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24 SURREY RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF 1j Massachusetts State Building Code, 780 CbIR SALEM Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divelling This Section For Official Use Only Building Permit Number:, Date Applied.^' . ' Building Official(Print Name) Stgna[ure ; ,• r�,,., Dater- SECTION L• SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers *7- S� rre-I � , 1.1 a Is this an accepted stree . yes no Slap 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: Zone: _ Outside Flood Zone? Public❑ Private ❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION2:, PROPERTY'OWNE '.'RSIIII' 2.1 Owner'of Record: TOr✓1 Ld &TKIA)-5 54!tea. f ro t A ©i 7rj .. / Name(Print) City,State,ZIP (% 2-L urge—y 97R-98f`/7G2 fP, �ATK .\sC��r�ar� .cv No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition Cl Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': S7- _ s a PrTra < Qcr� vvcr t3ri7feciss e�'�rM C-N rin ¢ f..�O o cl, ✓o�n.�cj SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: [tem OfficialUse Only- Laborand MaterialsI. Building $ o u 1. Building Permit,Fee S Indicate hrmined: ❑ Standard City/Town Application Fee 2. Electrical S ❑Total'Protect Cost',(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical ([IVAC) S Lisk 5. i\4echamical (Fire S Sn ression) Total All Fees: S Check No. Check e\mount: Cash Amount;. (/ G. 'l'otal Project Cost: S 7��a ❑ Paid in pull 0 Outstanding Balance Doe: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) a 'y�9 —r— 27_ 20/ �— �� y _ License Number Expiration Date i ame of CSL Floldcr u p _ List CSL Type(see below) C I04 ✓` ��� Type Description - No. and Street YP - �1 U Unrestricted Buildin s up to 35,000 cu. ft.) m 9 70 Restricted 1&2 Farnity Dwelling Ciry/Town, State,ZIP bI bfasonr RC —Roofing Covering WS Window and Siding n /) SF Solid Fuel Burning Appliances twC1014 C4$T: I Insulation "rele hone Email address D Demolition 5.2 Registered Hone Improvement Contractor(HIC) .0 /� /I ).D 6 C r�Ot-Q e 1 I [A ti "HIC Registration Number Expiration Date HI/K C. g2� HIC Registrant Nam No. and Street Email address 6197D p78-317 Ia�v City/Town, State, ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152. § 25C(6)) Workers Compensation Insurance affidavit mast 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 ........... O� 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 to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic 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 conta' d i this appli ation is true and accurate to the best of my knowledge and understanding. _ a -Z- 0 -2-013 Print Owner's or Autlwrizod.• •nt's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (trot registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M,G.L. c. I42A. Other important information on the H[C Program can be found at www.russs."mv%oca Information on the Construction Supervisor License can be found at www.ntass.go�' dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) _(including garage, finished basetnent/anics, decks or porch) Gross living area(sq. ft.l Habitable room count Number of fireplaces_ Number of bedrooms Number of bathrooms Number of hull/baths _ rvpe of heating system ___-- Number of decks/porches --------- -- l}'peofcoolingsystent _---- _ Enclosed- - ---__.—Open _ . i. `total Pl ojcct Syu:ire Footage" may be subztit ited for PotaI Projact Cost" --- -- -- i : Yr CITY OF S M ENf) LA-1 &A cHusETTS I BUILONG DEPAR-060NT y V I E j r Ydat-0yr z 130 W.A31-INGTON STREET, 3' FLOOR, TEL 978( ) 74 -5 9595 Ki.NmERLEY DRISCOLL FAX(978) 740-9846 ANL.%YOR THOsas ST.PIERRg DIRECTOR OF PUBLIC PROPERTY/BUILDNG CO\pIISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5 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 will be transported by: (name ut hauler) The debris will be disposed of in (name of facility) (u dresso(facility) signature of permit appl' int 2— Za -- 2-013 date dcbn:ait d.x CITY OF SiuEm) AXSSACHLSETI'S v BUILDING DEPAItTM&NT - i ! I20 CO.%SHLNGTON STREET, 3'o FLOOR t TEL (978)745-9595 FAA(978) UW846 KIJfBHRI EY DRISCOLL MAYOR T iioms ST.PiER1t8 DIRECTOR OF PUBLIC PROPERTY/BUMMNIG CO\L%IISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant information Iwl / D n Please Print Legibly h•6 More(BusltSorpnlratiamindivldual): /`/(�1 (`L to(: IF, P ADC !'t Vl G Address: � r /141, k _ City/Stat&Z(p: Sly t f vw} "4 6i 0r?D Phone H: 2 7 9"3/ 7-/6 6 2} Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction eytployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.2 1. ❑Remodeling ship and have no employees These sub-contractors have If. Q Demolition working for me in any capacity. workers'camp. Insurance. 9, 0 Building addition (No workers'comp,insurance S. ❑ We are a corporation and its required.) officers have exercised their l0.