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11 SUMNER RD - BUILDING INSPECTION
, , � The Commonwealth of Massachusetts ` <„D, Boazd of Building Regulations and Standards % CITY 'U n �,/ . . OF SALEM Massachusetts State Building Code, 780 CMR, 7 edihon Revised January ` u� Building Permit Application To Construct,Repair, Re vate Or Demolish a 1, 2008 �ti� One-or Two-Family Dwellin This Section For Official se Only Building Permit Nu ber: Date A plied: Signature: �1��/ " / Building Commissioner/ ec or of Buil ' gs Date , . - SECTION : SI INFORMATION. . 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers I 1 s ca. � YZt�P. l.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(tt) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided � � 1.6 Water Suppiy: (M.G.L c.4Q§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal sysrem ❑ I Check if yes❑ i SECTION 2: PROPERTY OWNERSHIP� I 2.1 O(�wner of Record: ^ (1 Y'l7� S lw 7 -_'�....�C i L S(.�wn v� -f_✓�<Y _ Name(Print) Address for Service: kGP�.�P 5e ,�� � 4' 78' '1� s- 6'223 igna[ure Telephone SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construetion❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)�' Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units O[her ❑ Specify: Brief Descrip[ion of Proposed Workz: � ry�a k� l,.,..� .ti /(� �., ` ��o...�s .,. ,s� iC, e- S n i9 �� �'!/ .0 r r �L c� ���o�, SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials � 1.Building $ � 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical g '❑Standard CitylTown Application Fee . ❑Total Project Cost�(Item 6)x multiplier x � 3.Plumbing $ 2. Other Fees: $ �/i�(�/� 4.Mechanical (HVAC) $ List: l \ /� � 5.Mechanical (Fire $ Su ression Total Al]Fees: $ Check No. Check Amount Cash Amount: 6.Total Project Cost: $ ,� ❑paid in Full �❑Outstanding Balance Due: ���;(. o� C'��-h-r,�� SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) �,7� �{_ j. —��.1_CfL ���������/�n License Number Expiration Date Name of CSL-Ho der / List CSL Type(see below) L( - 7 ('�n ��o� �s,,/ �• P /( !��_ �1vn¢. .. Address T e Descri tion U UnresVicted u to 35,000 Cu.F[. x R Restric[ed 1&2 Famil Dwellin Signa[ure cy M Mason Onl ��� �� 3�� + RC Residen[ial Roofin Coverin Telephone WS Residential Window and Sidin SF Residential Solid Fuel Burnin A liance Installation D Residential Demoli[ion 5.2 Registered Home Improvement Contractor(HIC) '2�1 ,l R M Comp n �Nam or HIC RegisVant Name Registration Number 5 c � D • � q Address I ��S/�� SO��g0.37lR Expiration Date Signa[ure Telephone SECTION 6.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(�) Workers Compensation Insurance affidavi[must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the lssuance of the building permi[. Signed Aftidavit Attached? Yes ..........� No........... � SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S ACENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 5 6 , � v.e.