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21 VALLEY ST - BUILDING INSPECTION
fhe Conunomvealth of Massachusetts Board of Building Regulations and Standards CITY OF \d7t Massachusetts State Building Code, 730 CMR SALENI Building Permit Application To Construct, Repair, Renovate Or Demolish a Revr.ved,thw 201 One-or Two-Family Dwelling This Section For Official Use Only ; Building Permit Number. Date,Applied: DuilJing Otliclul(Print Name).� gnatp .; . Date 1.1 Property Address: SECTION I SITUINFOR:iATION 2 1.2 Ass ssors Map&Parcel Numbers I.I a Is this an accep ed street? es� I O L3Z Y no Map Number Parcel Number 1.3 Zoning Information: �—�-------_ 9r-1 1.4 Pr Dimensions: Zoning District Proposed U" ��9 Lot Area(sq It)—' Frontage(11) 1.5 Building Setbacks(ft) I 'A I w Front Yard Side Yams Required Front Rear Yard Required Provided Required 9 Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Public Private ElZone: _ Outside Flood Zone? System: Check ifyes❑ Municipal❑ On site disposal system 2.1 Owner'of Record: SECTION2: PROPERTYOWNERSHIP1 nr� 1 yt? I V' in k-� S �d � � 41 me(Prinq Gty,State,Zip �— zo7 No m:J SIR�I Telephone L'mail Address SECTION 3: DESCRIPTION OF PROPOSED IVORK'(check all that apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration s Demolition Accessory g O,e Addition ❑ ❑ Accesso Bldg.❑ Number of Units .�_ Other ❑ Specify:Brief Description of Proposed Work': TCr w n tt t 9 A"r Lv7! IL w i' _ =—�I�'�"��S' G! e w:.t,,. ri,r 2! ✓In�i R SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only I. Building S C dA I. Building Permit Fee:5 Indicate how fee is determined: 2. Electrical S ZS� ❑Standard City/Town Application Fee 3. Plumbing < ❑Total Project Cost'(Item 6)x multiplier 3 s v a 2. Other Fees: S xyt �c 4. Mechanical (FIVAC) $ List: rYr/ 5. Mechanical (Fire _ Su ressiun) 'S Total All Fees:S 6. Tutal Project Cost: $ 21 t 6 d d Check No._Check Cash Amount:_ ❑Paid in Full O Outstanding Balance Due: SECTION j: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Ex Tau Date r License Number ; O G/ /210 S see below) Name of CSL Holder List CSL'rype g Val) -Type Description. No.and S1 Fet t) Unrestricted Buildin s u to 35,000 cu. IlJ /// r1.1 y�' g [Lesuicled t&2 F:unfl Dwelling r of % NI Mason Cltyll'uwn,State,LIP RC Rootln Coverin WS 1Vindow and Stain SF Solid Fuel Burning Appliances I Insulation p Demolition -- Et ail address 1 A Tele one 1�431-} 5,2 Regt feted Home Improvement Contractor(HIC) FIIC Registration Numbed s nation Date �C 110 4/ Sf v m y-Nmne or IIC egi r:!t�Name /y�/i Jl✓/hS t� r HIC Comp:20 V I& C: y� �I J �� Emuu auuress Nu.IV`trcett t n� '!'. — S . l Telephone Cit /Town,State, IP SECTION 6:WORKERS'CObIPENSATION INSURANCE AFFIDAVIT(M.G.L.r. 1j2.Q 2jC( 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 .......... SECTION7a:OWNERAU UM?;AT[ON,TOBE CON PLETEDWIIEN, OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1R � ✓ ✓1 C 1,as Owner of the subject properly,hereby authorize W Itcation. t9 act oft n behalf,in all matters relative to work authorized by this building permi pp i 1Z . / 3 n )tA�n ttt A� Date Pr Owner's Nmrle(E —'nfc Signature) UTHORIZED AGENT DECLARATION SECTION 76:OWNERt OR A By enterin my name below,I hereby attest under the pains and penalties of perjury that all of the information containe n this ap ationl#true and accurate to the best of my knowledge and understanding. Dane re Print Owner's or Authorize g*AEEE�TES : nhis/h HIC) Programa will not have access to the arbitration I. 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 Cutation on the program r gr nmusroaranty, fund under on the construction 0 Supervither sor Litant cense can be found at% �osn_ 4jp-S and at 2. When substantial work is pl u ned,provide the information below: finished basement/attics,decks or porch) (including garage, fi roml floor area(sq. ftJ Habitable room count Gross living area(sq. R) ,lumber of bedrooms Number of fireplaces Number of halt/baths Nunber of bathrooms Number of decks/porches Type of heating system Enclosed Open Type of cooling sy'stent 3. "lbtal Project Square Footage" nay be substituted ter,,Total Project Cost" CITY OF SUENMI NEASSACHUSETI-S ©UILDL\G DEPAR ..LENT 1-70 MASHCYGTON STREET, 3'FLOOR TEL (978) 745-9595 K1JiBEItI Y DRISCOLL Rux(978) 740-9846 AW0?; THOSLiS ST.PtaRRs DIRECTOR OF PUBLIC PROPERTY/BUM.DLNG COMMISSIONER 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 c 40, 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 disposal facility as defined by MGL c l 11, S 150A. The debris will be transported by: /) - l� (name oFhaulur) The debris will be disposed of in r (name of Facility) —__---(address of facility) . signature e,e,MI app ca t date CITY OF SALENI, NLNSSACHLSETTS t!