❑Electrical repair or additions J.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.(No workers'cump. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.)t employees.Liv'o workers' 13.Q Other comp.insurance rcquired.j •Any applicant that dive lag box el most also flit oat Iha wulion bdowahowing their warken•companudoa po&y intumlatiam !I Lwwuwn sm who suhm(t thus anidnris indicaing they am doing all work and then him u,h,i4,conirsch"moat submit a new ailtdavit indicating weh. :Ontimtors that chwit;his box most 411achad an additional shoat showing Iha nomo of the sub<amracton and their workers'comp.policy infomuton, l um an employer that is provldlnR workers'compemsadon hisaronce jo►my employees. Below Is the pollcy and Jab tits /nform"doro Insurance Company Name: _(-+3 —�(-t-v C-a o r 1&. /N . C t7 i Policy 4 or Self-ins. Lic.d: NPPel pO I/.��, Expiration Date:_f O'—Zo^20 r Y Job Site Address: z �{ -f`t�!'(�Y ^ City/Stott:/Zip: •S�(e""� MSC ( g 76 Attach a copy of the workers'compensation policy declaration page(showing the policy nombor and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a tine up to SI.500.00 and/or one-year imprisonment,as well as civil penalties in(he form of a STOP WORK ORDER and a line of up to$250.00 a Jay against the violator. [It advised that a copy of this statement may be forwurdcd to the OIRce of Investigations of(hc DIA for insurance coverages vccilicatiun. Ida hereby car er thr paint ai teuuhies u/perjury that the ia�unnutfou provided above is rrua and correct Siananlre: �Q Data: Phone r7• 9 7 S - .-l 7 /d G C> - - OjIl ial use only. Do not write in dtir urea,to he completed by city ur town n/jhla! i City nr'1'uwn: Permluticeese Issuintl Auilwrity(circle one): 1. Board of Ileallh 2.Building Departmunl J.City/fown Clerk 4. Electrical inspector 5. Plumbing inspector 6.0ther _.. CuntactPerson: _ - .. . ..----. _. phonetl• j 1f Massachusetts -Departmentof Public Safety - f! Board of Building Regulations and Standards Construction Supen isor License: CS-091429 1 ROBERT A RIDGE- 6 CLARK ST y. Salem MA 01970: Ev ` f%.( Expiration Commissioner 07/27/2014 - VIC- (�'oxliJlYGI[[(/Cl[LIJG-0��/��MSpc�/lSC7d� Office-of Consumer Affairs&-Business Regulation MEIMPROVEMENT CONTRACTOR pggeegistration 152345 Type - fEZpiration 8121/20,1A_: DBA RIDGE REMODELING'" ROBERT RIDGE 6 CLARK ST SALEM,MA"01970 - _ Undersecretary M`SSAC s�SETTS pRIVER S— — I+' LICENSE 0 W •,�t�kl 9 tBID F M NUMBER i s •zotz� NONE>S32788993 a o77 ,_K 07,-27=195 M) +0 xBr e-06 x'ROBERT A B6Cwut STREET — _ SALEM.MA 6157¢1716 ; p, t �/5� � s oo arx�mxxR..wnsmoB �',i h 2/20/2013 10:32 AM FROM: Fax Gerald T. McCarthy Insurance Agency Inc. TO: 1-978-740-9846 PAGE: 002 OF 002 A`o CERTIFICATE OF LIABILITY INSURANCE DATE ,MMm0'YYYY, 02/20I2a 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(les) 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 endorsementls). PRODUCER Phone. (W6)744-PA33 Fax (970)744-3575 CONTACT Deb TOUmaS GERALD T MCCARTHY INSURANCE AGENCY,INC PHONE (978)744-6433 FA" do (978)744-3575 92 NORTH ST w N E-MNL P O BOX 839 D s tlebblet@g[mccarihy.com PRODUCER 6392 SALEM MA 01970 cN T MERIC INSURERS) AFFORDING COVERAGE NAIC 0 INSURED INSURER . WESTERN WORLD INS CO ROBERT RIDGE DBA RIDGE REMODELING INSURER a 6 CLARKE STREET INSURER D SALEM MA 01970 INSURER D. INBVRERE : INSURER IF COVERAGES CERTIFICATE NUMBER: 22840 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, CLUSIONS AND CONDITIONS Or qI Irw P ICIPq I MALTS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS INSR TYPE OF INSURANCE ADD'L SUED. POLICY NUMBER POLICY OFF POLICY NOR LIMITS N9R IWO -(MM!OOLYYy];) _MWDDYYYY A GENERAL LABILITY NPP8101136 10/20/12 10/20/13 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 CLAIMS-MADE X OCCUR MED.EkD(Any one person) $ 5,000 PERSONAL d ADD INJURY ,$ 1,000,000 GENERAL AGGREGATE ,$ 2,000,000 GEN'LAGGREGATELIMITAFDLIESPER'. PRODUCTS-COMP/OPAGO $ 2,000,000 X POLICY PR6 I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AVI OS BODILY INJURY(Per accident SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accitlenq '$ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS NAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WCEIAN- OTH $ AND EMPLOYERS' LIABILITY YIN T RV IMIL ANY PROPMETONPARTNER/E[ECUTIVE E.L,EACH ACCIDENT y OFFIC ER/MEMBER EXCLUDES? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ O'SCEPTION Untie` E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS OeIGW DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACCIND 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY HALL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SALEM,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATME Attention: /��'�� / ur�/%�X✓ ACORD 25(2009/09) 0 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD