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94 TREMONT ST - BUILDING INSPECTION (2) t l Fhe Commonwealth of Massachusetts - CITY OF 1 Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR L, Building Permit Application To Construct, Repair. Renovate Or Demolish a Otte-or Two-Funtily Dn efling This Section For Official Use Onl Date A lied: Building Permit Number: PP Building Official(Print Name) Signatur Date SECTION 1:SITE INFORMAT ON 1.1 Property Address: q 1 �Ce,MGr�� al- 1.2 Assessors Map + Pa eel Numbers — 1.1 a Is this an accepted street?yes_ no Map Number Parcel Numbcr 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(11) 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? Municipal ❑ On site disposal system ❑ Public❑ Private❑ Check if yesO P P y' SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: �+ KL tfiyeStwer+4c aG�n�h Mrs f314�Ct N:une(Print) City,State,ZIP - �,revL1C (�l No..and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New Construction❑ Esisting Building❑ Owner-Occupied ❑ Repairs(s) Alterations) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work-: K;i, l" 0-K PoO We. rnd(C (actV'ntin ll '%J PeAdA, ReRe,1f RcCt.k k Pae1C SYatts� Uano� Mew pit a i3a ,d ��t%Oz, over, ;cy.'�w tocll SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Laborand Materials) I. Building 3'20 6O I. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee '_. Electrical S C ❑Total Project Cost'(item 6)s multiplier x i. Plumbing S ' (BOO- 2. Other Fees: S 4. Mechanical (I1YAC) 3 List: 5. Mechanical (Fire 5 Total All Fees: S Su �ression) Check No. _Check Amount: Cash Amount:_—__- 6. Total Project Cost: 5 ,3 C)(JC1.GQ) ❑ Paid in Full ❑Outstanding Balance Due: ___ ______ fnai o) 1 t SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(C'SL) __ Lw(�c$ License Number IGpualion Dale Name of CSI. I I»Ider J �/ 1'0 1)/Z, List CS T)pe(sec helow) _-- No. and Street Iype Description L16,qt3 pa _ �. ��Z U Unrestricted 113uildin Is u' to 35.IlUU cu. It.l cn.W form. Slate.ZIP Restricted Restricted I&2 FamilyDwellin M Mason RC Roolin Coverm / W'S Window and Sidon SF Solid Fuel Burning Appliances abs-hAR _ I Insulation "cie ixme Email;tddras U Demolition 5.2 Registered Home Improvement Contractor(HIC) 1,t1+or��i[� - C[7vSt2vcts-vv PyoS 7� /v-a7-/� I IIC'C'ontpan) Name or I IIC Registrant Nance IIIC Registration Number Expiration Dale 1 t2 No.and Street 13f,�806)e G 92F--1C-i-p24fL Email address Ci /Town, State, ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.1 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 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: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 co it in this !' t!on is true and accurate to the best of my knowledge and understanding. in Own Ps o \uthorizcd Agent'S Name(HQctronic.Signature) Date NOTES: 1. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program),will not have access to(he arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at III wit�}. "AN,.,;ov or! Information on (he Construction Supervisor License can be found at '_ When substantial work is planned,provide the information below: "rolal floor area (sq. If) _(including garage, finished basement'altics,decks or porch) Gross living area(sq. It.) __ Habitable room count .N umber of fireplaces Numberofbedroonts "-- ------ Number of bathroonns N ----------------- ----------_-------- umber ofhalf'hadns F pc of heating system _.—- Number uf decks, porches 1)pe of cooling system ---Open..