keforenadols. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Croy/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S 1,500.00 and/or one-Year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance Coverage verification. I do hereby cerdfy under thepains and penaWes ojperjury that the mformadon provided above is tree and correct S smature: - Date Phone#: 091chd use only. Do not write in skis area,to he comploed by city or town orkial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Perron Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in aloint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the o 'ate line. City or Town Officials ` Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant. Please be sure to fill in the permit/hcense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in - (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or perinit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02 1 14-20 1 7 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia