12 UNION ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
�y Massachusetts State Building Cade, 780 CMR, 7"edition Building peRpt
Building Permit Application To Gci vuct, Repair, enovate Or Demolish a
One- ? fwo-Farnily Drvellin
Jhis-Sectjo4 F Official Us Only
Building Permit Numbe : Date App1' • 2(p •O[>
Signature: Df, • O�
Building Co issioner/Inspecto of it p i g Date —�
SE IO ITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
IN IIAIIOV,ST
I.I a Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
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 J�On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[ N
2.1 Owner of Record:
is dlJrd7• st. / 'W4.
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) 1t Q
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) & I Alteration(s) Y I Addition ❑
Demolition IyJ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': Meta/ D//1 4o
5 4 r9' Ir lr �'�t S, !?1 �s Z7
4.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only `v
Labor and Materials
1. Building S �S' D o 0 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
L S' 006 ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ ( 000 2. Other Fees: $
4. Mechanical (HVAC) $ 8/ D 0 o List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount
6. Total Project Cost: $ /07 3, 900 ❑ Paid in Full ❑Outstanding Balance Due:
Coo W(�-9Qa ��y�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
l7&� (Z.{2 f e ^ License Number ' Expiration Date
Name of CSL- Holder b-t
f 0 .Gn•. �o�� List CSL Type(see below)
Type Description
Ad ess Unrestricted(up to 35,000 Cu. Ft.)
Restricted 1&2 Family Dwelling
Signature p p p cy Mason Only
g 7 O /Z (-7 l< �/ RC Residential Roofing Covering
Telephone 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 a building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACT/OR APPLIES FOR BUILDING PERMIT
//490,t of 2 / UNIDO✓�3/_GG (f__ as Owner of the subject property hereby
authorize Fu C f/t&-n t e to act on my behalf, in all matters
relative to work auth i ed by this building permit application.
17; fo g
Signature of Qwrffram^ Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I ,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. !
�_ �lO/zl//r✓ Ds2. d✓�/ry d /� G L '�
Print Na e
Signature of Ow or Authorized Agent Date
Si ned under t aims and penalties ofperjury)
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 IO.R6 and 110.115, respectively.
2. When substantial is work planned, provide the information below:
Total Floors area(Sq. Ft.)�ctUD `r� $� (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Gerald T. McCarthy Insurance Agency, Inc.
P.O. Box 839 -92 North Street,Salem, MA 01970
978-744-6433 -Fax 978-744-3575
November 26, 2008
CITY OF SALEM
BUILDING DEPARTMENT
SALEM,MA 01970
Re: Acadia Insurance Company Pol#TBA
Dear Insured:
Enclosed please find a certificate of insurance as evidence of liability coverage for the above
mentioned.
By law, certificates for workers' compensation insurance must be issued by the assigned insurance
carrier; therefore, we have faxed a request to the above mentioned company to issue a worker's
compensation certificate of insurance which they will mail directly to you. In the meantime,please be
advised by us that this coverage is, in fact,presently active for the period of November 06, 2008 to
November 06, 2009
I hope you will find everything in order; and if you have any questions, please feel free to call.
Sincerely,
"0 ---s-k 4,au1
Andrea Stockard
Customer Service Representative
as
JOHN WALSH INSURANCE Fax:9787459557 Nov 26 2008 9:12 P. 02
CDR _ CE,RTIFICATE OF LIABILITY INSURANCE 9sioa 1126/00
PRODIlC62 - 'THIS CERTIFlCATE IS LRSUED AS A MATTER OFINFORMATION
ONLY AND CONFERS NO RIGHTSUPON THE CERTIFICATE .
John J wa1a4 Ilia Agency, Sac HOLDER.THIS CERTIFICATE DOES NOT ANEND:EXTEND OR.
8 Or Box 4407'. . ... ;:�. ALTER'THE COVERAGE AFFORDED BY THE POLICIES 8ELOW.
Salem.MA 01970-6407
Pbonea.978r745 3$OO jgAX:.978 7457,9557 INSURERS AFFORDING COVERAGE NAICB
INSURF_RA �� $
.INSURER C .. _
INSURER D, . .. .: .
PJasbody bflC 960 .. .._, : . _: ... ..
E,
COVERAGES .. .
TIE POLICIES OF MURANOE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD OTDTCAYED.NOTWTTTISTA"O NG
ANY REQUIREMENT.TERM OR CONDITION OF.ANY CONTRACT OR OTHER DOCUMENT WfrH RESPECT TO WHICH THIS MRTTFICAT£MAY BE ISSUED OR
MAY FERTAIK THE TNSURANCEAFWO.RD:RNY.THE POLtCMS.MCftlWD MS
,HEIiFrIN 18 SUBJECT TO ALL THE TEN ,exCLUSKM AND CONDITIONS OF SUCH .
