17 VALLEY ST - BUILDING INSPECTION TI3-
CIA The Commonwealth of Massachusetts PSPECTIONAL S RVIAFr ,oF
!� Board of Building Regulations and Standards SALEM
�"t I Massachusetts State Building Code, 780 CMR�'�SEP h2 1 it 2011
I ,.
Building Permit Application To Construct, Repair, Renovate r emolis a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: DateA 'edr
Building Otiiciul(Print Name). Signature- . . Date
SECTION t:SITE INFORMATION
LI- operty Address: 1.2 Assessors Map&Parcel Numbers
1 v�lle14 ST
I.I a Is this an accepted street9 yes_ no
Mop Number Parcel Number
1.3 'Zmdng Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Q) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.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 es❑ P y
SECTION2: PROPERTY OWNERSHIP!
2. w er of Record
NN me(Print) City,State,ZIP
l7 l,Cn �.!ct� S/
No. and Street � Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Ownccupied ❑er-O Repairs(s) Aitemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Des cription�fProposedWork': ur'H
SECTION 4: ESTIhIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Mtaterials)
I. Building S Clla I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S 3 ❑Total Project Cost'(Item 6)z multiplier s
3. Plumbing S P tither Fees: S
4. %lechanicol (HVAC) S List:
5.i\kchanical (Fire ,) Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:
G. 'futal Project Cos[ S 2� ❑Paid in Full ❑Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Liceilse(CSL) ln6 (oZ G
26��v �`//6u License Number Expru on Date
Name of�r List CSL'rype(see below) V
4 2� Type Description
No.and Street ., r
�pp� d/9 z3 U Unrestricted(Buildings u to 35,000 cu. tl.
r T N lr'Pi(S I/� Iq - R Restricted 1&2 Family Dwelling
Cily/ruwn,State,"LIP ibt Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Bruning Appliances
1 IDemolition
Insulation
'rcic hone Email address D
5.2 Re stered Home Improvement Contractor(HIC) � SrY
/ / �o
fe/O�s t�L�rSF✓Lf `t t U Q Ale HIC Registration Number �t=Date
11 Cunip:uir��yName or HIC Reyistmnl Name
/ram `Sn ;�
o. , d Street �2. (�--Y�_��Q7�� Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c, 15Z.$ 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 67 n.S1n-c{"', >lC
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
7z
Print Owner's Name(Electronic Signature) I Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
--7 �� /�w� i
Print Owner's o�thorized Agent's Name(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(HIC)Program),will not have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
iaww.m;rssArov'oca Information on the Construction Sipervisor License can be found at www.niass. ov'dL
2. When substantial work is planned,provide the information below:
Total fluor 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 o0cating system Number of decks/porclies
Type of cooling system Enclosed Open_
i. "Total Project Square Footage"may be substituted For,,Total Project Cost"
- 1 DATE(MWDD/YYYY)
A�v� CERTIFICATE OF LIABILITY INSURANCE 7/29/2014
c THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
J CERTIFICATE DOES NOT AFFIRMATIVELY OR 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: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the
terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements .
PRODUCER CONTAC
Lauranzano Insurance Agency NAME: Berkley Assigned Risk Services
UNt e
107 Dodge St nrc.No.E . (800)634-4589 INC.No.). 866 215-8118
Beverly, MA 01915 ADDRESS: PolicySeNices@berkleyrisk.com
INSURERS AFFORDING COVERAGE NAIC#
INSURER A: Acadia Insurance Co. 31325
INSURED
Zachary Fellows INSURER e -
PO Box 155 INSURER C:
NSURER 0:
Danvers, MA 01923 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN SR TYPE OF INSURANCE A UL UB POLICY NUMBER POLICY FF POLICY EXP LIMITS
LTR INSR WVD MMIDDIYYYV MMIDD/YYYV
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
PREMISES Ea occurrence
❑ CLAIMS-MADE ❑ OCCUR ❑ ❑ MED EXP(Any one person) $
PERSONAL B ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGO. $
POLICY ❑ PRO-
JECT ❑ LOC $
AUTOMOBILE LIABILITY ❑ ❑ OMBLIMIT $
Ea accident)
ANY AUTO $
BODILY INJURY Per person)
ALL OWNED SCHEDULED AUTOS
AUTOS ❑ SO D ILY IN J U RV Per accident) $
HIRED AUTOS El NON-OWNEDPROPEDA MAGE
AUTOS Per accitlenRTYt $
❑ $
UMBRELLA LIAB ❑OCCUR ❑ ❑
EACH OCCURRENCE $
EXCESS LIAR ❑CLAIMS-MADE $
AGGREGATE
