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9 SUTTON AVE - BUILDING INSPECTION (2) i The Colmnotnvealth o a-I usett f fass,t,t i s Board of Building Regulations and Standards CITY OF j Massachusetts State Building Code,730 CbIR Ravis ALEar1201l Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tnvo-Family avelling 'fhis sectiortFbrOfficial UsaOnf Building Permit Numberr Datti Ap'_ted' Building Official(Print Name) $lgnaturs Data SECTION 1:SITE INFORtNIA OlY' L 1 Property Address: t� L2 Assessors Map Sr Parcel Numbers u� —4,le 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoninglnformatlon: 1.4 Property Dimensions: Zoning District Proposed Use Lot Aroe(sq it) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided ' 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System: Public 0 Private❑ Zone: _ Outside Flood Zone? Check if es❑ Municipal @i On site disposal system ❑ SECTION 1-' PROPERTII'OWNERSHIP!' ': 2.1 Owner'of Record: - Rtt . ('-r C t c,,Q t o..y` Name(Pri ) City,State,ZIP 07 '7 tS No.and Street Telephone Email A Tess SECTION 3: DESCRIPTION OF PROPOSED.WORKr'6heckall that apply} New Construction ❑ Existing Building❑ Owner-Occupied 5t I Repairs(s)Va I Alteration(s).0 Addition ❑— Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief D ascription of Proposed Work': c, t\ASv cx e SECTION 4: ESTINL4TED C.ONSTRUCTIONCOSTS- Item Estimated Costs: OfRcla) Use Only.,.. Labor and�raterials y'. 1. Building �7 L Building Permit Fee:S' In now fee is determined: 2. Electrical ❑Standard.CiVrutvrtApplication Fee.` 13'rotatPiolectCostr(Item.b)xmultipii6r x J. Plumbing i 2. Other Fees: S !. ,M-chanical (IIV.w) $ List: - t. ,Mechanical (Fits fUtal All fees:S_ Check N0. _Check Amount: Galt r\rttouut:_— I'ntal Project ('ua 3 S1 (ed0 0 11 1 , Full Cl outstanding Ihd.nnca Ltd: SECTION 5: CONs'rRUCTION SERVICES 5.1 Cmtstruction Supervisor License(CSL.) ��?��-._ _ f License Number E.epuauun Uote Name of CSL 1I[older List CSL Type(sae below) k? SA\���p(� \SC�— rype Description No.and Street U Unrestricted Buildings up to 35,000 cu. It. R Restricted 1&2 Famil Dwellin City/ro\vn, State,ZIP W Mason � RC Rooting Covenn WS Window and Sidin SF Solid Fuel Burning Appliances Insulation rely hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) i-731SD Q ( HIC Itegistration Number expiration Date I[IC Company Name of NIC Registrmtt Name l'? S� \ to C' �s� _ No.and Street Email address g21 S- 99 Ell i /Town State,ZIP Telephone SECTION 6: WORKERS'COINIPENSATION INSUEL%NCE 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 ..........J 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 to act on my behalf, in all matters relative to work authorized by this building permit application. Date Print Uv •r's iq.1 a(Electronic Signature) SECTION 7h: OWNEW 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 accurate to the best of my knowledge and understanding. mintUt er'sor; uthorited:\gatt'sN•une(Electronic Signature) -- Date NOTES: Uwner who obtains a building permit to do hisiher own work, )ran owner who hires an unregistered contractor (not registered in the Houle Improvement Contractor(HIC) Program), will 1L)l have access to the arbitration program or guaranty tend under M,01. c. 142A. Other important information on the FI[C Program can be found at tvww nt:u±.--uv/ova Information on the Construction Supervisor License can be found at www.mass.� '' Ilgt 3 W'hen substantial work is planned,provide Ine information below: rota) fioorarea(sq. It.) —____ _(including garage, finished bascmcntiattics,decks or porch) (7ros; living:rv.t(:q. tt.l .— I Iabittble room court _ Nimitwroffireplaccs_ _-------- Number ofmons it-baths ?hunbcrotbachroonts - ------------- Number of halEb --_-----_----- r".pc Lit'Iwming ;y;tCitt — `umber ofdcck 'purchds ___. .- - —_---- Enclasal t pen r`peotconlutg ;y•icm ..I �Lil I'r„itit ipi ira F���Lr;r" ni.ty I+a ;ub,tindal tea'"I' cil PtI'jart('o—t---,- . I CITY OFS:UZN[ HUSETi'S � `� i7t:tLnLvcD I!0 C(/Aj"LVGTO,V STttEE1', } °Ft00t <I S CO E4L EY O21SCO LL P VC(973) 7•W-9344 I fO.%4 3STPIEAAS ❑I7ECTOR OF PCOUC PR0PEA7y/8CILOLVC COSL�116SIO.VER Construction Debris Disposal Aff7davit (required for all demalitien :uId renovation work) In accordanca with the sixth edition of the State Building Code, 730 C111R section 111.5 Debris, and the provisions of IMOL a 40, S 54; ©wilding Permit N this work shall be at the debris resultin is issued with the condition that from I11, S ISOA. disposed of in a properly licensed waste disposal facility as defined by bfGL c 1'11e debris will be trnnsportcd by: (tlJ111C of I4UI�f) The IlQbris will be disposed of in —__ (nnnta nr tac,lity) ,iSn�mra ��permit dpplic.mt aCITY OF Siuym, jNL-1SSACHUSETTS BUILD NG DEP M.LENT 120 WASHINGTON STREET,310 FLOOR TEL (978)745-9595. F.kx(978) 740-9846 KI\IBERLEY DRISCOLL THoms ST.PIERRs MAYOR DIRECTOR OF PI:HLlt PROPER'►Y/Hl:1LDL*lG CO'.MIISSIONER Yorkers' CotnpensatIon insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibiy Nance(Busiiws.