9 TURNER ST - BUILDING INSPECTION (2) 1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR,7"edition Ois SALEM
f( , Revised January
a' Building Permit Application To Construct, Repair,Renovate Or Demolish a I, 2008
One-or Two-Family Dwelling
This SeS. n For Official U my
Building Permit Number: D pplied:
Signature:
Building Commissioner/4nsl5ectiMf Buildings Date
SECTION/:SITE INFORMATION
1.1 Proper y Address: 1.2 Assessors Map&Parcel Numbers
}v✓c�e2 S
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
iuv v Si, C S40jt, �,� �.,sltn,,, /l �y 7_
Name(Print) mat ddress for Service:
p l' Vt'6( ) -�-yo-r3`fZ�
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of ProposedWorkz: Lxlr2 20O B
In/42/t P,Y efn uOrt lC 2 Cbn,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire
Su ression $ Total All Fees:$
Check No. Check Amount Cash Amount:
6.Total Project Cost: $ OLD ❑Paid in Full ❑Outstanding Balance Due:
a D
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) NTGT 7
_3
Licensee Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
Add re s T e Description
Unrestricted(up to 35,000 Cu.Ft.
Sin ure R Restricted 1&2 Family Dwellin
$rii— M Masonry Only
f < l� RC Residential:Roofin Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) `/
r'� 1 f L aUi4' t✓I"'
HI ompany Name o HI Registrant Name Registration Number
1-3 Le6(� ae� C�) -Y-- 13
Address ®/'n n^. ,
��"A/Lti(M_- 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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
4 C^M , as Owner of the subject property hereby
authorize 1 lid J-y7 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature o'Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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
behal
� ✓�l
Print
Signature of Owner or Authorized Agent Date y
_ (Signed under the pains and penalties of perjury)
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 110.R6 and 110.R5,respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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"
INN CITY OF SALEM
lr PUBLIC PROPRERTY
-- DEPARTMENT
\INtNI 12C WMIONG I UN)I'SCta'# 5dll•.N, M.\Udl.l n it I IS Jl'17.
Tm1 )7&'13.9595 • 1:vt 97x-74VJN46
Workers' Compensation Insurance Affidavit: Builders/ContractursiElectricians/Plumbers
kunl(cant Information /q��( p Pleme Print Leeibly
V:IITI�tauaukns/gr;t7nl)atioNlndlvtduull: J`(�[/ �C(/ �7 Vf
Address: Ira L-e&joue cAy,,-
City.Stara Zip: S ` l j1/ [CI, Phone it: /Q
9 - ?Zq -S7"
.%re l uu an employer?Check the appropriate box: 'Type orproject(requlred):
11. 1 am a employer with 4. ❑ I atn a general contrad,n
nd 1 ft, 0 New construction
employees(full and/ur part-time).• have hired the sub-cors
2.J(¢� I ant J sole proprietor or gannet- listed on the artacheJsheet. �• ❑ Remodeling
.hip and have no cmpluyucs These sub-contractor S. 0 Demolition
working Air me in any capacity, workers'comp, insur ___q._0.OuiWing-addition- ------ —(kn workers'cutnp—insurance --5•- —-veto arc u Coporation srcquirLd.) 01TIMS have cxetcixcr 10.0 Electrical repairs or additions3.❑ 1 ant a homeowner doingall work rightorcxemptionpeI I.0 Plumbing repairs or additinnsmyself.(No workers'comp. c. 132. ¢1(4),and we o 12.0 Ruul'rcpJirsinsurance required.) t employees. (No workcomp. insurance mqui13.0 Other
'4n).gtpbcarrt I119 checks bob nl must also till out lots vucumt bcluw dwwinx their w•wkovi companuaiutt pulicy intinmuliun
'I Iumevwnen who oubmil Ibis otrldsvit indiurinx arty are doing all wurk and then hire outside contractors most.uhnk a now a1'Rdavit indis:alna etch.
•C'.woactors thin chock this box must Jaachod an aJlitiwul shun chuwitry nos maw of 1M rub-co wractun and their wurkon•stump.prdicy informanus.
/run wr en)pluyrr that[r providing Ivurkrrs'rutnprtrtndon hrturrurea jar my trap/uyrre. drhnv Js rhr pulley ant//ub a'ite
lujdrinutinn,
Insurance Conopany.Name:
Policy Ir ur Sulr•ins. Lic.it: .. .._ Expiration Date:
Job Site Address: C1ty'slate/Zlp:
.\leach is copy of lilt workers'cumpensatinn pulley duclarallun page(showing the policy nutuber and expiration date).
Failure to secure coverage as required udder Section 25A ut'JIGL c. 152 can load to the imposition of criminal penalties of a
line up to S1.500.00 and/or une-year imprismoncnt,is well J..'civil pcnalllcs in the Wan of a STOP WORK ORDER and a fine
nr tip rn S250.00 a Jay aguinst the violator. Ise advi.+cd that a copy ufthis statement may be IirrwarJcJ to the Orrice u!'
111%'-Nll.Jllmtls ul the DIA for mXlrarce covCrake 1 cl'lllealitin.