DIED ❑ RETENTION$ $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER
ANY PROPRIETOR/PARTNERIEXECUTIVE E.L EACH ACCIDENT $ 100,000
A OFFICEIMEMBER EXCLUDED? El N/A ❑ WC-20-20-004793-01 05/24/2014 05/24/2015
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 10D,0DD
f yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Election Category Election Status Name All Entities/Insureds:
Sole Proprietor Exclude Zachary Fellows Fellows
CERTIFICATE HOLDER CANCELLATION,
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City Of Salem _ THE EXPIRATION DATE THEREOF, NOTICE WILL.BE DELIVERED IN
Salem ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, Me 01970 AUTHORIZED REPRESENTATIVE
Signature:
ACORD 25(2010/05) BRAC 3139
Q-1-Y OF SALEM� NL-1SSACHUSETI'S
� sr
BL:Uml lG DEPARTNW—NT
3 �tiaab�3 1 120 %VASHLNGTON STREET, 3w FLOOR
TFL (978) 745-9595
F.L.�c(978) 740-9846
ICI N(gERLEY DRISCOLL 7�loot�s ST.PI>raRs
",kAYOR
DIRECTOR OF PU13LIC PROPERTY/BUILDING CO%L f1SSfONER
Workers' Cmnpensation Insurance Aird'avit: Builders/Contractors/Electricians/Plumbers
Anplieant information Please Print Leeibly
Naive(DusinusDOrganiraliom(nLlividual): . �4c4N sz r/ofc-�
Address: F e L,), _o x /Sn [�
City/State/Zip: �a9ti�a'C 4l D/ rhone ff: / 7% - X 7 "0 ?Pe
Are you an employer:'Check the appropriate boa: 'rype of project(required):
I.❑ I am a cro to er with 4• ❑ I am a general contractor and 1
P Y b. New construction
yuployces(full and/or part-time).• have hired the sub-contractors
� I am a sole proprietor or partner- listed an the attached sheet. ) 7. ❑Remodeling
y
ship and have no employees These sub-contractors have B. ❑ Demolition
working for me in any capacity. workers'camp.insurance. 9• ❑Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.❑Electrical repairs or additions
required.]
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[10 workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.1 t employees.(No workers'
comp. insurance required.] I3.❑Other
-Any applicum dtar checks box of most also fill out the secliun bdowshowing their woskrn'rumpenuifw pulisy intumrmtun.
'I lomauwm"whu.wbmit this amdnvir indicating they am doing all work and then hire outside caonctrsn mrut suhmit a new amdavit indicting such
a'emnwtun thin chstk this box mot atachaf an additiurui shawl showing nut none of the sub<antn000 and Ill elr woken'comp.pulley information.
l am un eutpluyer ilia!is pruvidiii )porkers'cuniperrsatlun htsurancefor my employees. Below/s Ilia poll y aedfob silo
Information. //��
Insurance Company Name: C o t-/ S�,r4✓r e3 /J5
Policy it or Srif-its. Lie. 0: 70 60.> Expiration Dote:�• �� I 2Y IE
Job Site Address: l7 LJ c do y' l City/State/Zip: _S4 Ll"
t
\ttach a copy of the worlren'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as w'cll as civil penalties in(he form of a STOP WORK ORDER and a line.
of up to S25000 a day against the violator. De advised that a copy of(his statement may be furwardcd to file Office of
In%esnilutiuns dhhe MA for insurance cnvcrnge verification. -
l du hereby eerily un of the putts asd penulrles of perjury that ilia infurnrutiau provided above J•true rued correct
Sin I c c� Dale:
phone 4 p >
011fciul use only. Ou not mite in dsis area, to be completed by city ur town n/Jlelul
l
City or ru+vn: __- Pcrmir/1.lcenscp__._..__. ..___..
Issuing Authority(circle one):
I. board of tleallh Z. Buildlnq Department 3.Cilyrruwn Clerk J. haeetrical hupcdur 5. Plumbing Ltapeeror
6.Other
I i
rhooe:
QTY OF SALEM, MASSAMUSEM
'IftJ} ;I BUILDING DEPARTMENT
120WASHNGTON STREET,3ftDFLOOR
TEL. (978)745-9595
KIMBERLEY DRISOOLL FAX(978) 740-9846
MAYOR THomm ST.nERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMNIISSIONER
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:
a z- E
(name of hauler)
The debris will be disposed of in:
(name of facility)
ty1111 �-/
(address of acility)
z
natur of applicant
Date
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
CoLS
upen isor
Li106626 t_en c „ZACHARY 304 MAPLDancers M Expiration
C 04/11/2016'
i ' ce of ConsumerAfamBlt.u/rs i on�es�s Regmualactliouina'
MIMPROVEMENTCONTRACTOR
Vje',11gistration: 175456 11 I%* tType:vation
el-
ta
-_50312015 s Individual
EL
ZACHARY FLOWf�`— t"
ta, 34y1 .
1
ZACHARY FELLOW
3 ROOSEVELT
I BEVERLY,MA 01915 Oodersecretary. j
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