13 VALLEY ST - BUILDING INSPECTION GEIVE�
The Common 7Rev4edVhjr
On'
Board of Building Regulations and Standards 2
Massachusetts State BuildinaLMSc1%V0.�IvIU. la �
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fctrnily Divelling
n This Section For Official Use Only
1, I Building Permit Number: Date A lied:
(-n Building Otticial(Print Name). Signature- Date
SECTION t:SITE INFORNIAT10N
1.1 Property Add s: 1.2 Assessors 6lnp&Parcel Numbers
�J I.I a Is this unaccepted street?ye — no Mop Number Parcel Number
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 YnZone?
Rear Yard
Requimd Provided Required Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone In1.8 Sewage Disposal System:
Zone: _ OutsiMunici al❑ On site disposal system ❑Public❑ Private❑ ChecP
SECTION2: PROPERTY OWNERSHIP,
2.1 Owner of ec rd: i A lot
tiD� rint) City,State,ZIP - F'
No.and Street eleph�T Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check al at apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)01 Alterition(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
ILI
SECTIOi ESTIMATED CONSTRU TION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building 3 I. Building Permit Fee:$ Indicate how fee is determined:
[3Standard City/Town Application Fee
2. Electrical 3 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S !!,gther Fees: S
d. `Iechanical (1-IVAC) $ List:
5. Mechanical (Fire S Total All Fees:3
Suppression)
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S 131y) ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cmtst vet' a.�,ervis ljcettse(CSL)
ILicense Number Espira on to
Name ofCSL Holder list CSL'rype(see below)
Type . ' - Description
NU. i
U Unrestricted(Buildings tip to 35,000 cu. ItJ
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
ItC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
le phone Email address D Demolition
5.2 Registered H r Imp ov tractor HIC)
HIC Regis ipruo4n iale
f1IC�ie t 1 0Ll(� _
Nu. at t Email address
Cit /Town, late ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.12510(6)).
Workers Compensation Insurance affidavit must be complete submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of uilding permit.
Signed Affidavit Attached? Yes ........"❑ No........... Cl
SECTION To:OWNER UTHORIZATION TO BE COMPLETED W HEN
OWNER'S AGENT OR CONTftA&OItAPPI40 FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by`Tftlr5uildinj permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my n. e b eA61ift's
by attest under the pains and penalties of perjury that all of the information
contained in this pplic and curate to the best of my knowledge and understanding.
Print Owner's o thr r ze ;one(Electronic Signature) Date
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(1-11C)Program),will nut have access to the arbitration
program or guaranty, fund under IM.G.L.c. I42A. Other important information on the HIC Program can be found at
.vwcv mass.cov:'oca information on the Construction Supervisor License can be found at wvvw.mass.',ov/dos _
2. When substantial work is planned,provide the information below:
'rotal fluor area(sq. R.) s t(including garage, finished basementlattics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'type of heating system Number of decks/porches
1'YpeofcoolingSystem Enclosed Open_
1. "total Project Square Footage"may be substituted for"rotal Project Cost"
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CANC'ELI.ATION: CUSTOMER MAY C'ANCEI. THIS
AGREEMENT\TITHOUT PENACII'OROflLif.AT10N
fl\'IH:LI\'ERI.N`G N'RITFF.N NOTICE.TO THE HOME
UERIT HY NIIDMGIIT ON THE THIRD flUSIN`SS
lt.\\' AtTEN tiiGNAG 'NITS At RF.FINIE.NT. 'TILL:
STATE Slll•RJLn1EN1' ATTACHED HENETII
COMA AIMS A FURAI TO USE IF ONE IS
........-o...r.-u nr I.AAV IN
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The Commonwealth of Massa�h7teffs
Department oflndustrialAccidents � 1�
ogee of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017 -
wwKmass.gov/dia
Workers'Compensation Insurance Affldavit:Buflders/Contra rs/Electriciaus/Plumbers
Aimlicant Information Please Print Legibly
Name (Businesslorgmizffdodlnaividual):
Address:
Ci /S 1 : e#:
Are an employer?Check the appropriate box: Type of project(required):
- v 4. ❑ I am a general contractor and I
1 i am a employer with / }eve hired the sub contractors 6• ❑New construction
employees(full and/or part-time). 7, Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet ❑ g
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees end have workers' 9. ❑Building addition
[No workers' comp.insurance comp•insurance.,
required.] 5. ❑ We are a corporation and its
10.gi
lectrical or additions
3.❑ I got a homeowner doing all work o>fic�have exercised their 11. ing repairs or additions
myself. [No workers' comp. right of exemption.per MGL 12. 00f repairs
insurance required.]I c. 152,§1(4),and we have no 13.❑Other
comp.insurance required.]
*Any applicant am cheolm box#N in=also fill om the section below showing thdr walmn'compa mdoo Poiiey infamrstim-
t Homeowners who admit this affidavit indicating they are doing all work and then hire outside oaatmawn must submit a new affidavit indicating such. .
tContrecton that check this box moat attached an additional shear showing the name of the wb comactam and gate whether or not those entities have
.employees. If the sub-contractors have employees,they must provide their woken'comp.policy number. -
I am on employer that i4 providing workers'compensation insurance for my employees. Below is the po&7 andlob site
information
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy.of the workers'compensation Ifellcy,declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of it
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to$250.00 a 4kagamirt the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of e D A forinsprence coverage verification.
I do hereby ce fy u th ai a penalties ofperfury that the lnformadonprovlded above is tr a and correct
Sism
Official use only. Do not write in this area,.to be completed by c*or town allleiai
City or Town: Perndt/Liceuse#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Ctty/Town Clerk C Electrical Inspector S.Plumbing Inspector
6.Other '
Contact Person: - Phone#:
a��® CERTIFICATE OF LIABILITY INSURANCE
DATE(mnvoom^n)
E. ,
S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEN1111812014
D OR ALTER THE COVERAGE AFFORDED CERTIFICATE
THE POLICIES
OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INS URER(S), AUTHORIZED
RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
ORTANT: If the certificate holder is an ADDITIONAL INSURED, the poncy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
ificate holder in lieu of such endorsement(s),
ER -SH USA,INC. CONTACT
ALLIANCE CENTER NAME:
PHONE . AXLENOX ROAD,SUITE 2400 C ° IAXNTA,GA 30325 E-MAIL
ADDRESS:
omeD-GAW-14-15 INSURERIS)AFFORDING COVERAGE NAIL INSURER A:SIealast Insurance Company 26387
T-HOME SERVICES,INC. INSURER a:Zurich American Insurance Ca
SA THE HOME DEPOT AT-HOME SERVICES -- 16535
2690 CUMBERLAND PARKWAY,SUITE 300 INSURER C:New Hampshire Ins Cc 23641
ATLANTA,GA 30339 INSURER D:Minds National Insurance Company - 23817
INSURER E:
COVERAGES CERTIFICATE NUMBER: wsuRERF:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE ETENS SUED TO THE INSURED REVISION
ABO EB OR.THE POLICY PERIOD
INDICATED: NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT THE IN U DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS,
EXCLUSIONS ANDO ONDITIONS OF SUC
NSR H POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
S LIN TYPE OF INSURANCE POLICY SEE POLICY EXP
A GENERAL LIABILITY POLICY NUMBER MMIDONYYY MMIDDIYYYy
- GL048877i4-04 LIMITS
X 03/012014
COMMERCIAL GENERAL LIABILITY CURRENCE $03Po12015 EACHCC 9,000,0M
A AG T RENT D