------"—-- I:nclused .___---- i "total Project Square Footage"may be SubSliluled for"rote) Project Cost" -- CITY OF SALEM lk 1r PUBLIC PROPRERTY DEPARTMENT .nu::Xf1 Y:1XIN,91 N„1 w 11C\VANtUNGI t^i l m EL•1' r $,1I P.N,I.t.1 vs.u.I It V 11.';177: I'1:1: 011.713.9P)3 s I:tx '/7M-74C•9x16 - Workers' Compensation Insurunce :\tBdaviC Builders/Contrac torsi Electrldsns/Plumbers \ 1111crnt Information n Plc• � Print Le 'hl \4aina 111urnk,ilJrawnrimlvinJrvuluull: CVn,�'r .,c�L--$ CM ,�S'�2c]Gy-Z ) tfdre.w R1 r"CSC'4Hr� vt r}S 1�y'L r Ciry,Srarc%ip f3F.hl V /h"d 9G I'honeil: P& T-933'� .t re) so an employer?Check the appropriate boa: 11.p1 1 ant J cm lu er with 4. I')M orpr�ject(reyulrrJ): W+ P ) ❑ I :un a general contractor end 1 mnpluyccs(full anJ/urport-time).• have hire)the sub-eomracwr r'• ❑New construction 2.❑ 1 ;sill a sole praprictmr or partner• listed on the anaeheJ sheet 7 7. ❑ Remodeling ship and have no mnpluycus These subcontractors have g. Demolition working liar me in any capacity, worken'camp, insttrance. INn workute'comp, insurance 3. ❑ We are u rnl 9• ❑OwlJing uJditiun portion anJ its 3.❑ nyuireJ.) otllem hove uxdreir d their 10.[]Electrical repairs or additions ' :Jill J homeowner doing JII work right ardaemption per NIOL I I.p plumbing repair%or additions lnysclf. (tvo worken'comp, c. 137,§I(i),and we hlivd no 12.❑Ruul'repuin insuranco rcyuired.j t employees. (No worker' crnnp invurancw reyui a j 13.0 Uthar •4ny.,ppLcuX IOW ehvc%s bea el muN alw rill ew I),vrYbun IN law Inuwin iMand Iir wwxms'cum nuulwl'I Iunlw,4n11ra w110 Submit this amdsvil indtaslin t % �rk a N Iadiey ulhumWitX► •r' Cone .Mttaaae,Thal,Mee This ho%mug Jllihpl an addl1Ii1WWI,�hwt.huw1na the nam o(lhe tuh.entranon and ntee wuM1al7w alYfdailµr1,11•tw}eilnily�w /am sin derp(ayer thus It providing workers'rurrapensadon hisitrance for illy rntplayear, Br/ary la thr psi/Ay unr//uA si/� injunnutLrn, Insurance Conipany . mite: �V >��. .. U��.tic-e Policy As or Sclr-ins. Lic.H: - — ' --__ nn Expiration Data: Job Ji1e Address:_.7 [/Lr•. -S'� �.. City,5latdizlp:5� i^-,.a 6 t 970 Attach it copy or the workers'cu ipunxanon policy ducla►unon pugs(showing the policy uunlbor and expiration data). failure to sccura cuteruge as required under Section 231%ill'%IGL e. 152 can lead to the imposition oferiminal penalties ors fine op to'-" SuO.rM Jndlur une•yeor imprisonment, as wull is civil pcnalucs in the farm ors STOP WORK GIRDER and a fine nfup ran i230.1M a Jay'dumb' ills vimlanlr. Ile advised that a copy urlhi%atumnunt may be IurwarJcJ to the 011ice yr Iq\'e-1 11tal0 It's ul 111a 01A for in,urarce co vcragu serilicdtnln. /du he rrhy s citify nuJerythe`poin.r told pnwhiur u/per/ury that the infunnurlon proviJed ubu.y is true and(arras•'. r)//la'iu!nsv on/y. Du mnr write in this ureu, to he cvurp/reed by city of town a//2riuL i ('ill or-1'nwn: —'— pennir/Lleeme I. � I„uing Aulhority (circle one): I. IL,arJ u(Ilrahh 2. Iluddin� IAparnuvol 1, 'IbN11 Clerk 4. L•'Icctrical Inspector i• Plumbing lo,peetor h. Othvr l'„ntacl I'tnun: , Phone .l: i Information and Instructions r �laisachuseus G%:ncral Laws chapter 1 i2 requires all evnpW)cion in the provide service of another undetr�nny nlract of h l;)r their ire s. Pursuint to this +litute, an ueplas'ce is defined as every per'. •.pre,s or uttplieJ. oral It written." or any Iwo or more �n !On is Jclined a an individual,partnership,association,corporation or tither legal cntiry, wtio@ or other legal cndly,employing employee@. However