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6 UNION ST - BUILDING INSPECTION The Ct nunonwealth of Massachusetts Hoard of Minding Regulations and stalldalds I ( Ut 1- Massachusetts Stile Building ('ode. 7tiO('!\1R. 7'„ edition Mt Nl( II' \I.I 1 13l ilding Permil Application Tu CunSlruit. Repair, Rcno�atc Or Demolish a Kr, O SIB n - n " n u-FuniA Derr//irl,q ='rr'•\ Phis S ction For Official Use Only N -- 13u,IJing Permit um c Date Applied: t �_�___ I3wl ntg ('unvm aonrd In,It r i uddnlgs Datc --TION 1: SITE INFORMLA'1'ION LI Propert ress: j 1.2 Assessors .Map & Parcel Numbers - - ---. u Map Number P:an•I Numhvr 1. I a is this :m ai;iepieJ street: yes__.__ t 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area uq 11) Flowage ill) 1.5 Building Setbacks(ft) Frt,jnl Yard Side Yards Rear Yard Required PrOVIJCd Regmred Provided Requoed PruuJrJ 1.6 Water Supply: IM.G.L c. �0, §53) IJ Flood Zone Information, 1.8 Sewage Disposal System: . Zon Outside Flood Zone'! Puhlit' G Prolate❑ "— Municipal ❑ On Site disposal s!+Inn ❑Check if yes❑ "- I SECT[DN 2: PROPERTY OWNERSHIP' 2.1 Owner'ur Record: ✓o/l .� 1 t Print I Addres-litt Service St gn:!lu'P Pr Telephone SECTION 3: DESCRIPI ION OF PROPOSED WORK(check all that apply) New Ctmstruition�,C Existing Building Owner-Occupied ❑ 1 Repairs(,) ❑ \Iteranunl s), r\JJiliun ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Spcaiy: Brief Description of Proposed Work': O ,i1-✓) � r ----- i SECTION J: ESTINIATED CONSTRUCTION COSTS i Estimated Cuss Item (Labor and Maten ilsl Official Use Only I. Building S I. Building Permit Fee: $ Indicate how Ice i..s Jewonoicd 2. Electrical $ ❑ Standard City/Town Application Fee _ � ❑Total Project C(y (Item G) x multiplier s _ J. Plumbing S 2. Other Fees: S_ lip — 4" Mechanical IHV'AC) .S List: _ 5. Mechanical (Fire) ----------- Suppression) Turd All Fees: S _ Check Nu.o heck Amount: Cash \mount_- j b -fatal Project Cost: $ /4/S �Q aid in Full ❑ Outstanding Balance Due:---- . i SECTION 5: CONSTRUCTION SERVICES F itstruclionSupervisorW 'LI icensed Co / /,' ',/t.(p `P s/` �— LwenN¢ Number li\p11atton Date _ — — Namr of C'SL-/I�IoIJer 1,1,1 CS1. r\Iv t,cc below I _ \JJrcNN �A/� SRC t- t'niestimed to r to ;i(X)0('u 1:1 1 R Resumed L@_' F.muh Dw•dlinc 11 IeIlaalie .`i NlasonrN Only RC ResiJenual Ruoline ('rn felcphoit•• \\-S RcNidrnuul \11 ndu„ and SiJiiie 7f(' �// `< SF Re'ldanlial Solid Fucl Buouup \ i_incr hi.Lil Ltln b.-. (� 3/ �/ D RcNidewial Ikuwhw..I 5.2 Registered Ilorne Improvement Contactor (IIIC) IiI -Conipany Nanworl-11 Re, .(rant ❑me ReEutrau )it Vun�hrr t tGGeLr c `G / �!S//✓u.Jl' F.xpirau„n Date Signature 'telephone — SECTION 6: WORKERS' COMPS SATION INSURANCE .AFFIDAVIT(M 25C 6) .G.L. c. 152. § 1 1 Workers Compensation Insurance affidavit must be completed and submitted with this application. P:ulure w pn,s iJe I this affidavit will result in the denial of the Issuance of he building permit. Signed Affidavit Attached'? Yes .......... No .........