&Organizaiiorofndividual): \L\���nn\t..•� �1 �r 2AA�.\A Address: 1'7 SCNN QC%A�G C k, CA:&, City/State/Zip:_LN AM O\9 2� Phone l{: R 7% �,-O� 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. ❑ construction New constrtion employees(full-and/or part-time).' have hired the sub-contractors 2.�R 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ®Remodeling ship and have no employees These subcontractors have 8. ®Demolition working,for me in any capacity, workers'comp.insurance. 9• Building addition (No workers'.comp.insurance 5. ❑ We area corporation and its required.). - officers have exercised their 10.91 Electrical repairs or additions 3.❑ t am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No workers'cump. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers'. l3.❑Other- camp.insurance required.] ;Any applicants ihat chtxks box Yl must also fill out the seakta blow showing ihefr wmkcW wmpm mioo p li y infurmatfon !I romeowne-m who submit this affidavit indicating they am doing all work and then him o4tside commeran most submit a new affidavit indicting such :Commica that check this box must anwhod an a lditiowlshat showing the name of the subi mmcton and their workers'camp.policy bucamation. lam an employer that Js providing ivorkers'c ompensaden buurance for my employee% Below Is die policy and Job site iuformutiom insurance Company Name: Policy 4 or Self--ins.Lic. q: Expiration Date: ' Job Site Address: City/State/Zip: ,utach 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 c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 undtor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be:forwarded to the OI'lice of Investigations ol'the DIA for insurance coverage verification. 1 do herebb certify under the ins and pe taides ofperyury that the fief ormallon provided above is true and correct. Si_n,tttlr�"�e � `e �/p� Data• _r[ t 1 5 o d: 4� � cTT 1b0 OJjcfal use only. Do not write in this area,to be coaipleted by city ur town oJjlelat City or Toren: Permit/Llceme# Issuing Authority(circle one): I. Board of health 2. Building Department 3.City(fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person:-_ - _______ Phone 4: ri I � I oa 4t Massachusetts Department of Public Satety; ,; t- --� ,.Board of.Bdilduig Regulations andSiantlards,-"`,;;; � Cunstructiim Supen'isi4r License:CS-073793 DAVID S r OItE D 6 / ANVERSNVERS 1VIA 01923' �. LL`" Commissioner"^; .... .r'4.03)0712014 it I, I i i t l 1 07/01/2013 00:14 9787778415 PAGE 01 CERTIFICATE OF LIABILITY INSURANCE 7ii%2013 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER. 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: S the certificate holder Is an ADDITIONAL INSURED,the PORGY00111)meet IN,endorsed- N SUBROGATION IS WANED,eubJept b the Wine and condlBona of the policy,certain policies may requln an endorsement. A MittemeRt on dde certificate does not confer dyhte to the certMeats holder In lieu of such endonemem(s). PRODUCER WNTACT COUNTY INSURANCE AGENCY INC NAME: 123 Sylvan St (978 774-2463 p;(978)777-9415 Danvers, NA 01923 ADDRESS Ej Ixe mol mramw CMEWR "Go INSURER A:Commerce INSURED Tlnkham, David INSURER e: Tinkham Building a Remodeling INSURER C: 17 Salvatore Circle INSURER O: Danvers, Ma 01923 INSURER E NSURE 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, EXCLUSIONS AND CONDITIONS OFSUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LYN TYPE OF INSURANCEJOE VIM POLICY NUMBER M Mtg�V LIMITS GENERAL LAABILOY ENCE $ 1 000 000 COMMERCIAL GENERAL LIABILITY amrtenca $ 50 000 CLAIMS-MADE OOCCUR neperipm) $ 000 A BDSGDD 8/29/128/29/1 V INJURY $ REGATE 1000, 0MIT GEML AGGREGATE LIMIT APPLIES PER: OMP/OPAGG i 1,000 000 POLICY PRO LOC i AUTOMOBILE LIABILITY (Ea edtlden ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS Per eccd $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CI.AIMS-MAGE AGGREGATE i DED RETENTION § WORKERS COMPENSATION q H_ AND EMPLOYERS'LIABILITY YIN My M0PRIENIUPARTNER/EMF,CUTIVE OIMUIRMEfIBEA ❑ N/A E.L.EACH ACCIDENT $ ExCEWE09 (elmdCs M xp E.L.DISEASE.EA EMPLOYEES ayedeepgunder OES!`.RIPOON OF OPERATIONS be1w E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (MeCh ACORD 101.AddlBonel Remersr Schedule,If mere space Is required) Carpentry Ops CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS, Salem, Na 01970 AUTHORIZED PRESENTATIVE (9)1988.201 CORDCORPORATION htsreserved. ACORD25(2010/05) The ACORD name and IDge are registered MarliS Of ACORD