CLAIMS-MADE M OCCUR LIMITS OF POLICY XS PREMISES Ea occurrence S 1,000,000
OF SIR:$1M PER OCC MED EXP(Any one person) $ EXCLUDED
PERSONAL BADVINJUN s 9,000.000
GEN'LAGGREGATE UMITAPPLIES PER: GENERALAGGREGATE $ - 9,DD0,000
X POLICY PRO, LOC PRODUCTS-COMP/OPA G $ 9,000,000
B AUTOMOBILE LIABILITY SAP 2938863.11 $
03/0120A 03/012015 COMBINED SINGLE LIMIT
X ANYAUTO - Ea accident $ 1,000,000
AUTOS SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per Pelson) $
AUTOS
HIRED AUTOS NON-OWNED BODILY INJURY(Per accident) 8
AUTOS PROPERTY
O M
PER DAMAGEPer $
UMBRELIA LIAR OCCUR $
EXCESS LVt8 CLAIMSMADE - EACH OCCURRENCE $
DED RETENTIONS - - AGGREGATE $
C AND EMPS.COMPFNSATION ., WC0 4 91 01 8 82 AOS $
C AND EMPLOYERS'LIABILITY ( ) 03/012014 03101/2015 WC STATU- OT&
ANY PROP RIETOR/PAFITNER/EXECU YIN
TNE ( )WC049101884 AK ITS
D OFFICERlMEMBER IXCLUDED7 NIA 03/012014 03l012015
(Mandatory In NH) WC049101883 E.L.EACH ACCIDENT $ I'llwo00
FL
It as,de scribe under ( ) 03/0120M 031012015 -DE SCRIPTIONOFOPERATIONSbelav E.L.DISEASE-EA EMPLOY 8 10f0000
C WORKERS COMPENSATION EL.DISEAsE-Ppucv UNIT E -000,000
C
WC049101885(KY,NO,NH,VT) 031012 2015 (EL)LIMIT 0M 03/01 1,000,000
WC049101886(NJ) 03/012014 031012015
I
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks Schedule,N more space Is required)
EVIDENCE OF INSURANCE
I
I
I
I
CERTIFICATE HOLDER I
CANCELLATION
FEFERR
ICES,INC.
POT AT-HOME SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIE58E CANCELLED BEFORE
ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
_ ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
Of Marsh USA Inc.
Manashi Mukherjee _34 N':.;le_.
/
-GsvFrrzr ,-ffa ia`nand B Hahne
. a
10P:3s l a � ite li0
73o ton, l'�l ss3 311>zse#? Uhl 16
Horn Improvement Contraewr Registration
Type: SppLumeni Card
THD AT HOME SERVICES, lK. '
2890 CUMSMiRAlf3 RAAKWAY SUITE 300
ATLANTA GA.30339 __.. _... —
Update Address ind refm ear&m2rk reeran For chnge.
. . . - ' -. Addy= : j Sznwz3) � Emp9g;mnl r-., Zn3,CA;d'""L- �:9oI CORM tT A4aias'Es 1lasInes.Aauladn3 LiC'ti m or Y-W, MOOD YaliJ for lndivld"ll Iasi Only
?sg�
Cy. , e� •m, il.3
ore the b'.a8:mndate. IfiCroncda eaTrata:
+"i CP,dxE�1P'{`s191u.4�7�ASTC7�d7FAL..,.�' (9�useers6a.oaa�� vA, 'e3emetLE;sine:;�F' grlatica
E 6t sIs?ratluw .•126M Type: iIO vnrk I''- 5zx is 797S
'Pitpii•Aofi--_irwblFs SuppleimnECard Roma, Is.
11D! T HN,I StFdVICEM,wG a 1,
. .
'Y HE HCYVti1�DEFOfi AT tIDWSi $EK24'IGES
,%k, A+b ki6mE
?Ggb CUMJ Ei L D'PARKWAY S
C,3,OM* Gnderac,eWcy- - .. at iv th a 3 .2
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QTY OF SALEM, MASSAQHUSE M
a
BUILDING DEPARTh ENT
120 WASHNGTON STREE T,3')FLWR
TnL.(978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMM ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUIIAING CpMMSSIONER
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
VI►
(address of facility)
ignature of a plicant
e