- _ SECTION 7a: OWNER AUTHORIZATI N TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize - w act on my behalf, in all matlnn relative to w•.t� authorized by this building permit application. I Date Signal (LAI —� SECTION 7b: OWNS t OR :WTHORIZED AGENT DECLARATION _I I, f /j �. L" L�� , as Owner or Authorized Agent hereby declare that the statements and information on the fu egoing 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 Enallies of perjury I —'� NOTES: J I. An Owner who obtains a building permi Indo his/her own work.or an owner who hires an umeulsteied ron(rt lol (nut registered in the Home Impruveme t Contractor(HIC) Program). will not have access to me athinatim, program or guaranty fund under M.G.L. o. 112A. Other important information on the HI(' Program and Construction Supervisor Licensing (CS ) can be found in 780 CMR Regulations I IO.R6 and I 10 R5. respecn•cly -------------- When substantial work is planned, prod le the Information below: Lnal floors area ISO. FL1 (including garage. finished basement/atocn. Decks or pofch, Gross living area I Sq. .I Habitable room count of ti replaces Number III hedroums Number N Number of 11AUh.uhs Number of hathroot -___ -_— --- -- Number oI decks/ p,,rchcs I'vpe of heating system -- .IinclosaJ - P}pe of cooling sys(am — --- —� t "Po(al Project Square Footage" may he I ubsuwteJ for Total Project Cost" CORD CERTIFICATE OF LIABILITY INSURANCE CSR SW DATE(MMIDDNYYY) `Q UNITEDR 1 05 14 08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MF&TIns. Construction Div. ? RIGHTSERS NO Cons HOLDER. H S CON CERTIFICATE DOES NOT AMEND,EXTEND OR Construction Division 77 Accord Park Drive Unit B-1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Norwell MA.. 02061 Phone.: 781-15*261-2000 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A: Northland Insurance INSURER B: American International Co. United Roofing Contractors,LLC INSURER C: SaMA Brentwood9 Avenue I-��a NSURERD: 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. LTR.7GENL YPE OF INSURAN _ POLICY NUMBER. DATE MM/D - MATE MMR)D __. _... tlM1T5. EACH OCCURRENCE $ 1000000 LIABILITY $ lOOOOO AMERCIAL GENERAL-LIIABILITY CP554790 05/08/08 05/OB/09 PREMISES Ea ocwrenm CLAIMS MADE IL{ 1 OCCUR MED EXP(Any one person) P$2 0 PERSONAL S ADV INJURY 0000 GENERAL AGGREGATE 0000 GREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO0000CY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ _ (Per person) SCHEDULED AUTOS HIRED AUTOS - BODILY INJURY - .S (Per accident) NON-OWNED AUTOS PROPERTYDAMAGE $ (Per eccideni) . GARAGE LIABILITY AUTO ONLY-EA-ACCIDENT' $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE S S S DEDUCTIBLE S RETENTION S _ --. WORKERS COMPENSA31ON.AND - X TORY LIMITS ER B EMPLOYERS'LIABILITY WC 697-01-90 05/08/08 05/08/09 E.L.EACH ACCIDENT - s100000 ANY PROPRIETORIPARTNERIEXECUTNE E.L.DISEASE-EA EMPLOYEE S 100000 OYFyFICEWMEMBER EXCLUDED? SPECIALP OVIS'r EeIox E.L.DISEASE-POLICY LIMIT 5500000 ' OTHER DESCRIPTION OF OPERATONS(LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Village at Vinnin, Phase II, Salem, MA, Stadium Condos; The Meadows in Danvers, Cloister Condos in Salem, Highland Condos, Salem, MA CERTIFICATE HOLDER CANCELLATION - EACOPRO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL SO DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL East Coast Properties IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 400 Highland Ave. REPRESENTATIVES. Salem MA 01970 AU 0A2ED REP TATYie� ACORD 26(2001/08) /�� ©ACORD CORPORATION 1988