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8 TEDESCO POND PLACE - BUILDING INSPECTION "5 The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF y' Massachusetts State Building Code, 780 CMR SALEM g Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date pplied: _ & Aa� �s Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: n' r q/� 1.2 Assessors Map& Parcel Numbers C6 Y 1bC I' 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 11) Frontage(if) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L a 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 yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 OwnKr of Rec rd: t I1J a F,�:" /�re,� c� 7e sco " P�t I-Ta« Stu( 9 Name(Print) City,State,ZIP R�e. Co 41 ,t- f Lc f ,SDk�o a ky No.and Street Telephone Email Address SECTION 3: DESCRIPTIONS OF PROPOSED WORK=(check all that apply)New Construction❑ Existing Building Owner-Occupied, Repairs(s))9 I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': AlAiT W N,,,471W* fin c—l& p aL 1 / r / SECTION 4:ESTIMATED CONSTROCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ om 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ / 8. OZ70 ❑Total Project Costa(Item 6)x mul 'plier x 3. Plumbing $ }71D — 2. Other Fees: $ 4. Mechanical (HVAC) $ 080 _ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 9 i SCJo, ❑Paid in Full ❑Outstanding Balance Due: Cq �/ SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) F��J U 0tyJ x-el�, J (4 � y License Number E< ration a[c Name of CSL Holder /_ All 4uTzrs Ai List CSLType(see below) No.and Street Tv e Description /�'�—��D U Unrestricted2 Fal(Buildings u el ing ea H.) City/1'own State,ZIP / Restricted I&2 Pmnil Dwelling M Masonry RC Roofing Covering WS Window and Siding 7 P S '75 7p 1,U V/� / SF Solid Fuel Burning Appliances �7 �lV�L �/ fro <Oh I Insulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC ompa Name or HIC Re i,lran ame HIC Registration Number Expvati Date ��trn� A J_ykc y n �, C_ <, No.• d Street �c,,�t� Email address c.Lx S 2bZ " !J lCW City/Town,Slate,ZIP d 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 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. + (B f"e G° !. . Print OsAr's Name(Electronic Signature) /-t om 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 contained in this application is true and accurate to the best of kn wledge and understanding. �I7DI-lly J 'f� a y P ' or Authorized Agent's Nan aectroni atare Date NO S: I. 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 can be found at �eww.mass.�'ov/oca Information on the Construction Supervisor License can be found at www.nrtss.«oe:%dns 2. When substantial work is planned, provide the information below: Total floor 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 SALEM n—I a PUBLIC 13ROPRERTY DEPARTMENT .itn::M:rY:'MINYnI \Itttxt 11�Wnsnl.�sati�Sixekt'� Snu.N, M.tD.1611i itl IsJl97: I'r.l.:174715`1iti5 •P.tx. '/7N•71C•781b Workers' Compensation Insurance :Ulidavit: Hui lders/Cuntracturs/Electricians/Plumbers llnRlicaut Inrorinution / Plc tse Print Leeb Name 4—//Kar ofc� ltldre.m LA /� /Z✓�iy�Zl City'Starci%ipt SCv Phone if: 7,5V 1Arc tou an employer?Check the appropriate box: '1•ype of project(required): 11"-- I am a cmpiuycr with /�) _ 4. ❑ I vn a guncral coultaclor and employees(lull Jnd/ur part-time).• have hired the.uh•cuntracturs h' 0� �cw construction 1 Jill a sole prnprictor or partner- listed on the attached sh - eet 7• Rcinodeling ship and have no cinpluyces These sub-contractors have g. 0 Demolition working fir me in any capacity. workers'camp. insurance. 9 - — — - -- -----" — GuiWing-:nlditiun— --- --- - )Iv`n wntitcrs'comp. insurance 3-0-Wa arc u rnrporanun and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 I ant a homeowner doing all work right of exemption par hICIL I LE] Plumbing repairs or additions Inysclt tKo workers'comp, C. 152,¢1(4),and we have no 12.0 Ruuf repairs insurance required.) r employees.LNO workers' comp. insurance required.) 13.0 Other 'Any.5,pbcad datl chuck,Want must:dsu Jill uol the w0lon Wuw a awing Iliuir w•wkvti cantpanuaiun policy iahaniatiun, i tum v,wnan wMt lob"lit this affidavit indicting Ihry age doing all work and then hire uuiride epnrneron mwl.udmk a new alridavil indiuling wleh. 4'onlmior,Am chock this bas mom amachad Jn iddiliuwl.,h wt.hawing this nanlo of tM rubs illtaUafa and'hint wuhun'corny,policy mfwmatinti. /Jun an culployer that h providing ivorkers'cumpenradon hmareace/Lr ary etnploill, I Be/mv/s the puNay and/ob site h1formlatian. / I / % Insurance Company Nnine. L1lj. ,W,t.r, �CrJsf, Policy N ur Sclf--ins. Lic.h: t,L o-1 Expiration Date: Job Site Address: Ted$ Cp ��.,�,( c Y p:�/> Lt/9 /1/d O/y7lJ — C'it 'Slatd2l .\Ruch it cltpY of ilte workers'cumpt-mation policy duclarallun page(showing the policy numbur and expiration date). Failure to secure coverage as required under Section 25A ul•JIGL c, 152 can lead to the imposition of criminal penalties of a tine tip hI S1.500.00 and/ur une-year imprismmnunt, Js well as civil penaltcs in the form of a STOP WORK ORDER and a rine Of up to S150.00 it day aguiost the violator. lie advised that a copy urthis stulcmcnt may be lurwarded to the 011ice of Itl\ of 111c UTA lar IOstiClrce cotcragu tcrllh:ation. l do hereby rertiify i tier the p.lin o All) i 11ier /per/rrry filar 118e iu/brinallem provided above is jr oud correca run •:r 7�. Up&•ikf are Only. Do Ilnl'.rite in thlr urea,to be completed by airy or town a//ieiuL t City ar'I'mtra: __ _ Pcrinitil.ieeme 0 hsuing.liulhurily(circle tine): I. Iluard of Ilealib 1. Ihlildin;( Rcp;Ir till cat L t:ill'I'un n Clerk 4. Electrical Inspector 5. Plumbing lospeetor I G. 011vr _ Cmilael Vvrsum: - I'hunc y I Information and Instructions uneral Laws chapter 152 requires all employers to provide workers' compensation tar their employees. ,Massachusetts limeta ".. a .every person in the service of another under;Illy cuntrnct of hire. I'ursuatlt to this ,an empfore is defined as \preDY Jr implied. Jfrl or written." �n employer is defined as"an individual, partnership.axsocwtioa,corporation or other a de entity,or any two r t more .f the t:mgoing engugcd in a Joint enterprise,and including the legal repreYCllfativea Jt deceased empluye4 ur the receiver or uuslce of.in individual, partnership.association or other legal entity,employing employees. However the hree owner of a dwelling horse having not more than to do nr apartments nun and unso uc i nee frepair work oherein,or the nsuch dwellicupant of ng house ,j%wiling huuse of another who employs persons or all the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.' \IGL chapter 152, g35C(6) also states that"every state or local licensing agency shad withhold the Issuance or renewal of a license or permit to operate a business or to construct buildings in the commoaweultb for any applicant who has not produced acceptable evidence of cumpdaace with the Insurance coverage required." �dduwnally, bIGL chaplet 152, a25C(71 states"Neither the commonwealth nor any of its political subdivisions shall stint into any contract for the perfomlance of public work until acceptable evidence Of cunlpliwlce with the insurance requirements of this chapter have been presented to the contracting authority." Applicmtts - -— — -Piense rill-aai_the workcra'compensation affidavit completely,by checking die boxes that apply rf your situation and i necessary, supply sub-confractor(s)name(s),uddresgesYam t!phone numbers)sing witl�theitcertiFicr4e�) insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the insurance. If an or LLP does have members or partners, are not required to carry workers' compensation employees,a policy is required. Be advised that this atfdavit may be submits d to the Department of Industrial accidents for confirmation of insurance coverage. Also be sure to sign and date the udldaviL The affidavit should he returned to she city or town that the application for the permit or license is being requested,not the Department of low or if ou arc required to a workers' industrial Accidents. Shoes call the De you have partment at the number lirding st d below.y questlaySelf-assured compallieslshould enter their compensation policy,p D self-insurance license number on the all ro date line. City or Tawas Omclala rinted legibly. The Department has provided u space the button Please he sure that the affidavit is complete:old p of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the n[ e applica Pl:usc be sure to till in the permiUlicense nwnber which will b- reference number. in addition,an applicant used as a re ffid vit that must submit multiple pennitilicatt>seaePPIlcati its Addressurrent I ons in any "the year,ven livan�hnuld submit unll'IUUunrUnA In