[du hereby re a„der the ptrin.y and )rnrdt/er ujper/ury that the injurrnurlan provided above is true ru.d correea
u le•
Official use dilly. Du nor twits,in this area.to be cumpletrd by city ur tmvn,11 ieiut i
(.'ity or'fotrn: _- _ - Permit/I.Icence
Isvuina Aulhurily (circle one):
I. Iloard of Ilvaldl Z. Iluildillq Ikpartinew .1. Cil)i Ibn a Clerk J. L•'lcctric l lalpcclur 5. Plumbing lolpeclor I
h. Olher
('.'pact 1'trwll: _ . . I'hune Y• .
information
and Instructions
for their employees.
Massachusetts Gcneral Laws chapter I J2 royuirrs all eery `lion in the icry ce of another i;to provide workers' euulelrtnuy C ntnct of hire,
Pursuant to fills+latua,an emplos� d is defined as"...every ill p
,.press or implied, oral or written."
An einploper Is defined as"in individual, partnership,association,corporation or other legal entity,or any two or more
it the fJfC5Jltlg engaged In a JJIRI eRlCrprliC,and includrlig the legal representatives of a deceased employer,or the
ve
1 CCCIVCf Jr lfUllCe JI.ut Illdivldual,partnership,asaaclatioa or other legal entity,employing employees. HOW CVCr the
owner ot'a dwelling house having not more than three apartments and who resides therein,or the occupant of the
,iwelling house of another who employs persons to do mainanunce,construction or repair work on such dwelling house
or an the grounds or building appurtenant thereto shall not because of such employment be deemeJ to Ix an employer."
.%IGL chapter 152. p25C(6) also states that"every state or local licensing agency shag withhold the Issuance or
renewal of s license ur permit to operate a business or to construct buildings In the commonwealth for any
:renewilnt it license
has not produced acceptable evidence of compliance with the insurance coverage required:'
%adltiunully, 61GL chapter 151, 4. 25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ufpublic work until acceptable evidence of cunlpliurlce with the insurance
requirements of this chapter have been presented to the jontracting authority."
Applicants
——-- rt the-workers_compensation affidavit completely,by checking the boxes that apply to your situation and, if
Please ants
ddress(cs)—L phony numbers)along-witft theicceniftcrls(�)of
necessary, supply sub-contraclor(s)name(s),a
nswance. Limited Liability Companies(LLQ or or sited iebili on insurance.(If an)with
or L employees does other than the
members or partners. are not required to carry P
employees,a policy is required. Be advised that thin affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign sad dale the aMdav not
The epa tm should
he remlmed to time city or town that the application for arermit or the law or if e is being
g requested,
queued to obmuttu workers'
of
lndustriul Accidents. Should you have any y regarding
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
city arrown Officials
Please be sure that the affidavit is complete;md printed legibly. The Department has provided u space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
1'l.asc be sure to fill in the perlit/license nunmber which will be used as a reference number. In addition,an applicant
drat must submit multiple peonitlliciluse applications in any given year,need only submit one affidavit indicating current
Site Address"the applicant should write"all locations in (city or
Policy information(if necessary) and under"Job
town), A copy of the affidavit that has been officially stamped or marked by the city or town lnay be provided to the
id affidavit is on file for future permits or licenses. A new affidavit nmust be filled out each
applicant as proot'that a val
ye:lr. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
I i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
i Ile i yl Ilse III I live Sri gatnms would like to thank you In advance for your cooperation and shuudd you have any questions,
please do nut hesitate to give us a Call.
Tho Ucpanment's address• tolephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oflfes of Investigations
600 Washington Street
Boston, MA 02111
"Pei. 0 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
�t..i,ed i-20-05 www.mass.gov/dia
JpH CERTIFICATE OF LIABILITY INSURANCE °"'E'""D'°"""
OBHD/,D
THIS CERTIFICATE IS ISSUED AS A MATTER-OF INFORMATION ONLY AND CONFERS NO stio irs UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY Ol t 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! N the cedlBeato holder is an ADDIT104IAL INSURED,the polky(Ms)must he endorsed. If SUBROGATION 18 WAIVED,sub)eet to
the terms and eondldons of Vle Policy,Cortaln Polk os may require an endomemant. A statement on this ealdflcatu does not confer Flights to the
eenMcote holder In lieu Of such omtanemen4 .