POUCIES.AOQNEGATE LMRI"SSHOWN MAY HAVE BFMN REDUCED By PAM CLAIMS. . . -.. _._. .,. ....
TYPHOPMBURANCB POLICY MAID DATE TE LIST"
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CER#1FICAT�HOLAER.._......._._..».',. . ...,_ ..._.,.... .... . .. ... ....... .. CANCEUATION .. '
SHOULD My OF THE AB WE OESCHIBED POLICIES BE CAMDELLED BEFORE THE OWMTTON
DATE THEREOF.THE EBUMG MSUIMINN L BIOEAVORTO MAIL 10 `DAYS LN101Ir
. NOTMTO THE CERTIFICA-M HOLOM NAMED TO THE LEFT,BUT FAILURE TO 0080 SHALL
aeff H011Or'an IMPOSE NO OBLIGATION OR LtMLITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
6 IInion Street
Salem t4A 01970 NTATIIFS
AUTHORIZED REPRESENTATNE JWIj. nL `
MAX W. BetteCCU=t -
ACORD 25(20M108), .. OXCORDR MIFPION MS
2008-%252t28 WALSKMNJ IN 9787459557 Paget
�N CITY OF SALEM
a„ -Z1. It PUBLIC PROPRERTY
�� DEPARTMENT
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ri,i,978-745-9595 • hsx: 978.740-984G
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ` Please Print Leeiblv
VametOusiucs's/O/rBanizati�nn'7-l'nJlvi<luatl: YTD�ID/1/FnJ �d7��Oy✓//fll.�lf LL�,
Address: 7 l /—Q i/t v�d✓r+/f S�
City,State,Zsip:
\re you an employer? Check the appropriat ox: 'Type of project(required):
L❑ I am a employer with 4. Iffi 11 am a general contractor and I G. ❑ New construction
employees(full and/or part-time).' ave hires the sub-contractors
2.❑ 1 ;can a sole proprietor or partner-
listed off the attached sheet. : 7temodeling
ship and have no employees These subcontractors have S. Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
LNo workers'comp. insurance 5 We are a corporation and its
required.]
(((((( ______officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per NIGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Root'repairs
insurance required.] t employees. LNo workers' 13.0 Other
comp. insurance required.]
-any;yphca l that checks box 9l must also lilt out the section Wow showing Iheir wurkus'cumpenution policy information-
'I Iomauwtaxs who submil this affidavit indicating they are doing all work and then hire outside contractors must auhmit a new affdavit indicating such.
�Contncturs that check this box must atiwhcd.n additional sheel showing the name of the sub-contractors and their workers'comp.policy informatlun.
l am can employer that fs providing workers'compensation insurance fur ray employees. Below is the policy and job.vile
iufurirauun. /• ,r f�"`'( j7
Insurance Company Name: O r -T. jute e!UO l .._!XJS-
Policy it or Self-iris. Lio.r: __.... _. ._. ___.__ Expiration Date:
Job Site Acltln:ss: 2- CityiSlate/Zip: ✓���/ � D/f 70
.knach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of`IGL c. 152 can lead to the imposition of criminal penalties of a
tine up (If S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. He advised that a copy of this statement may be furwardod to the Office of
Invcstigalious of the DL\ 1'or insural:co coverage vcritication.
d do hereby certify under the pair itd penaltie.v ofperjury that the information provided above is true and correct.
S;c:,atone: -- -.._ M Date: IUD v � 7 zoos
O/)'ie•iud use only. Do not write iu this area,to be completed by city or town ojjiciad-
City or Town: _ _ . __ Permit/License k._--_-- -- ... ...
Issuing Aulhurity(circle one):
I. hoard of llealth 2. Building Department 3. Cit)ffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
G. Other
Contact Person: __._ Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fix their opiployees.
Pursuant to this statute, an employee is defined as"...every pel:son in the service of another under any contract of hire;
express or implied,oral or written."
An employer is defined as"an individual,partnership,associatiou,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,paitnership, associatiou or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall nor because of such employment be deemed to be an employer."
N1GL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally. MGL chapter 152, 325C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perforwnce of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
.Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
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 or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address" the applicant should write"all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Olticc of hivestigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF SALEM
yy�5
PUBLIC PROPRERTY
P�
DEPARTMENT
12, uAil V.t,:i,\11 It I:1 TO }AI lit. \L%Ii.\i ... :I I ,._I'/ _
11:1. 778-N?Ai95 • 1`.%X: 778.174 9841,
Construction Debris Disposal At'tidavit
(required Ibr 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 4 is issued with the condition that the debris resulting from
this work shalt he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
(nark(ilhauler)
I'lie debris will be disposed of in
(name ul facility)
(address of fhcilim
signalure of permit applicant
;late ----