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12 SOUTH ST - BUILDING INSPECTION y The Commonwealth of Massachusetts a Board of Building Regulations and Standards CITY OF ��V ALEM Massachusetts State Building Code, 780 CMR Revised Mar SdMar J 2011 L Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling >1 This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Srgnat re ate SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers u 1.1a 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 Sppply: (M.G.L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Di/spysat System: CY/ Zone: _ Outside Flood Zone? Munici al,,;O site disposal system ❑ Public Private❑ Check if yes❑ P P y SECTION 2: PROPERTY OWNERSHIP` 2.1 Owner of Record: r S )) 1 ll �/� -y1 / r SA�eN �� N ! Name(Print) City,State,ZIP / '�_ Sou ✓ 15�_I No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) VT Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief escription of Proposed Work 2: /✓.te a �4� d1.f21� .r( r r o_ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ B , A& 1. Building Permit Fee: $ ndicate how fee is determined: ' ❑Standard City/Town Application Fee 2.Electrical $ i �a-yo s G 6 l Project Cost (item 6)x multiplierT� x /, 3. Plumbing $ eo 2. Other Fees: $ $` 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: $ M Check o.�p94W Cheek Amount {'7/0Cash Amount: 6. Total Project Cost: $ 3 �i70 ,of aid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number' Expira on D e Name of CSL Holder t Lis t CSL Type(see below) 3 a V`A No.and Street Type Description ,/�VI 0,M q � O o, �� U Unrestricted(Buildings s u el ing cu.ft. '(/ y t'� ` R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding Q SF Solid Fuel Burning Appliances �7 y �.dS/� �(� /�Q� I 1 Insulation Telephone Email address D Demolition 5.2 Registere�d,Home� Improvement Contractor(RIC) �b 7 73�_ l � �_`'`� ��JJ'' n.�II✓LC 1 HIC Registration Number Ex ira ion Date HIC Compan N e or HI Registrant Name l o t � � ,1I Q- dU 90 /q94, No.�an�d Street Email address / 'ri0tAQR /V� 8l`r7 �/ )P-77`(- �e�2 Ci /Town, Stag 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 I,as Owner of the subject property,hereby authorize \1 A t.:� Ay t A /9x1, Ir to act on my behalf, in all matters relative to work authorized by this building permit 9pplication. S� Print Owner's Name(E ectmnic Signature) Date SECTION 7b: OWNER`OR AUTHORIZED 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 ace the best of my knowledge and understanding. �0 �- 7 . ur G Print Owner's or Authorized Agent's Nam ectro is Signature) ate 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. ovg /oca Information on the Construction Supervisor License can be found at www mass.eov/dns 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 S�u.F-,NI, N'LUSACHUSETTS • Bun DIING DEPARTMENT • P 130 WASHINGTON STREET, 3"0 FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 ��tgFRi RY DRISCOLL MAYOR THOMAS ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COM3,nSSIONER 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 willbe transported by: -name of hauler) The debris will be disposed of in (nank of facility) (address of facility) signature 1117 t app icant date debri.lffdm CITY OF S.U.&NN L'L-1SSACHUSETTS BLILDIING DEP ART%iENT a 120 WASHINGTON STREET,Sao FLOOR TM (978) 745-9595 FA.r(978) 740-9846 KI),fgFRi FY DRISCOLL MAYOR DIRECTOR ST.Pwjuti DIRECTOR OF PUBLIC PROPERTY/BUMDING CO\MBSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,Please Print Legibly Name(Busirnss:OrganizatioNindividual): .1 �1 H Address: 6 � 4 �0 11u? City/State/Zip: v< '-A Phone #: $ ' -7 7 -( — �6a Are yo an employer?Cheek the appropriate box: Type orproject(required): 1.011 am a employer with�'1 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-&meyt, have hired the sub-contractors 2_❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ®-Re'modeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9• ❑ Building addition [No workers'comp. insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I l.❑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 applicant that checks box#t most alw fill out the section below showing their workers'compensation policy information. 'I lnmeowms who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a crew affidavit indicating such. :Comracton that check this box most attached an additional sheet showing the name of the sub-contractors and thew worsen'comp.policy info rnation. I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site information. Insurance Company Name:_ o Policy#or Self-ins. Lic.M [A) C A-S Ofa T/ c/g Expiration Date: 1016 Job Site Address: 4-A SL , City/State/Zip: -&41 61 vo 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 a 152 can lead to the imposition of criminal penalties of 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under r i s and penalties ofperjury that the information provided above is true and correct i n:t ire• q Date: J Phone#: / 7d' — 7��.3 Official use only. Do not write in this urea,to be completed by city or town offrciat City or"town: Permit/License# Issuing Authority(circle one): I. Board of Ifealth 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person Phone#: ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) h 06/20/2013 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 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). CONTACT PRODUCER NAME: CPCU,CIC,AAI, Mark Tarpey Tarpey Insurance Group Inc (PANE AN.'Eat: 781.246.2677 A/C,Ne):781.224.0973 442 Water St E-MAADDRESS: PO BOX 567 INSURER(S)AFFORDING COVERAGE NAICN Wakefield, MA 01880 INSURER A: Acadia Insurance Company INSURED Built Well Building & Remodeling Inc. INSURERB: Safety Indemnity 33618 DBA: Bob Carroll INSURER C: 3 Old Stonewall Ave. INSURERD: Danvers, MA 01923 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 12-13 term 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. ADDLSUHK SR rypE OF L F I YE P LTR INSR MD POLICY NUMBER MM/DD MMIDD LIMA GENERAL LIABILITY CNA03234621 10/06/2012 10/06/2013 EACHOCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY PREMISES Ed occurrence $ 50,00 CLAIMS-MADE OCCUR MEDEXP(Any one person) $ 5,00 A PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ - 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 1,000,00 X POLICY JET LOG $ AUTOMOBILE L bMUTY 243416 10/30/2012 10/30/2013 Eaaccident $ 1,000,00 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ B AUTOS X AUTOS NON-OWNED $ X HIREDAUTOS X AUTOS Peracci t UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ ER $ STATU WORKERS COMPENSATION WCA506514 OR TOR 10/06/2012 10/06/2013 X V LIMITS- O H- AND EMPLOYERS'LIABILITY My PROPRIETORMARTNER/EXECUT YIN E.L.EACH ACCIDENT $ ZOO,OO A OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 if yes.DESCRIPTION antler E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Mach ACORD 101,Additional Remarks Schedule,if more space is required) Residential General Contractor 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. Shaina Doberman & Matt Richard AUTHORIZED REPRESENTATIVE 12 South St. Salem, MA 01970 William B. Tarpey ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Board 4'r Building S11:11dw.d. License: CS 53049 ROBERT J CARROLL 3 OLD STONEWALL AVE DANVERS, MA 01923 Expiration: 8/10/2013 ........ ...... Tm 20277 biflc�e of Consumer Affairs&Busidems ReIgifialfiia Az AdTdjj M MEMPROVEMENT CdM TYPIP: egtstrabon 077,55: BUILT WELL BLDG i REMODELING INC. FZ41 04,Carrioll :3 Old Under �� IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 2013062100711 802585 Pg;390 06/21/2013 03:48 DEED Pe 1!1 QUITCLAIM DEED We,Mary Dunn,also known as Mary M. Dunn,an un married woman, of 12 South Street, Salem,MA; Dickran Avegian ,a married man,of 33 Albion Street, Salem, MA; and Judith Crosbie,a married woman, of 3 Gallows Hill Road, Salem,MA; owners of 12 South Street, Salem,MA 01970,grant to Shaina Rae Doberman and Matthew J Richard,of 19 Beck Street#2, Salem,MA 01970, ,for consideration paid of TWO 'ivftt—, e� HUNDRED THIRTY THOUSAND($230,000.00)dollars Qu:#cPai4r+ �o�7eewnCe Ile The land together with the buildings thereon,situated at 12 South Street,City of Salem, Essex County,bounded and described as follows: NORTHEASTERLY by South Street,one hundred(100) feet; SOUTHEASTERLY by land now or formerly of Snigurski,one hundred(100)feet; SOUTHWESTERLY by land now or formerly of Gauthier,one hundred(100)feet; and NORTHWESTERLY by land now or formerly of Gauthier,one hundred (100)feet. Said premises contain 10,000 square feet,and is shown as"Mary A. Dunn, 10,000 S.F.", on a plan of Walter M. Wheeler,C.E., dated December 18, 1946,recorded with the Essex South District Registry of Deeds in Book 3505,page 13. For grantor's title see deed dated August 16, 1999, recorded at Book]5930,page 524 with the Essex County South District Registry of Deeds. EFFECTIVE PREMISES BEING: 1.2 South Street,Salem,MA 01970 I,Mary Dunn,aka Mary M.Dunn,do hereby release all my homestead interest created automatically pursuant to M.G.L. c.188, §4,at which time I was unmarried. 71 si— Witness my and and seal day ofJune,2013. ry D by Dickr Avegian,Power of Attorney see Po r of Attorney recorded herewith. 1th Crosbie Southern Essex 103r 481 PROD 7Ckran AVCgIan Dalfl: O6l21/20 3 10: 9S,,e4 .ee 2013062100000. Fee: $1.048.00 Lons: $230,000.00 COMMONWEALTH OF MASSACHUSETTS Essex ss. Then personally appeared before me,the undersigned Notary Public,personally appeared the above named,Dickran Avegian and Judith Crosbie,and proved to me through satisfactory evidence of identification, which were Driver's Licenses,to be the people whose names are signed on the preceding document,and acknowledged the foregoing instrument to be their free act and deed before me. +"PR Att me Mary Frances Milburn +a Vcm F+,�A otary Public Return to: Attorney Mary Franoggt s Yi a�N`= y Commission expires March 13, 2013 bt �y1�.'�'EAITM %,-A SErr$NN`p` YYYN,WW