leafing(city or policy intormution(if necessary) p0 town)."A copy of the a officially ffidavit that has been ocially stamped or marked by the city or town may be provided to the applicant s proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each year. Where as a home that owner or citizen is obtaining a license or perinit not related to any business or commercial venture f i.e, a dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. I he 1 yl I iS it invesfigatlons would like to thank you In Jdvance for your tooperatioll and Should you ha%c arty quebtiolls, please du not hesitate to give us a call. The D,:partment's address, tcicphunc and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Ofllee of Investigations 600 Washington Street Boston, MA 02111 Tt1, # 617-727-4900 ext 406 or 1-877-MASSAFE Fax 0 617-727-7749 ;(,%,,cd 5.2o.05 www.mas3.gov/dia CITY OF S��i_F. T Ni, ILL-kSSACHLSETTS , BULLDLNG DEPARTMENT 120 WASHNGTON STREET, 3' FLOOR TEL (978) 74S-9595 FAx(978) 740-9846 KI.NIBERLEY DRISCOLL OR T Homu ST.PIERAB MAY DIRECTOR OF PUBLIC PROPEATY/HCIIDLNG CO%L\(1SSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris,and the provisions of MGL c 40, S 54; Building Permit At 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: /I (name of hauler) The debris will be disposed of in (name of facility) �f,&-m &nd (address of facility) signamr f /rmit a � ica t 6 d e a.h��,rra,x ORiee*o�m°"ei� x.�"{(Tis" dliid egos 1- - ' HOME IMPROVEMENT CONTRACTOR VRegistration. 110428 Type: Expiation 10&02012 OBA a COMPANY ,- JOHN KELLY JR - z - 6 ARBUTUS RD SWAMPSCOTT MA`01907 Undersecretary .+.,. massachusetts- Department 0f Publie S:ifcth 4 Buard o1'Building Re- lations:md Standards .ConStt�dcjjoa i se _Supervisor Licen License: _CS 690 .,. '- Restricted to.* 0a . JOHN J KELLY e 6 ARBUTUS RD SWAMPSCOTT, MA 01907 Expiration: 121142011 <-amnrissiona•r Tr#: 10584 r A CERTIFICATE OF LIABILITY INSURANCE °"'�'�"D°Y""' 8130/10 THS 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(es) 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 endorsaneM(s). PRODUCER CONTACT NAM: Benevento Insurance Agency Inc PHONE . (781) 599-3411 FAX NO: (781) 581-7200 497 Humphrey Street VW ADDRESS: Swampscott, MA 01907 PRODUCER 4586 _INSURERS)AFFORDING COVERAGE _._ NAIL# _._. IMMEO INSURERA:Nautilus Ins Co John Kelly INSURER S:Liberty Mutual dba Kelly 6 Company INSURERC: 6 Arbutus Rd INSURER D: Swampscott, MA 01907 INSURER E: IN$URHt F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES 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 TFE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPEOFINSURANCE ADD $ POUL1'RAIR®ER PM�Elm ...YYY1tea UaTS GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000 A X COhMERCULLGENERALLIABRITY NN052972 8/25/10 8/25/21 DAMAGE To RENTED $ 50,000 CLAMSMADE 1XI OCCUR ME 0 EXP(AV.m p.) $ 5,000 PERSONALS ADV INJURY $ 11000,000 GENERAL AGGREGATE S 2 000 000 GENTAGGREGATE LMITAPPLES PER PRODUCTS-COMP/OP AGG S 1.000.000 POLICY PR0. LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE L W iT ANYAUTO (EaaTc m) $ BODILY INJURY(Per Wis.) $ ALL OIPI ED AUTOS BODILY INJURY(Per a ent) $ SCHEDULEDAUTOS PROPERTYD/ GE $ HIREDAUTOS (Per a¢rind) NON-OWNED AUTOS $ $ UMBRE� a LIAB OCCUR EACH OCCURRENCE $ EYCESSI,en ClA1MS-MODE AGGREGATE S DEDUCTIBLE $ RETENTION $ S B WORKERS COMPENSATION 0110799 8/27/10 8/27/11 X WC srATI1- GTH- AND EMPLOYERS'LABJ BTY ANY PROPRETORIPARTNERIEXE1)TNE YIN EL.EACHACODENT $ 100,000 OMCERI EMBER EXCLUDED? N/A (Mand kiln,In NH) EL.WSEASE-EA EJPLDYE S 100,000 Ifyynd-ajl under DESCRIPTTONOFOPERATIONrbelDw EL.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OFOPERATIONS/LOCATIONS/VBBCLES (ADaJ,ACDRDIM,Ad2do R mda SdmUa,Rmoreslsrssmgdmd) General Contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE City THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY Of Peabo dy ACCORDANCE WITH THE POLICY PROVISIONS. Peabody, ma 01960 AUTHORIZED REPRESENTATIVE V _.. ©t 09 ACORD CORPORAXFOW. All rights reserved. ACORD 26(2009109) The AC ORD name and logo are registered marks of ACORD TEDESCO POND CONDOMINIUMS 8TEDESCO POND PLACE KITCHEN LAYOUT 52.5" 19.5" 45.5" window Dbl bowl sink 30.5" 27.7 109.5" stc ve 6" 28.25" 41" 24" R ef window 22" 77" 39" opening TEDESCO POND PLACE MASTER BATH --- - _ --- -a-----SHOWER-------------- ---------------------------------------------- TOILET 0 0