1-31 TANGLEWOOD LN - BUILDING INSPECTION t'
v' The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Ois SALEM
Massachusetts State Building Code, 780 CMR, 7's edition
Revised January
Building Permit Applicatio To Construct, Repair, Renovate Or Demolish a 1, 2008
One or Two-Family Dwelling
Ibis Section For Official Use Only
Building Permit No Date Applied: ``L. S� ('
Signature: 2,. 0 x
- Builfing Commi Insrkctor of Buildings Date_ .. '. >.
SECTION 1: SITE INFORMATION
1.1 Property Address: V 1.2 Assessors Map&Parcel Ntunbers
1-31 TANGLEWOOD LANE e2a-n lo P,51 Z 41' (�
1.1 a Is this an accepted street?yes no NTap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
I
onmg Distract 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❑ P
Zone: _ Outside Flood Zone? Munici a n site disposalsystem ❑
Check ifyes❑ y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
highland Con t Salem Trust 00 H; L1and Avenue , Salem
Wacr�im�� Address for Service:
9�� y �>/_-3 T lephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that,apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': ��Xaod Rep
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only ,
Labor and Materials
1. Building It, L.Building Permit Fee:$ v"Indicate how fee is determined:.
��!!
id"5tandard City/Town Application Fee !!i .
2.Electrical $ --U O''fotal Project Cost'(Item 6)x multiplier arJ z
3.Plumbing $ 2. Other Fees: $.
4. Mechanical (tIVAC) $ --C) List:
5.Mechanical (Fire $ Z�— Total All Fees: $ -
Suppression)
Check No. --Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 nLicensed Construction Supervisor(CSL)
' ��� / �j/�An� / License Na'mfiber Expiration Date
Name �S�L-Hol �J/�6`!6 List CSL Type(see below)
(( Type Description
Addre s �� � `� , ^ /Jq� /,��� U Unrestricted(u to 35,000 Cu. Ft.)
G(�/ / `/ // R Restricted 1&2 FamilyDwelling
Sign at o —nn M Mason Onl
9�e 7'CXl l.3 r) �51. RC Residential Roofin Covering
Telepho WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
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 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNE 'S AGENT OR CO TRACTOR APPLIES FOR BUILDING PERMIT
I ✓ as Owner of the subject property hereby
authorize to act on my behalf, in all matters
r5kitly to work authorize y thi building permit application.
i n to f Owner Date
SE ION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1 , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of er'u )
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.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"
1
R� CERTIFICATE OF LIABILITY INSURANCE
THIS
CERTIflCAT'E IS ISSUED A9 A MATTER OF INFORMATION ONLY AND CONFERS No RIGHTS UPON THE CERTIFICATE HOLDER. /THIS
beRTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, WMND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERnFicATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
lithe
REPRESENTATIVE OR PRODUCER,AND THE CERTIRCATE HOLDER.
the io sate der is certain T AL , 91a poke C?5) Trust be endorsed, H SUBROG ON IS
the tamp and conditions f suchf the endor ment poBeiea may require an endorsement. A astNHINIat on this certificate does not confer au t to
eorBecata holder in lieu of such andorsemen rights tG the
PRODUCER ACT
T L 9outhmayd Insurance Agency
660 Main St, suite 9 79 -0 N . (970) ES7-0201
Wilmington, MA 01887
L louiseetl ins.com
27B
INS Ae AP DIND C ERA NAID r
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G 6 M Enterprises R ranite State
Michael Mercurio INSURER .
P 0 Box 438
Wakefield, MA 01880 INSUR
NaU0. R:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OR INSURANCE LISTED BELOW HAVE—BEEN AM
TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWRHSTANDNG ANY RE-OUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHSq DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PfiRTAN,THE INSJRANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LM"SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
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&CRIPTpI OR OReRATgN9/LOCATgN9/VENCLE9 IAnsn ACORp T07,AA{awW RelroHs 9cIHauH,Nmon apse amgdrael
ghland Condo @ Salem Trust, Cloister Condo Trust, Loring Hills Condo unitill Trust,
acttim Condo Trust, Meadows 8 Danvers Trust, Village @ Vinnin Sg Condo Trust II
Dr Condo Trust, One Salem St Improvement Association
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE SEE SCPjB r o ROUOBE eE CANDELLEa BEFORE
All Associations Listed above THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
C/O East Coast Properties ACCIORDANCE WITH THE POLICY PROVISION$.
400 Highland Ave. E
nloRXED PImtENTATNe
Salem, MA 01970 a
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0 1988.2009 ACORDCCTRPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
CITY OF SALEM
PUBLIC
P ROPR ERTY
' I DEPARTMENT
1-QVC.lduffl•.'l�/'•f1.)il� •to77t1:�Ylswll,.:l'1 -
construction Debris Disposal A111davit
(required lur all demolition utd renovation work)
In accordaun:e with the sixth edition of the state Building Code, 780 CMR section 111.3
Debris, and the provisions of MGL c 4U, S 34;
per__ _ is issued with the condition that the debris resulting from
Building Permit licensed waste disposal facility as defined by MGL c
this work shall he disposed of in a properly
l 11. S 150A.
The debris will be transported by:
- f ��f�� /w glop-d'3rY
1 name ul hauler)
The debris will be disposed of in
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n/ (name ul au Ily 017
I;Idtlrl�aullxJnyl �
.lanatwe of INC applicanl� JjY�
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CITY OF S.U.&M, NLASSACHUSE-M
3CQ.D6vG DEpAw.w%T
120 1V.jiHMTON STuffr. )"'FLOOR
71SL (978) 1+5-9599
FAX(978) 74498"
KENCOEA"y DRISCOLL ]7tamssT.PIRRRi
gAYOR OlRurot Op tt BLit pWpERTV/KIL DV0 CoaOMSO.INER
Workers' Cstepeaaatlos Insuranco Affldseit. DuildwilContractors/EimtrlelansiPIUMAen
+nnllcant InfnrntatION Meat Frlyd LegiM
Vamatlluun.+.ars+n�++M^I"'hv'd"II MIKE MERCURIO, d/b/a G&M ENTERPRISES
P.O. Box 438
AddmsS'
Wakefield MA 018880 339-203-1556
City/State/Zip: Phow
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fine up to S 1.500.00 amYwr one-yew imprisetutwrK as wolf as civil penakies is tea facts wro STOP WORK ORDEA and a Rae
Of UPI*S2f010 a Jay ayainae the violator. IN adviiel that a wp of this atatemene maybe rum- l id ro the 011ln of
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/Jw hereby rrrr W fj N#!dO he and penwidw el pedury tAer rAe informodow provild u& ✓is or"v d v wrraa
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City (or ruwn• Permit4.1eeaear__.
Iaulnt Authortly (circle Ade):
I itweJ ul lle.11h 1. Ruddlna Uvparlmvnl i. City/town Clark t. Elscfrical lAcpwar f. Plumetna In.peetor
i. Ocher.
l•.nUd rcnan: _ Phone a:
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s Board ul Buildm Rc_til uurn.and St lntlartl.
License: CS 91942
Restricted to! 00
MICHAEL L MERCURICO
127 OAK ST
WAKEFIELD, MA 01880
Expiration: 1(412011
!'npmi..6nicr TW: 8110
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