+ . �i v r� �— , as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authori ed by this building permit application. Si ature of Owner Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION ,F �Q/�lP���� �, i��j,,, .,n�� ,� . ��Qe� (',r� /�ilnc�,as Owner or Au[horized Agent hereby declare that[he statem nts and information on the foregoing application are true and aecurate,to the best of my knowledge and behalf. , Print Nam O ignature o wne Auth ized Agent Date Si ed under th s an enalties of er'u ��- NOTES: �- l. 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 Conhactor(HIC)Program),will not have access to the arbitration program or guaranry fund under M.G.L.c. 142A.Other important informa[ion on the HTC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1IO.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors azea(Sq. Ft.) (including gazage,finished basemendattics,decks or porch) Gross living azea(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. "Totai Project Square Footage"may be substituted for"To[al Project CosP' � TJt� Conztr:onwealY]i ofMassach:tsetls ,...;..._._..._ .... !7e ar " i„ ! p hne�:t of7ndustrinl Accidents �` . " �yi� Office oflnvestigations 4 � � , _� � t„ y••,l� 600 Wasl:ir:gtorz Street ��^.`��,•.� Boston,lblA 02III ��';.y-���/ www.�nass.gov/dia Worlcers' Compensation Insurance Affidavit: $uilders/Contractors/.�lectricians/Plumbers Applicant Information Please Print Le 'bIv Name(Business/Organization/Iadividual):_ �'� �� ;_. n i r t,��,�, - CO Address: rJ $ S�d c� c ,P// D r City/State/Zip: • o . Phone#: ��$ $ O ���1 q Are you an employer? Chec tLe appropriate bos: 1.�I am a employer with /� . 4. ❑ I azn a general con7actor and I Type of project(regufred): employees (full and/orpart-time),* bave Lired the sub-cantractors 6� ❑New cons�uction 2.0 I am a sole proprietor orpaxh�er- listed on the attached sheet 7. �Remodeling ship and bave no employees These sub-contractors have g_ � bemolidon worlcing for me in any capacity. employees end have workers' [No worlcers' comp.insurance comp. insurance.x 9_ �Building addition required.] 5. � We aze a cocporation and its 10.�Eleclrical repairs or additipns 3.0 I nm a homeownec doin aIl wnrk officecs 6ave exercised their g l I.0 Plumbing repairs or additions myself. [No workers' comp. right ofexemption per MGL 12.0 Roofrepairs insurance required.] t c. 152, §1(4), and we have no employees. [No worlcers' 13-Q Other comp.insurance required.] 'My appliconl thnt checks hox Yl mus[nlso fil]ou[the sectlon below showing theirworkels'compensation polity inCorsnation. t Homeowners who su6mit this nfFidnvi[indicating ihey are doins atl work and then hi¢ou6ide conaactars must suhmit a new n�duvit indicatlng suc}�, rContraclors that check this hox must ettnched an addirional sheet showing the nnme of tht sub-eontracto[s nnd smte whether or not�hose enfiues hnv� employces. If[he sub-eontrecrors hnvic employees,they must pravide thcir workcrs'comp,policy number. I nm an enepinyer t/m!isproviding ivorlrers'campensation insuroace for niy empZoyees. Below rs ihe policy and job site informatian. Insurance CompanyName: S ,-,,,,� , .y Policy#or Self-ins.Lic.#:�0(���2p 10006'� Expiration Date:_ Z 2 l a�O 9 7ob SiteAddress: Pr 5 �, c....',_ 1�rX City/Stete/Zip: v�,kiLGn , lr�. 0��20 Attach a copy of the worlcers' compensation policy declaration page(showing the policy number and expiration date). Failure to secuce coverage as required under Section 25A ofMGL c. 152 can lead to the irnposition of criminal penalties of a fine up to$1,500.00 and/or one-yeaz imprisonment, as well as civil penaltiu in tbe form of a STOP WORTZ ORDER and n fine of up ro $250.06 a day against the violatar. Be advised EUat a copy of this st¢tement may be forwarded io the Office of Investigations of the DIA for insurance coverage verification. I do leereby cenijy irxder tliep¢ins and perenities ojperjnry t/�ar tLe inforinaYion provided above is true¢nd corred Sienature: �- , Date 4�2$��OP Phone#: �� � S SS"D —3//�'s Ojfecial rise only. Do not ivrite in this area, !o be completed by ciry ar tv�vn ojftciaL , City or Town: PermiULicense# Issuing Authority(circle one): 1.IIoard ofHea)th 2.$uilding Department 3. Ciryfl'own Clerlc 4.�lee[rical Inspector 5.Plumbing Inspector G. Other Contact Person- Phone#• , i ' ' fr I - , �' "i '. ':; ri vi`�. i;'r��(.. 'i�r('"...ii���i., ��"? F,�%. , � o t f �J:.. .-r.!,;, ,.... I3o�i� c� oi��Bui�di„U rZegula{ions a�!d StancE��rds t.)ne';Ashburton piace - Roo�iz 1301 B!oston. l�lassach��setts 0'?�10� I�ome li��provement Contractor 'Re�istration � i 1'G � Re istration: 727 �., Q ' ( ?ype: Ltd L.iability Corpor . I ��Piration: S/15/7..010 Tr; 7r7'<97 CH,AMPION W'INDOW c� PF,TIO ROOM SOU � AN-THOIVY COViELLO ', I 75 STOCKI�(ELL DR. i AVON, MA 02322 I I �,,I Updat iAddress and return carcL p4arl. re:ison for cfinr:<�e � � � A<f��'ess . E2cne�val Bmployment l,oti( Ca �ci . .. .. �,xa,s. �, I J/e. .� ..�cn r..Cn �'�., ii � �u !t:: I, I;u.�rJ ul 7 wldm;!f t ul fliuns::nd h1.�nd:�rJs LiCCnsl' Of rc',�,�stPe[lon � ilid (Or individuf utiC;�nl" ,� i ,;,I:" i10ME INIPROVEVIGNT CON7'RACi OR �,; bcforc [he capi�..tio�i 1 i c. [1'Cnund re[urn tu: . — Fe]is:ra:ion: �I?%'!79 'i C;Ue:rtl o(Eiuildin<_ E2e�u ahiuus an(1 Standvrds � � cnpir:�itio::: 9/1U2010 Tr'.F 2'72�� One A.vhiJurton Pincc R�i� i.i(I[ '/��rs: Lfd !.iybilily Corpor I Huslun, i�'la. 0'_i OS .::hiblMP Iql'J ININDUW i f'A�I10 fi00M�O�U7H � � ^ � � .'1 '. � � , ,,,,r,�oNv c�oviei_i_o I , / � I � � i �/ �'i:��S'fOCh'.WF.LL. DR. L„o�..."7._u.._I—�. �'� 1 / ' L^��--- �°,�•JON. MA 0237.2 \Jniinisn�:iiur; Not valicl wi h ut Si�nature ; r� i i ( . ��p/�,I•,rywIY'��.�` ...`��1i �:�o�n„ :�. l/ I' �.., ..f; , ���y . N]Gp�. },� 1 O. l ..!/i r 92C C�"�.✓��2c f<.,. Cr a"ye�'�+,�j¢�k' ;�ryq��'7 o i'��I�d�l3i�iPUin I c.�irLiLiunti a,ud�fand:u�il:e � ����5 � w� '�:ConstructionSu�ervisorL Iemsc . �' License� GS g7?� , a ,�`������� ,ys.. . Birthdzte y/611962 �I � Sy � Expirati'on �(G/20t0 li Tr:. 97226 �����, � t � , Restn'ctibn: �00 �i'�g�' �E�.,���:: � I i � �ti ,"�M'I-IONY COVIElLO I ' i __ . ?;7 Ci�LONIAI. URNc `"�.^�.... ,.�.:'% ."� .' . � ... .�:... CL!NTOPI, N1A 0151U (:nm�iii.a.ainncr i I ' �' I ' ! i I I ' I I � ii I � , I i i � i �{w� g'�'y' yy�'* /p ,�ygp� y�9 °�'�� yM, Y �p� qgp��p'� - --_._. -- ___ _.__._---- ---------------- .*��ro����,1 Y✓�J`� 9 ��I�.aJ'i�� a..8� C..�P'rCJ�L� 1 T lftl�F7fS./-RBV�.r� -.OPIU RL� nnn:(M�+ionrrvvv; ' -_ .~'___ �_ CHAMP-1 � 11/19�0.', ��0 -�� . THIS CERTIFICATE IS ISSUED AS p Pu9ATTEft OF INi"ORM�1"fIGN � ONLY ANU CONFERS NO RIGHTS LIPON THE CEI:TIPICATE :,c��� ; :Lnsuranr_e Agencj HOLDER. THIS CERTIFICATE DOES NOT AMEND, EX fEND OR . .. . :i�1 t.:r,zinceallor Dr. ALTER THE COVERAGE AFFOkDE� tTY THE POLICIES BELOW. . ..:ce±:�:'..uri,:,,w Hi].ls T[X �3101% - ____.___'._T . ' �_�xa '59-341 020? Eix:8.`i9 341-3709 IINSURERSAFFORDINGCOVERAGE ' NAICit _ __. .__._ . ..___._....- ' ---._._ - _._.._.-- � --"-r--�'---._...—__.—..... ...----�-- _.... _ .. .__._..._ .. �1fdcD ! wsuaeaa: OHIO CASUAI,TY 24074 � ' INSURERB' INDIANA IT7SURANCE COMYANY ! 22659 � �� ;' Ch:.unp:ion Window & Patio Room -- � - -- - -- - - o:E Boston 9outh LZ�C iNs�Reac Sent InsurancE _._— — '— i ' '_- _..._ I_ _._. . � 75 Stockwell Drive #'7 ! iNsuaeao: � :4von MA 0?.3',1.2 - ------ -_...— _._..__ ..I... _......... .. � ', INSUftER E' i. ._,��._..�_��.___ �_..._ry ._ ._. _._..._._.. l>JVERAGES _....__"_._.._____ ___,_- _.._.._'_—� __-._...___.._' �� iHF P(iLiG[5 pF INu^UI'v1NCE I.IS'fEf)BELOW HAV�'BEEN ISSUFD TO i FIE IMSURGD NAMED ApOVE FOR THE POUCY PERIO�ilvDiCATED.IVO1WIl'HSTANpWG ' :\NY IRE(�illill:Mf PIT.1'EIYM OR COMC>ITIbN OF.ANY i:0A1T1°2ACT Ofk O'iMER OONMEMT WITH RESPECT TO WHICH THIS CfRTIFlCAT[MAY BIE.ISSUED 01? ?,In`/PL 1�15 tVii, iHC IPISUftnNCEAPFQHIIFD�Y'1'HE POI.IGIES DI'SCRIt1ED HEhEi��IS SU&IECT TO ALL THE TERMS.EXCI.lISipNS ANO CONDtfi0iv5 Gl�f;UCi: �. =OLIi I �(:RCiiAlf IA.ff5'iHQ�V,I I�1'i i'IAV(� FLtI"'ObUCC� i� V41JCl.AIMS. . :,o� . .. .. . ._._.._ , ._ . ____. . ___TGbLTCVFFFEC7I0E �P6uCP��S1skATIOTi___._ .. ._ . . . . . . . i�ISRI� T(II RIP .IIFiAnll . �'OIILI?IUMJeR ___� OATEIMMIpDIYY) � OATE(RSM/[1pIVY) � LlMlii .._ ..___ _.._... _ �.,_ .._ _ � . .._.. __._ . ._'______...... i, r-:,�i_i urry 'I I �li':naioc�wiaF�acf � fi. :I. OCO, OUO ' '� ,:�nnni � �� -.,r:rae- vinan.rrriIIAA.5�7S848b 12/01/08 12/01/09 °a[�is�����-��o����v�� �� 1 �, 300 000 i i .I ii �mn e�,ne � ; � occw3' � , Meooa �n yo 0o soo� , 5 000 _._.. .._. � ----.._ . _._ .._...__.... � ��.' rea oNni..unoviniuwv 11, 00O,OOG . ..__._ ___._._ __ ,__._._ _ .____- ' ceNr.ru��n�cr�rcar� s 2, 000, OUG i _ ..-._- --- � --� ' '— -- ---...... _..__ � •I i �rrd�inec,r�irniri.i>errniiut aea�. i>rzouucrs-comwoancc, s2 000,000 . I I i I 011(V .� F Hn' r�..�� — _"— I _J .___. JE(1 �X lOC i :._._i_t " '_--T � I 1lIlUMOF.fI�ElLL�i11LITY 1 --....... i I I COMI3iNl U SINLLIE I Ifdll � �� � : ANYAIITU (Ea:cc I nl) . I I .__ ...... I..___ __.. I : AI I..OWNL-Di\U10S ' �ODILY INJUFI' ,� � ��. . .i Sf,PIf1DULI:UAU'fOS I (PerP�'rson) ; ; .. __'_—"'"___..___......_.-..._._.....__....._......