pR. CER - °Me•CT Derek CataldO
R.M.Catakto Insurance Agency Inc ( (781)289528C>301 F 781 289 5289
230 Squire Road 'M L dErek(�nncatalddinsumnos.com
PRODUCER
Revere,MA 02151 IABBID•4•
Phone (781)289.5286 Fax (7B1)t89-6289 INSURER AFFORGNO COVERAGE _ NAICe
INSURED INSURERA: NandnalGrsngeMulual -•_
Scott Lminsseur - INSURERS:
13 Lahlano Drive INSURER C:
INSURER D:
Ipswich,MA 01938-,272
INSURER
INSURER F• -
COVERAGES CERTIFICA VIS NUMBER: REY1310N NUMBER:
THIS IS TO CERTIFY TKAT THE POLICIES OF INSUT;I NCE LISTED SELOW HAVE EEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED: NOTWITHSTANDING ANY REQUIREME NT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,T IE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POUCIE:I.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE NSwou POLICYNUMBER Mm (MMNC LMIIs
_ GENERAL LABILITY EACH CC 7.000.000
CURRENCE f •-_,
PAEMIS aOCLIRnE9 f 51:10.000
COLTMERCIAL GENERAL LaBILRY 10,000
❑ ❑ CLAW-MADE 2 OCCUR MPJ0560WL MED EX AL&A VINJURY $
A ❑ 07/12I2010 071128011 PER9aNALAADV eIJURr s _,ODO.000
❑ GENERAL AGGREBAR f 2,000,000
OENL AGGREGATE LNRAPPL@S PER PRODUCTS-COMPATV AGO S 2,000,000
❑M/ POLICY ❑ PR
EC- ❑ LOD COb19s1E13fNGLE LMrt f
AUTOMOBILE LIABILITY (Ee Rcc4NNI _g
❑ AWAUTO BODLYINJURY(PmPffi�) S Y
❑ ALL OWNED AUTOS BODILY INJURY(Par;;d",fle:n $ _
I❑I�--!I SCMEDIILEO AUTOS PROPERTYOAMAGE a'
l..J HIRED"Tos (Pm neddent) T
g
❑ NON-OWNED AUTOS g
❑ ::W
ENCE f _
UMBRELLA LAS ❑ OCCUR 0
❑ E%DESS LIAe ❑ CLAIMBMAOE f
❑ DEOUGTBLE f
RE ON a OTH-
WORKERSCOMPENSATKNI
AND EMPLOYERS'LABILITY Y/ mENi a
pFFICEWMEMBERI---A%CW�ED7ECV11UE NIA
EA EMPLOYE f
�Myyegqndnlay M nx)
k0FSCRIP of OPERATIONS belw POLICY LMR f
WA Df IPYMN OP OPERATIONS/LOCATIONS/VEHICLES (n[Num ACCRO Mal,Atl®se,wl RmnNMN Sehadula,RnwU spaU fs meaWmd)
CARPENTRY j
CERTIFICATE HOLDER CANCELLATIONSHOULD J
THE EXPIRATION OF THE ABOVE RE
ION DATE THEREOF,NOTICE WILL BE DELIVERED NED BEFORE
.. _ AGCORDANCE WITH THE POLICY PROVISIONS.
.. _ AUTHO S-- oos
0
®1998.2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are raglssered marks of ACORD
ACORD 25(2D091o9)OF
Page# of pages
Proposal Submitted To: Job Name Job IfSO L, C—,5 P n Nn� &- M
Address , Job Locat�On
Date Date of Plans
Phone If Fax# Architect
We hereby submit specifications and estimates for:
_�T /art D..r1Yr.,.`,-.
a s /c
We propose hereby to furnish material and labor - complete in accordance with the above specifications for the sum of:
$ / i2 J!-> � c -`v` CwBC /)Q G sr'�S Dollars
with payments to be made as follows:
R
Any alteration or deviation from above specifications involving extra costs will Respectfully n n
be executed only upon written order,and will become an extra charge over and ( G/
above the estimate.All agreements contingent upon strikes,accidents,or delays submitted
beyond our control. Note—this proposal may be withdrawn by us if not accepted within days.
CAcceptance of JJraposal
The above prices,specifications and conditions are satisfactory and are t !/
hereby accepted. You are authorized to do the work as specified. Signature
Payments will be made as outlined above.
Date of Acceptance / Signature
NC3819
CITY OF SALE.M, xSSACHUSETTS
• SUMIOLNG DEPIRTMEDiT
' 120 W.�.iHLYGTON STREET,310 FLOOR
TEL (978) 74S-959S
FAX(978) 740-9846
KISBERLEY DRLSCOLL
MAYORTHows ST.PtERRs
DIRECTOR OF MBLIC PROPERTY/DUUMLNG CONNISSIONER
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 It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 9 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
I 11,S 150A.
The debris will be transported by:
1' ee�r U'✓
(name of hauler)
The debris will be disposed of in
(name of fudny)
(address of facility)
signature of permit applicant
Mate
dbnvlf.lw
Office of Cons°me� r I g B�'° Reg°1 4o �
HOME IMPROVEMENT CONTRACTOR Type.
on: 8349
Registrad .ts16
Expiration: .218I2013 Individual
___ ��
SSEOK=, ===3=,TSCLEVA
I�
SSE�tYF1
OTT LEVA
SC _
13 LEBLANC DR. tif.
IPSWICH,MA 01938`< _As;' Undersecretary
Massachusetts- Department of Public Safety
Board of Building Re mlations and Standards
Construction Supervisor License
License: CS 91683
SCOTT LEVASSEUR
13 LEBLANC AVE
IPSWICH, MA01938
Expiration: 713rM2
(ommissiuner Tr#: 509