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26 VALLEY ST - BUILDING INSPECTION I'lie Commonwealth of Niassachusetts O1 --Board of Building Regulations and Standards CI1.1. OF Is) Massachusetts State Building Code. 73Q C'hIR SALEM Building Permit APplicdion TO C-0I15(rnct. Repair, Renovate Or D• u i h a One-or ris o-kantilY Dnrllin. This Section For Official Use Only Building Permit Number. \p Building Oliicinl(Print Nwnv� Siyttalurc U ie SECTION 1: SITE INFOR'SIAT40N Ll Property Address: 1.2 Assessors Slap aft Parcel Numbers I.la Is this an acce ted street? es no INIap Number Parcel Number 1.7 Zoning Information: 1.4 Property Dimenslons: Zaning District Proposed Use Lot Area(sq It) Frontage(111 1.5 Bullding Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G................1.e. qU, §3q) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood 2, Municipal O On site disposal system ❑ Check if yesO SECTI0N2: PROPERTY OWNERSHIP' 2.1 Ow ert of ecor , 9 n[O.)5 E'Lrrr S% %f. Ni fine(Print) C ily.State,zip n( r iiz y7q- 7`1S- 7yll No.❑id Street J relephone Email Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ AMOAddaion Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Spcci Brief Description of Proposed Work-:_ 6 SECTION 4: ESTIMATED CONSTRUCTION COSTS liens Estintated Costs: 0111c1a1 Use I Laborand .\faterials) 1. Building S Z C90 I. Building Permit Fee: S Indicate how fee is determined: 2. Llectrical SV,0(0) ❑Standard Citffown Application Fee ❑Total Project C'usl'I liens 6)x multiplier .1. I'lunthiny S1. Other Fees: $ J. M"11.utical ill\.W) SList ' 3. \lech.mical tFin �u ue>siont Srot:d .\II Fees: 5 ('heck \'u. ('heek Allio utt: _ l'.uh \relent: n Total I'rnject Cost: S ❑ Rud in Full 13 Outstanding B.tLutce Due: r SEC CON S: CONS'1'RUCTH)N SF.RVICF.S 5.1 (`onstructiun Supervisor License(C'SI.I I-a l �- -'3 ! /1 -L 3 I icen,e Number f\pvatwo 1);Ih: Nanw ul l'SI. HulJcr 1iSlCSI. I)pe(ice helut\1,__._--__—.._ - 7- ---'----J ._-- - `--'-- 'I)pu no I)cicripliun No. and tirrcet U (4vcslrideJ I IluiWin 4s Ii p1 15.11110❑1. 11.1 y✓_l 6 ��. _._-,_ li Re,tricled IlC� P.Imil 11-41in w City oa n,Rtate.LlP %I Mason KC' HtMdin C'orerin _ N'S R'induw m-1 cidin � SF Insul FuelIhlrning \ppiiances 6 I Insulation I'ctc hone Fn1ui1 address U Demolition 5.2�Registere flume Improvement Contractor(HIC) I lf�iv/ �esTtf B 1✓ 5 IIIC Itcli6tr Lion Nunllwr lisp Ale 14C4 lay,) a�e ur III It e istrunt Nume l )C� /( -6 -7 Nu. ;uyl Slrcct�� ��I et" dv �. ,?/2- Yl/7� 0 2 Lmall address T— Ci (Town, State ZIP Sr A "rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152. 1 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...........O SECTION 7s. OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. P4>,&-rT6-f e--(S S M-t—L^ er 7 Zo I'rinl Uwner's Nwne(Electronic Signalurc) Date SECTION 7b:OWNEW 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 ap%p�li�c(pyt�'on�is(/t`Sue a ccurate to the best of my knowledge and understanding.,_ •� Print Uwner's ur:\ulhuriied,\belt`'+Nan h.lectr .tilynaturo) 1 )t-4- U'> ZP� No'rES: I. .\n Owner\shu obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor Uut registered in the Hume Improvement Contractor(HIC) Program). will no have access to the arbitration program or guarmty lund under M.G.L.c. 142A. Other important information on the HIC Program can be round at l Information on the Construction Supervisor License can be round at \\'hen substantial murk is planned, pro\ide the infunn.10on below: rota) floor,area 114. 11.1 _ _--___I including garage, finished basement attics.Jerks or porch) (',rossli\ingareal sq. 11.) habitable room count \umbcrol'tircl1laccs Number ofhednnnms .. .. . . \timber al hathroom4 Number of Half hauls I)lie ol'hcatingsystem - . . Nwmherofdecks, porches I. "Ioial Prltivo cquare Footage-nta\ be substiuucd tiv'*I'ol;d Project Cost" <: CI-I'Y OF S,U-Eml AkSSACHUSE"ITS s BUILDING DEPART>(EtiT 120 %V.NSNLNGTON STREET, 3iD FLOOR TEL '978 745.9595 FAx(978) T$0.9846 j.N113 R[ FY 0RISCOILL THotL"ST.PIER" Ntkyoa DIRECTUROF PUBLIC PROPERLY/BI:R.Di\G CO\LAl15SIONER Workers' Compensation Insurance AITIdAvit: Builders/Contractor-/Electr(chnslPlumbers A : :llcant In Awm•rtion ^ Q /^?