9 TAFT RD - BUILDING INSPECTION i
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7a edition OF SALEM
� Revised Jwrnury
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or rwo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: Atrr/'
6)/5-)/a
Building Commissionerl Insirector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro Addre n 1.2 Assessors Ma & Parcel Numbers
1.1 a Is this an�-d�st"reet?ycs no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(il)
1.5 Building Setbacks(ft)
-� Front Yard Side Yards Rear Yard
Required rovid ro
Provided RcquircJ Ped Required Pvided
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? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: � /�
� 9 ✓ �T�
e nnty Ados7ss for Service.
.gnature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Additiond
[2.
emolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
rief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
m Estimated Costs: Official Use Only
Labor and Materials
Building
S / I. Building Permit Fee: S Indicate how fee is determined:
Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing Is 2. Other Fees: S
4. Mechanical (14VAC) S List:
5. Mechanical (Fire s
Su ression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6.Total Project Cost:
1 5 ❑Paid in Full ❑Outstanding Balance Due:
7f r�� •voU
R
r`
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Su�yy7 ervlsor(CSL) Gj aG°(
fL�/7 / Z /
S�QiUP � /d .% License Number lixpimtiunl ute
Name of CSI.- I lulder I I.ist CSL Type(see below) (J
rs pe I Description
.Address U Unrestricted(up to 35.000 Cu.Ft.
R Restricted IR2 Family Uwellin
Erc �ny�`�- M M Ord
?s 3f 7 `Y� RC I Residential Routing Covering
fcicpinme WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Regbt red Home 1 vintent ntra for( 1
I IIC Company Name or I IC a istran Name 24 Ca Registration Number
)1
Address VZ
Expiration Date
Signatu 'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.f 2SC(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 ..........O 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 to act on my behalf,in all matters
relative to work a t on y this building permit application. J�
G �
I .)Knarilreof.- ,ner i / Date
SECT,10K_71i OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the fiarcgc tng application are true and accurate,to the best of my knowledge and
behalf.
Signature of(honer or Authorized Agent Date Gr dV f C/
(Shined under the pains and penalties of du
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 WJ have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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.UY-N, NLX5SACHUSETTS
BLamews DEptim.i6WNT
1_O W.tsHmTON ST amr. )'a FLOOR
11s. (978)74.9599
P.uc(97� 7�49bN
IQ MBEALEY DRLSCOLL 111O""ST.FMAM
VfAYOjL DIRECTOR OF/L 6LLC pWraRTY/K RDLVc CO.N M IO-NIA
Workers' Campensatlen Insu►ance Aflldsvit Oril&rs/ContrsctorWEI@ct►IclanslPfrmben
annlleant Informatloill Pleeu Print IA"
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Address:City/state/zip: 1'Bone M'
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( with _ 1. 0 1 ills a Simse d caafactae awl 0 I. ant•vanPlayer a have hired tie stAwav tr"itees a Now eweOestioe
etnpleyaw(IWI asd/a patFtiar) 7. Rmrotielin
2.0 1 am a sole proprietor 4w poom listed oil the attaehod ahaat: ❑ g
ship wed have rm anpbyam Them vAb c.tatelaeq here L 0 Demandion
wofting rotr ma in asy capocity. "'�N'comp.instrsaoe. 9. Q Dwil i g addltioe
l Na weriars'tenµ insurance S. 0 We an a corpsrMlm ad is I0.❑Eleawial repairs or adtlitioree
ra.Ittifedl olikss Aare d ascisd that
).0 1 am a hmmmraw doing aU weft ri It�,1(4� �161101.1. I I.Q plumbing repairs or addklets
myself.(Ne worbae'tomµ 12.0 Reef repairs
insurance required)r cmployaw&iNe eterkere' 13.0 alhw
comp,ins uanc s regain&)
•nq:yhYtaer nr atttrY Nil rl wail a1r fle utt er mrt�OrM raeira edr eariaa'rat�et�dr/.May iwatnaaaa�
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/aw aw M/bl"«that b�rer//fwt redM'caapardrs/waareas/ir q taepArywa SdYrar 6 nbePl/b�awI/le0 slat
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In.urrnce Company Name: _�1-41 �'l U� a
Pnlicy 1 orSSelf-ins, Lis.r.. ����j l �3 f( Eapirmioa DW: %lj -72Gle)
!ub Sifo AJthsc !�2 T+ r Ciry/ltatefZipr_(' 4 Q 71
.utact a copy at tta wertars'cospaaaWe valley deeblrstbte pap(atowhig Ito Polley ersMr and explrstlee de/s}
F'ailun to s"un covenile ar requinid ureter lcabn 25A o(NOL a. 152 coo lad to the impoeiUate ohximinal panald"ova
fine up to S I.l00.00 sad/or one-year imprisonment.as wed ae civil peerhiee is the tares are STOP WORK ORDER and a firm .
