6 SUMNER RD - BUILDING INSPECTION (3) 1900
The Commonwealth of Massachusetts
W
Board of Building Regulations and Stan�� SE(ZV�C�S CITY OF
Massachusetts State Building Co A SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Reno�v.aje V%DeAo1IVQO
One-or Two-Family Dwell' % E
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature ate
SECTION 1:SITE INFORMATION
1.1 Pro erty Address•� 1.2 Assessors Map&Parcel Numbers rimrni � .Sr. 01a µ-�{-
I.la 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.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of RecoSd:
�Ine (n Scim nrp- kd Salewk tA*
Name(Print) City,State,ZIP
(pSyr►1vC�r QEEF CbT74H f%C3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constructionlf Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition '❑
Demolition Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': Rem del eKifhv pt h
new shrx.�-/f f,/mn
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(LaborOfficial Use Only
and Materials
1.Building $ 7�^� ❑1. Building Permit Fee:$ indicate how fee is determined:
2.Electrical $ � tJ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ QrDO 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Z� ❑Paid in Full ❑Outstanding Balance Due:
IN5K-�� q-b r,�0 00T- D ifJ.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervis,rLicense,(CSL) Qq�30b r)f�
Cos Q/�I r t,' -. , License Number Expiration Date
Name of CSL Holder, _
•' ' , List CSL Type(see below)
�I✓C� t"a H�' � t fay,
No.and Street p"�'�' gut Type Description
-r�SX�I'e��,�,tA 8'�yOJ U Unrestricted Buildin s u to 35,000 cu.ft.
City own/I' ,State,ZIP 7 Restricted 1&2 Famil Dwellin
M Maso
RC Roofin Coverin
WS Window and Sidm
SF Solid Fuel Burning Appliances
Insulation
ele hone Email ad&ess D Demolition
5.2 Registered Home Improvement Contractor(HIC) &/'„�
Q /tYO/H1 Re�' HIC Registration Number pir ton ate
C�any Name or HIC Registrant e
G?I�1-4yle ��Clr A4� G.
No.and Street Email a ress
Ci /Town,State,ZIP Tele hone
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 ��( do_Gass `
to act on my behalf,in all matters relative to work authorized by this building permit application.
.__fftA l , ,. n
Pont Owner's Na he(flectr44c Signature) ate
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below�,I he �jattest under the pains and penalties of perjury that all of the information
contained in th' pli nn ttrtf s true �d accurate to the best of my knowledge and understanding.
P Owner gent's Name(Electronic tgnature V Date
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
wlvw.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass govidns
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"
i
CITY-OF SM-ENI, ANSSACHUSETTS
k
BUILDING DEPART>tL\T
120 WASHIINGTON STREET, 3w FLOOR
T EL (978) 745-9595
c
Fla(978) 740-9846
KIMBERLEY DRISCOLL
T HoNus ST.P3E.RRs
DIRECTOR OF PUBLIC PROPERTY/BCILDRG CO\NISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / \ �' Please Print t epihlV
,�1;1I11C(nusinass Organiratiom'I mlividual): A��-W (� (��CP�
Address: b �yck L—c,,1^e
City/State/Zip: IU�&�PI µd 10613 Phone 1t: NtE
Are you an employer?Check the appropriate bus: 'Type of project(required):
I.❑ I am a employer with 4. ❑ I am s general contractor and I 6. ❑New construction
employees(full and/or pan-time).' have hired the sub•contractars
k 2 I ins a sole proprietor or partner- listed on the attached xhcet. t 7. ❑ Remodeling
.hip and have no employees These sub-contractors have 8. 0 Demolition
working liar me in any capacity. workers'comp. insurance. 9. ❑ Building addition
INo workers'camp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers' sump. C. 152, 91(4),and we have no 12.0 Root'repairs
insurance required.) t employees. (No workers' 13.❑ Other
comp. insurance required.)
•Ail y uppic n tell ahcckr bun 41 murr also fill out ilia sccriun bdow showing their wader)compensation policy
m inliirmatien.
'I locawoers who,il this slridnvit indicating they arc doing all work and then hire outside contractors most suhmil a new alltdavil indicating such.
l\nnrncton)hall check this box most enached an addoitina shut.hawing the mane orthe sub.tuuncton and their worimm'cutup.policy intermatian.
I unr on employer that is providing ivorkers'comper.sadorn insurance for my earployees. HdAlov is the policy and fob.silo
irrfornrution.
Insurance Company Nmne:
Policy it or Self-ins. Lie, 0: Expiration Date:
Job Site Address: City/State/Zip:
AHach a copy of the workers'compensation policy declaration page(showing the policy number and esplradon data).
Failure to secure coverage as required under Section 25A ur\IGL c. 152 can lead to the imposition ofcriniinl penalties of '
fine up to 31,500.00 and/or one-year imprisonment,as well as civil penalties in the form o(o STOP WORK ORDER and a fine
OF up to 525o.00 a Jay against the violator. 13C advised that a copy of this statement may be funvarded to the OI'lica or
Invc-,ugoiuns ul'lhe MA For insurance coverage verification.
i do hereby certify it sins nod per ' s of po ry I/rat the it funnutlurr provided above is-true and correct
ll 'n I IfC' Date'
I'hunc_• 1 ��
O//iciu!use tndy. Oa not write in Ibis area, tube completed by city ur town a/fici rl
City nr Town: - —.-' -- Permit/1.1censc g—_....-- ..---- . ..---
Gluiag Aulliurily(circle one):
I. Board of Health L Mlilding Ilepai Iment .1,l'itylruwn Clerk -1. Electrical loipcctur 5. Plumbing inspector
b. Other
I CooH l Pcnon: ,
a
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120WASHINGTONSTREET,31DFLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS ST.nERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
CAMda
..(name of hauler)
The debris will be disposed of in:
Tr.Atofln T�ns 'o0 r1Lc{riay
(name of facility)
(address of facility)
Signature of applicant
c?
Date
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CERTIFICATE OF LIABILITY INSURANCE oATE{MrVOP(wm
�l 0811012014
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 cettificats holder Is an ADDITIONAL INSURED,the policy(ies)must he 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 endarsemen s).
PRODUM CNOONNITEIAGY Chas.F.Hartshorne&Son,Inc
Chas.F.Harlshome PHONE7$1-245�300 No 781-246-010
3 Chestnut SL gAn.,
Wakefield,MA 01880 'L
MICHAEL A LAUR NO
INSURE S AFFORDING COVEEAGE NAICe
INSURERA:NGM Insurance Cornpny 14785
INsuRCC GeradD Caserta INSIIRtiR is
5 Birch Lane
Topsfield,MA 01983 I�uREr1O:
INSURER 0:
IN�RE-
INSURERF:
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,
EXCLUSION5 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INTBNR TYPE OF INSURANCE POLICY NUMBER T MLUO LISOrs
A X COMMEROIALGENERALLULBUTY EACH OCCURRENCE Is 1,000100
CLAIMS-ODE ❑X OCCUR MPK5188X 10l18/2013 10n812014 PREMISES =U S 600,00
TORUNTED
MEDEXP(Any Ono $ 10.00
PERSONAL&ADVINJURY S 1,000,00
GENL AWREGATEppLIRMpIT APPLIES PER; GENERAL AGGREGATE $ 2,000,00
POLICY❑JECT p LOC PRODUCTS-COMPIOPAGG S 2,000,000
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OTHER:
AWrOMOBILELUu11LITY CDM&NEB IT s 1,000,00
B ANY AUTO LOWS O472412014 0412412015 SMLY INJURY IPW pqR ) S
ALL OWtED PSCHEDULED BODILY INJURY IPAramidenq S
AUTOS ALFTOS
HIREDAUTOSAUTCOS�NEO Pef 8Ctld01 s
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UMBRELLA I= OCCUR EACH OCCURRENCE S
EJICESSLIAB CLAIMS 1ADE AGGREGATE S
OEA I I RETENTIONS PER Y�
WORKERS COMPENSATION STATUTE ER
ANY PROPMETORIPARTNER&V-CUNVE Y E.L EACH ACCIDENT
OFFICEMEMSER E%CWDED9NIA
(Mmdmry In NH) E.L DISEASE FA EMPLOYE S
u MMOwda E.L DISEASE-POLICY LIMIT S
O F ERATK)NS helOw
DESCRIPTION OF OPERATIONS I LACATNNISI VEIIGIES(ADCNo 101,AdIBOW R-WIRS SChtd018 WRY b.dbchad iMWYSPass Is M-'l )
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE OEUVERED IN
Town Of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
Salem,MA AUTHORE:EDREPRESENTATIVE
MICHAEL A LAURANO
01888.2014 ACORD CORPORATION. All rights reserved.
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