_ lase Print Leaihll Name IRusina.c, Organ ualimv lmliv iidueal.,)� ✓/9/y✓— aat 51 -4eav \]dress: C�/// / s / �� r�� c� City/State/Zip: PhoneIl: tire you an employer!Check the appropriate box: 'type of project(required): yr�xl am a employer with 4.. 0 I am a general contractor and 1 6. ❑Now construction L employees(roll and/or p .• have hired the suit-contractors 2.0 lama sole proprietor or parinur. listed on the attached wheat. i 7• ❑ Remodeling ,hip and have no employees These sub-contractors have 8. ❑Demolition workingrbr me in an ca ocit . workers'camp.insurance. 9. Y P Y ❑ Building addition [No workers:comp,insurance 5. ❑ We are a corporation and its required.] . o.Meant have exercised their 10.0 Electrical repairs or additions 3.0 I am a homeowner Joins all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(Na workers'comp. C. 152, 11(4),and we have no 12K'Itoof rapaits insurance required.l r . employees.(No workers' Gump. insurance required.) I 13•0 Other •.\ray appII,am OW Omits but rl mist ales all out the vetim butaw.hawine their"ken,compensation pahey mn,rmotlon. 'I Lenuuwtate wha wbmil this 11:IMvit indivaine they an doing ilt wvra and Ili=hire ou4ida eantmeron m,,I mhmit a now anldavil indicating suck :r,.mnrlun thal rhwk this box must mxho l an uldtauntr.heN,huwing ilia nwne of the lubsunlrutem and their woAgea'wrap,pulley inromtadaa. 1 am an employer that It provfding ivorken'campautrallon Laurance for my employees, Below/a Ilia policy and Jab W. irrjarnrudnn. In,ur;utca(:nmpany Vame: �i I'nlicy Our Self-inn. Lie N: /Y/�/nI �Q_P_(,7 1 l _ Expiration Date: lab Site Address: �1� V�I t!I�` s� Cilyistute/2ip: Attacb a espy sal the workers'Compansa I(on polley declaratlan page(showing the policy numbar and oxplratloa data). Ktiluru to wcura coverage as required under.Section 25A of NtGL c. 1.52 can lead to the impositian of criminal penalties of s tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to M0.00 a dry against the violator. Re advised that a copy of this.,latcment may be furwardud to ilia Oftica of Luv,iigatiuns ofthe 01A for insurance coverage vcriticatiun. /do hereby errs rm 6 pabrr mid prnulllre ajpvrjury/hut the is/unrruNwr provide]above/e/rat and correct _�.:r•,ttuc' •p `� 11Ira: I'd-0 l7//icral rue,mly. /7a oar,ware in ihiV area, to St cmuplettJ 5y city u/sown a�/trio[ (:icy nr ruwo: _ __ _ ___ PcrmiuLlcctae i h,nin,• tilhorily (circle one)) I. Iloord of Ilcallh 1 Iluildinq Veltartment 1. ("ily,Town Clerk J. h:hctric.tl 6ul,cctor i• I'htnthinq lutpector G. lhhcr l CITY OF S.u.&al, NWS.ICHCsms t3l'tLDLVG DEP.tATtE\T I '0 WASHLNGTON STXW, 1'4 Ftccl rM k973) 743.9595 KIMBEALEY DUWOLL P.kx(97� 740.9 84d MAYOR MONIAll ST.?MR" DtiscraA OP PC sue PROPEATWatanme,CmallSSIO.V EA Construction Debris Disposal A111davit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section I t 1.S Debris, and the provisions of,blGL o 40, 3 54; Suildin Permit M g is issued with the condition that the debris resulting from INS work shall be disposed of in a properly licensed waste disposal facility as defined by aNIGL c I 11. S I30A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name o(ratably) I,ddnrr or nt+l„y) +yn�Nte or permit ipphcanl !ue 06/07/2012 THU 9: 35 FAX Farquhar and Black 0001/001 A� CERTIFICATE OF LIABILITY INSURANCE 6/7/20�2"" THIS CERTIFICATE 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). PRODUCER CONTACT Christopher Kennedy Farquhar & Black Insurance Agency, Inc. AICNE. 