of up to 5220.00 a Jay rusime the violator. Ile advised that a copy of this stmeemne Maybe fumorded to the 0111ee of
Inr.,ueuriutet ul'the nlA for insurance cowraes ncrilk itioa
/Je Awrbp cMJ/)t uw/N rAa priwa rw1 yew./ e/ fry rA«rAe ink«wrdaw/rari/ad ulsra is raw rnI awed
P•ona A:
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1 are 0,,0% Oe not writs iw this rtrq ti Ail.rtwyh/d Ay rely«Uew.r//i•irrl
fut.n: Yrrmil/Llrenrtl__ _. __
lcirctauna►:
d u(Ilraltb 1. RudJley M.F.Srtmvnf I. ciltrowe Cleft a. Ctrcbical htfpeclar f. Otunlbtnll Infpeelor
r
l Person: _ _ P110nf 1:
q
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
i'.u: pIH I:C V'.\JM1I..JVsa a1C 1'
I'n: va••'I4'!9N P\t:/767 S'
construction refurll Debris
Dldp�a'ion wok)VIt
in accunlame with the siull edition of the State Building Code, 730 CMR section 111.3
visions of MGL c A 5.34; the debris resulting
e
is issued with the condition that ed by iM� flout
Debris, and the pro
Duildinl{Permit M 6certsed waste disposal facility as defined by
this work shall be disposed of in a properl y
ll1. S 150A.
The debris will be trunsportcd by:
In nn of hauler)
The debris will be disposed of in
(n.untuI x, tty)
. naturesit IMM 1.1pplNant
Jate
4 L...Ji...
, L106/14/2010 13:08 9786833147 PAGE 01/01
A CERTIFICATE OF LIABILITY INSURANCE ��`�laiio
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
M.P. Roberts Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1060 Osgood Utreat HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
North Andover, MA 01645 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
INSURERS AFFORDING COVERAGE NAIC#
TNBUREo INSURERA; AtlantiC Casualty .Insurance C
STEVE HADLEY muREne: Merchants Mutual Insurance Co
...._._... ... ................ ... .............__.......... ...
D CONTRACTING INSURER C: Liberty Mutual
239 JEFFERSON AVENUE ... _ ........__........___._...._...
SALEM, MA 01970 .INS VRERD
ENSURER F,;
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEATO 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 BYTHEPOLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,EXCLUSIONSAND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE 13EEN REDUCED BY PAIDCLAIM5,
M MGM
OUCY CrLECTVE P
Nam TYPE OF INSURMCE POLICY NUMBER LIMITS
GENERAL LU(OILIIY EACH OCCURRENCE 5 1(000,000
A X COMMERCw.GEnEMLLIABILITY L143000654 7 8/09 7 9 10 DA A Ei�Tr@NTED --
/ / / VREMI$Es_(-aEWRI!gIM)_ $ 100,000
� cIA NS MADE LI OCCUR MED EXP(Any..p. sm) $ 5,000
- _.__. PERSON4L$ADVINJURY S 10000,000
- ........_ GENERAL AGGREGATF $ 2,000,000
GEN'LAc RE;ATE LIMIT APPLIES PER PRODUCTS-rOMPNOP ADD S 2 OOQ 000
_.. i
POLICY PR LOC ��- ._..—
AUTOMOSILEI_IABUTY -
COMBINFDSINGLELIMR ANYAUTO $ 3DO,000
(EeapcltlnN)
8 ALLOwNEDAUTOS :7AM0277014084 10/28/09: 10/28/10 BODILYBNJURY
X SCHEDULEDAUTOS ipwpffa ) S
X HIRED AL TOG —. - ....__..
X NONOWIVED AUTO$ BODILY INJURY S
... .._._ ___ PROPERTY DAMAGE $
a0MAGE LIABILITY QUID ONLY-EA ACCIDENT $
ANYAU O - .A
OTHER THAN EAACL $ _
AUTO ONLY: AGGi3
E(CESS/UM8RELLAI.IA5IUTY tAGGRLGATE
CCURRENCE $
_ OCCUR _ CLAIMS MADE S
S
DEOLICTINIE — ..._
RETENTION .— $ .._..
WORKERS COMPEI!<ATON S
AND EMPLOYERS'WI ILITY WC STATU• I OTH-
C ANY PROPRIETORIPATTNEREXECUTME YIN WC231532906403 -- TOR,Y_LmatT.S R
OFFICERMEMBEREXalAED7 7/8/D91 7/B/IO EL.EACH ACCIDENT $ Soo LQQ
(Maltlahpy In NH) ..U.
FA;;LOYEE $ rJDQ,QQQ ..IFYyeeA,tlaxprlba urea- EL.DIS FSSE-
Msa-AL PROVISPJNrI ft, -
OTWR EL DISEASE-POLICYLIMR S 500,000
DESCRIPTION OF OpERAHONSI LOCATIONSIVEICUMIMMUMONSADDEDBYENDORSEMENT/SPEOALPROUTSIONS
RE: 9 TAFT ROAD SALEM, MA
F-978-740-9846
CERTIFICATE HOLDER CANCELLATION
S HO LLD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TH E EXPIRATION
CITY OF SAT
GATE THEREOF,THE INUING IMURER WILL E EA NDVOR TO MAIL Y0 DAYSWRJTTEN
-
BUILDING INSPECTOR NOTICE TO THE CERTIFICATE HOLDER NAMEDTOTNE LET,BUT FAILURE MOD W SHALL
120 WASHINCTON STREET IMPOSE NO OBLIGATION OR LIAINU Y OF ANY KIND UPON THE INSURER,ITS AGENTS OR
3RD FLOOR REPRESJTNTATIVES.
BALM, MA 01970 AUTHORISED REPRESENTATRR
ACORD 25(2009/01) 01988-2009A OR COR O
r6sarrcd.
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