the ,a the furegumg engugcd m a joint enterprise, and including the legal ropcesentatives of a decease)cmpluyer,:v the t ecetver or trusea of an individual,paamershtp,Assocthe owner of a dwelling{house having not more than three do nr'n coon ents an construction sthepav work oo such dwelling house dwelling huuee of another who employs persons or.,tt the grounds or building appurtenant hereto shall not because of such employment be JeemeJ to bean cmpluyer.' �IGL shaper 152. rf_SC(6)alw slues tltaI ,every slate or local Ilcensl@g ageaey shall withhold ea Issuance or renewal of r license or permit to operate a buslasas or to construct buildings la the Comm oawculeb for day with the :,pplicant wbo has not produ ccd acceptable states eaevidence denser he onuAncO nonw alth not lany of its Politic"'nsurance gsubdivisions shall idditionally, %IGL chapter 15_, T- enter into Any contract for the perfomance ul'public work until acceptable evidence of cutupli once with the insurance requirements of this chapter have been presented ro he coneroeting authority." Applicants plu+t:as rill out the workers' compensation affidavit completely.tpne numbers)alons with their hecking the boxes that lcartificatets)of y to Your nand, i necesauy, supply sub-contractor(s)name(s), address(co)' P _ with no limployegs insurance. Limited Liability Companies(LLCworketdtcompensasonattuuronct,(If ao)LLC or LLP does have er than the members or partners, An not required to carry employees,u policy is required Ba advised that his atHdavit trey be gigs and to the Departmentof affidavit f fid vi he rods ed to ton confirmation ity or town thus th cO cO cation for the peon ipL Also be eOrolicetw�s being requested,not he Ucpartmcnt off Industrial Accidents. Should you have any questionsregarding the law, it'yuu we required to obtain a workers' compensation policy,pies$@ call the Department at the cumber listed below. Self-insured companies should enter their Salt-insurance license number on the a propitiate line. Clry or Town Officials partment has provided a space at ibly. The PI the aiFJuvit that the or you to g1l out davit sin he event the Office complete and printed of of has to contact you regarding the tapphe liaanL 1'1 vbc be sure to till in he permitllicense nuts ions in anr which ulg en l be used ear�need reference csubmrt nor. latFdavit indica addition,An ting current that mutt submit multiple pennitllicense applications y y Y in policy infra matinf the uftldav l hat has been officially stamSite apcd or marrkedss"the tbyvtileucity or tow write n nalocy sroviJcJ ro the or Y D tuwnl•"A cupY applicant as proof that a valid affidavit is on file For f*uttre permits or licensee. A now affidavit must be tilled out each yatr. Where a home owner i citizen is obtaining a license or permit not related to any business or commercial venture a Jug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit I he ,>nike Ill Investigations %Quid like w hunk you in advance for your couperuiou And ghoul)you hove:a,y yueauons, plcabe Ju nut Willare to give us a call. ber fhe U.paruncnt's aJJtess, telephone and Th C Commonwealth monwealth of Massachusetts Department of Industrial Accidents Offlee of fnvesilgadoes 600 Washington Street Boston, MA 02111 'fe1. p 617-727-4900 eat 406 or 1-877-MASSAFE Fax N 617.727-7749 waw.mass.gov/die CITY OF S.U.&NI, .NWSACHLSETTS BULLDLNG DEPARTNONT 110 WASHLYGTON STREET, Yo FLOOR TEL (978) 74S-959S FAX(978) 740-9846 KIJBERIEY DRISCOLL ,MAYOR THo.HAS ST.Pm uts DIRECTOR OF PLBLIC PROPERTY/BCIIDNG COWNIMIONER 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 # 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\Oz �\g�CV\V\rA (name dfhauler) The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant date J.hnulf bx 1 CITY OF SM-E.M PUBLIC PROPERTY DEPART NIENT w.a..a,n o.era� %"VM 170v.o dGMW9,.sar•SA,&- Vwa�oa:srnON'0 tea.r.ar,s-ss" *FAX 978-746.964 HOMEOWNER LICLNSE EXE.MMON Fleece Fttiat Date G lob Location Home Owner Address r :C . Home Owns Telephone Preaaot Mai lag Addreae .a Sc zr,,L P L. The current exemption of"Homeowners"was extended to include owns-occupied dwellings of two Units or leas and to allow,such homeowners to engage an individual for hire who does not possess a Hcem%provided that the owns acts as supervisor. DEFINMON OF HOMEOWNER Persons)who owns a parcel of land on which he/she resides or intends to reside.on which there is, or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such i torneowner"shall submit to the Building Official,on a form acceptable to the Building Official, that he/she be responsible for all such work performed under the Building Permit. The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner"certifies that he/she understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requir m ts. HOMEOWNERS SIGNATURE �� .APPROVAL OF BUILDING NSPECrOR See other side for state code 4 -71w iamm, ,e¢(.w, ✓Kaadar/a(r�ael(� ,�.Office of Cousumer Affairs&liusiuess.$egWittion HOME IMPROVEMENT CONTRACTOR = x Registration._' 140576 Expvabon 10/27/201-1 Tr# 289061 Type:..-..:DSA CUMMINGS CONSTRUCTION STEPHEN CUMMINGS 21 Pocahontas Dnve Peabodyr MA 01960 lludersecre_.m Massachusetts- Department of Public Safetc Board of Buildin Re-gulations and Stantlartls Construction Supervisor License License: CS 83956 m STEPHEN D CUMMINGS 21POCA14ONTAS_DR PEABODY, MA 01960 Expiration: 10f12012 f'onnnissioner Tr#: 5304 ACORD CERTIFICATE OF LIABILITY INSURANCE 06/22/2�' PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rose Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A'.MERCHANTS INSURANCE GROUP Cummings Construction INSURER B:Guard Insurance 21 Pocahontas Drive INSURER C: INSURER 0. Peabodv MA 01960- INSURER E. COVERAGES 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 OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS L. INSRD TYPE OF INSURANCE POLICY NUMBER DATE MM/DDM' DATE(MM/DOH' A GENERAL LIABILITY BOP9099351 11/08/2010 11/08/2011 EACH OCCURRENCE _ $ 500,000 DAMAGX COMMERCIAL GENERAL LIABILITY PREMIESESS E RENTED occurrence) prrence 50,000 PREMISES S CLAIMS MADE DOCCUR MED EXP(Any one arson S 5,000 PERSONAL B ADV INJURY S 500,000 GENERAL AGGREGATE S 1,000,000 GEML AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S 500,000 PRO- POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Es accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNEDAUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR F—ICLAIMS MADE AGGREGATE S S DEDUCTIBLE / S RETENTION $ _ $ B WORKERS COMPENSATION AND STWC134307 08/04/2010 08/04/2011 $ TORV LIMBS °ER" EMPLOYERS'LIABILITY 100,000 ANY PROPRIETOR/PARTNERrEXECUTIVE E.L.EACH ACCIDENT 6 OFFICEWMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEES 3.00,000 If yes,describe under EL.DISEASE-POLICY LIMIT Is 500,000 SPECIAL PROVISIONS belox OTHER DESCRIPTION OF OPERATIONS/LOCAPONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUT REP SENTATIVE . " ACORD 25(2001/OB) ©ACORD CORPORATION 1988 Page 1 of 2 INS025(o W B)m