1 (791)599-2200 qAC No: (7e1)581-3990 85 Exchange Street - Suite 101 EMAIL Chris@ FandB Insurance.com ADDRESS: PRODUCER 00031899 CUSTOMER to 0 Lynn MA 01901-1475 INSURERS)AFFORDING COVERAGE NAICi INSURED INSURERA:Essex Insurance INSURER Clemens & Sons Construction & Roofing Inc INSURERC: 44 CLiff STreet INSURERD: - INSURERE: Lynn MA 01905 INSURERF: COVERAGES CERTIFICATE NUMBER:Salem 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADOLSUBR POLICY EFF POLICY EXP LTR INSR MD POLICY NUMBER (MMIDDIYWY) MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ex occurrence $ 50,000 SMi A CLAIMSMADE FOCCUR DG3766 /17/2011 /17/2012 MED ENE A,.,epers.n) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE .$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO $ 2,000,000 X POUCY PRO LOC '$ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ee accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED AUTOS BODILY INJURY(Per eecidenq $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ _ $ WORKERS COMPENSATION WC STATU- OTH- ITER AND EMPLOYERS'UABILY YIN V T ANY PROPRIETOR/PARTNENEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in Ni E.L.DISEASE-EA EMPLOYE $ Ryes describe under OESCRI PHON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Workers Compensation policy in force with ACE Group effective 9/23/2011 to 9/23/2012- ACE issuing certificate also CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 93 Washington Street AUrHORIZEDREPRESENTATIVE Salem, MA 01970 C Kennedy/CPK ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD nTi;nzrax no-/ iV/g1zV11 ( :V0: .s1 AM IAur. Z/UUI rdX Bervul . ACORD. CERTIFICATE OF LIABILITY INSURANCE 1 010 4 2 01 1 THIS CERTIFICATE IS ISSUED A$A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVFLY 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:lithe certificate holder ism ADDITIONAL INSURED,the pcifty(ies)must be endorsed. It SUBROGATION IS WAIVED,sutgect lathe terms and conditions of the policy,certain policies Inny require and endorsement. A statement on this certificate does not canter rights In the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX FARQLTIAR&BLACK INS (AC,No,E.C: FAX (A%C,Nol: 85 EXCI JANGF.S'I' EMAIL ADDRESS: PRODUCER 7:YNN.:MA 01901 CUSTOMER 10 DTI INSURER(S)AFFORDING COVERAGE PIANO INSURED INSURER A: ACEATIEIdICAN LNSURANCE CONIPANT INSURERS: CLENfENS&SONS CONSTRUCTION fi ROOFING INC INSURER C: INSURER D! 44 CLIFF STREET INSURER E: LYNN,NIA 01905 INSURERF: 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 CONTRACTOR 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. INSR ADOLSUER POUCYEFFDATE POUCYEXPOATE TYPEOFINSURANCE POLICY NUMBER IMMOMYYYY) (MMDOIYYYY) LIMITS LTR INSR WVD GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISES(Ea occurrence) MED EXP IAny one{ierson) $ PERSONAL RA ADV IPLURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOG PRODUCTS COMP OP AGG S AUTOMOBILE LIABILITY COMBINED SINGLE S ANY AUTO LIMIT;Ea.I,ddenO ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per persml) HIRED AUTOS BODILY INJ URY S (Per accident) NON OWNED AUTOS PROPERTY DAMAGE 5 (Per accdent) UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS MADE AGGREGATE S DEDUCTIBLE $ RETENTION $ $ WORKER'S COMPENSATION AND EMPLOYERS LIABILITY YIN UB-1'9OP 15941 092/121111 Opi23:2012 E L.EACHACCIDENT $ 100.000 ANY PROPERITORTNRTNEMEXECI-I Y E.L.DISEASE-EA EMPLOYEE $ 100,000 OPITCERIH.E.MBEIR EXCLUDED" (Mandatory in NH) - E.L.DISEASE POLICYLIMiT $ 500.000 B -mwmnN DESCRIPTION OF RIPTI04 OF OPERATIONS @a m, DESCRIPTION OF OPERA AOONSILOCA LIONSNEHICLES!RESTRICTIONS!SPECIAL ITEMS THIS REPLICES ANY PRIOR CERTIFICATE ISSUED TO THE CSHLUTI.,ATP.HULGERA tE CYC.WORIO;RS COFIP COVERAGE. CERTIFICATE HOLDER CANCELLATION CITY OF S:ALEM SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE BUILDING I)EPARWENT WITH THE POLICY PROVISIONS. 93 WASHINGTON S'i AUTHORIZED REPRESENTATIVE SALEK CIA W970 ACORD 25(2009!09) 1988-2009 ACORD CORPORATION. All rights reserved. Z00/Z 000 xoe TH pue avgnbae,6 XH3 Z£ :6 OHS ZTOZ/LO/90