^ i BUILDING DEPART>IENT R YT'crr r 120 WASHINGTON STREET, 3'D FLOOR TEL (978) 745-9595 F.A_K(978) 740-9846 KI\fBERLEY DRISCOLL ,MAYORT1aonlAs ST.PtF-RR& DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractor.,UElectricians/Plumbers Arinficant Information Please Print LeeiblY Maine (Busines&Organiratiowindiviclual): 1�p7\.9'4 Ns7 _�C � ✓�f-f Address: y63 l GI h f C City/State/Zip: Pie 4 6 Phone #: /a a / / �7 Are y u an employer?Check the appropriate box: Type of project(required): I I am a employer with 4 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 inn it sole proprietor or partner- listed on the attached sheet.t 7.10 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9• ❑ Building addition [No workers*comp. insurance 5. ❑ We are a corporation and its required] - officers have exercised their l0.❑ Electrical repairs or additions 3.❑ 1 am a hoincowner doing all work right of exemption per MOL I LEI Plumbing repairs or additions myself. [No workers' comp. C. 152,§1(4),and we have no 12•❑ Roof repairs insurance required.] t employees. [No workers' (;,❑ Other sump. insurance required.] -Any applicant Sur checks box NI mutt aleu 611 out the section below showing their workers'compensation policy inlbrmation. 'I lomeowtxns who submit this affidavit indicating they arc doing all work and then hirC uutbidC contmct°rs must submil a new of idavil indicating such. $:,,mmctors Ihul chcck This box mug anached an additiutul Sheet showing Ihe nwne of the subwuntnclorb and their workera'comp.policy infosnution. I um an employer that is providitrg workers'eunipeusadou insurance for my ernpla},ees. Below Is the policy and job site itrfornration. Insurance Company.Name: t'l7 Policy#or Self-iris. Lic. #: 0Ai kt Ae4 2!44 �_— Expiration Dale: 4G�o3 ' Job Site Address: 2t u+9 I [rd C / City/State/Zip: -f.Q J7 ,,u rH 1.1 Attach 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 ot'&IOL c. 152 can lead to the imposition of criminal penalties ofa fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a day against the violaror. Be advised that a copy of this statement may be forwarded to the Office of Invesfigutionsofthe Dl for insurance coverage verification. 1 do hereby cer ' tide the pains amdVenhi s f perjury that the inforrrmtiaa provided above /ss�'s it a and correct. si,"n I Phone Official use only. Do not write in this area,to be completed by city or town off chil City or Tuwn: Permit/I.lcense# Issuing Aulhur4y(circle one): 1. Board of Health 2. Building Department 3.Cityffown Clerk 4. Fleetrical Inspector 5. Plumbing Inspector 6.Other _..__.. Contact Person Phone#: [ THIS RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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 endorsement(s). CONTACT IRooucER Phone:978-7453300 NAME: ohn J Walsh Ins Agency,Inc Fax:978-745-9557 PHONE o ER- FAX ,O Box 4407 A/C No): Salem,MA 01970-6407 ADD'EBB: )avid C Bruett CUSS°oMErs ID p:9SQU101 INSURE $ AFFORDING COVERAGE NAIC N NSURED Howard A.Squires INSUAENA:Northland Insurance Co 8 Valley Circle INSURER8:Hartford Peabody, MA01960 INSURER C:Commerce Insurance Company 34754 INSURER D INSURER E MSURER 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 THEPOLICIES DESCRIBED.HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR gun POUCY EFF POIJCY EXP UMITS LTR TYPE OF INSURANCE POLICY NUMBER MWDDrfYYY MIND GENERAL UASIUtt EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL S177866 06/03/2013 06/03/2014 PREMISES Eaoccurrence $ 100,00 CLAIMS-NMDE O OCCUR - MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ 2A�A0 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea acddent) ANY AUTO BODILY INJURY(Perperson) $ 100,00 ALL OWNED AUTOS BODILY INJURY(Per acadenl) $ 300,00 C 9RETENTION AUTOS RXQ118 07/1712012 07/17/2013 PROPERTYDAMAGE $ 100,00 (Peraccident) S $ D AUTOS g LIAB OCCUR EACH OCCURRENCE $ R CLAIMS-MADE AGGREGATE $ S E $ WC STATU- X OTH- WORKERS COMPENSATION AND EMPLOYERS'LIABILITY 06I0312013 O6/03/2014 500,000 B ANY PROPRIETOR/PARTNERIEXECUTNE Y� NIA 08WECAA2945 E.L.EACH ACCIDENT $ OFFICER/MEMSER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ SOO,OO (Mandatory in NH) $00,00 If yyes,descn"a under El-DISEASE-POLICY LIMIT $ 0 SCRIPION OF OF ERATIONSbelay DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,AddIdooal Rema*s Schedule,H more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Howard Squires ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE / ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 1