_...._._ � NIIif:DAU'tG'.; [iODIIYINJURY y � NOnbn�iall I�aii:0.$ (Peracctl nl) ' I ___ .. _____ _....__.._ ....____.._.. ___ . _._.____ �I i PRO!PNTV DAMAGf 4. ',. I . .... . : � lPer iccU nl) i 4 __. .._ ___'_ _ -'__�__-_`_"—_' ,. ___"' _ _-_"_ ,... I 1f\GF I I IItILI'iY � �UTO ONLY CA ACCIDf NT I 5 _ I ...I AN`(A11T0 -- I _.. .. I OTHCR THhN ��ALI, Y J.__... ..... I I i IAUTOONIY' ��.� l9 � ___'_... � ' _ ,..__`_ -�-- _ __...._.._ I � dCti6SIl14AftRbLLA LIABiLITY � � � EACI{OLCURf'IiVCI �� J.O OOO � �)VU .. . , . ___ ._.. ....._ .._. . ��'. I ir � or.cuR I..._� c�ni,eis�,i�aor I CU037.933U i 12/O1/08 ,' 12/01/09 ncca�cnn s10 , 000 , 00C.. _ - ,� 'I � . ..,, I .. . 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I I � I __,___ _---- ------1 �_ � i ! ---=---------- --- _ . i:ti.5::FlPI ION DP QPFItATIDNS I I.Of,ATI0N51 VEHICL2S I BXL"W SIONS nDDED BY ENOORSEM[NT l SPECIAL PRO`/ISIONS , � !Rl7r=iC?.TL HOLUEY2 T CANCELLATION -.._.. _........______,.....-'-.___-_____ .-.__.._._ p0R P� SHOU�O ANY OF TNE ABOVG DFSGRI6ED POLICIE51:1[CANCELLE�BFFDRE'fI1E E%I'ue�nqp �, OATE THEREOP,THE ISSUING INSURER WIIL GN�LAVOR T0 ldHIL 3� _ D�Y:i WRRTfdE� I .'�OR PRI!:SL''IJTA�I�ION USE ONICC NOIICE TO THE GERI'IFICATE HOLD[k NAME!)TO l'NF LFR,F1UT FFII.UH[TO 00 30 S:IAI.t. �' g�$'?{$g}{)"a'XZ[}[}[}�'.}iZ{'i(S{�[}{�K'�.��$.:[$ IMPOSE NO OdLIGAT10N ON LIAFIILITY Oi ANY V(INO UPON 1'MIP M9UNEI't.ITS AGENTS OR ..K3ZJ�}�}:};.�4K�{".,{}C.�ti{J�YXi .`�i `f}C�it}C ,.����.�+��.�.x��y�y���y�Y� .�y REPflESENTATIVFS. -- '__`-'-__"_"___.........___..____..._'__..__....-._...._.........._.. ��'�:`G-{Y.XX�C}:X7:7:.K:�}CY}'.'�{Y Y.i{�.Z.':?S'.r.�.ti:{YiT .1UTHORIZEDiEEPRE5I:NTAIIVE u2Z'C T2:33C3�. _ ____"___'_._" __'_. . . .__' _ __ _._ . .....___._ _'_"____'- "__"_-'___'...._..._..._.__ i�`,ltC('1RD C:)hPCll2la s�ON 9cb� .,:)'r�) .'' �Ihr1i0:) . 't � ui , • I ORDER NO: 444 I ITEM: 1 � I DATE: 10/23/09 I � A Wall � � i m � � i � i - I '� ' as sne•� I I Dimensions � I Wall Width: 83.188" . Wall Height 81.625" I I La out I 6.5625"(Comer Post)+75.5"(2 Lite Window) + 1.125"(Base Plati) I PAGE: 1 of 1 I ORDER NO: 444 i ITEM: 1 � DATE: 70/23/09 I B Wall I ; i � ; � � � I � 177 3f4" I • � I Dimensions ; WaIlWidth: 177750" ' Wall Height 81.625" I I � � I La out I � 6.5625"(Corner Post)+51.5"(2 Lite Window)+5.0625"(Wall Mullion)+51.5" (2 ite Window) + 5.0625"(Wall Mullion)+51.5"(2 Lite Window)+6.5625"(Comer Pis I , PAGE: 1 of t I i I ` ORDER NO: 444 ITEM: 1 i DATE: 10/23/09 � � I C Wall � i � II � W � � i � i � 83 3f16" � Dimensions � � ' Wall Width: 83.188" � Wall Height: 81.625" � I � li ', La out I 1.125" (Base Plate)+75.5"(2 Lite Window) +6.5625"(Corner Post) PAGE: 1 ot t � I � � � � i - . � .5G5' :. � � /� .OS" 2.498" ��I i.603" ' i.a4" �= I � — �� o J _ O / I 'I L ��� b 6.5" � ��=� 2.E?�" �' �-- 25D0" —�' .- -�' �,� C'.-, � I � rt I I � T— d�. � � �' ��� ,� �_ � , � � �� � I i j, -,- -' -` I C��� I .I-- � � C � �,� �� I � � ���� � � oe" � c�, �; � �. � � � i � �- � I �. 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