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61 VALLEY ST - BUILDING INSPECTION (2) - a� The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF JS Massachusetts State Building Code, 780 CMR SALEM 3`b, Ja vised.11ur?IN l Building Permit Application To Construct, Repair. Renovate Or Demolis One-or Two-Fundl.V Divellhkq This Section For QKicial Use Only Building Permit Number: k6ate Applied: Building Official(Print Nmne) "I Signal D) SECTION 1: SITE INFO ATION . 1.1 P p VA Address: 1.2 Assessors Nlap& Parcel Numbers { LCY I.la Is this an accepted street?yes t/ no Map Number Parcel Numlxr 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Fronlagc(II) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if ycs0 Municipal ❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner$of Record: 1VOAI I Fr-LIKC VA61LCN4O 51ILF-M MA 019V Na me(Print) city.Slate.ZIP 6) VALLEY S}. 617-664-,V74 No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ .Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': Rt,PZ Ar-I/V& is, 0/N/l- WS W/7—H ZVF uy SECTION 4: ESTINIATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) n y I. Building S 2l(jCPr�'.C,0 1. Building Permit Fee: S Indicate how fee is determined: 2. Electrical g ❑Standard City/Town Application Fee ❑Total Project Cost(Item 6)x multiplier __x _ i. Plumbing S �. Other Fees: S 4. Mechanical (ll\'AC') S I,,, 're IFire S Su t tression; Total All Fees: S -- — Check No. _Check Amount Cash ,Unount 6 Total Project Co,t: S Z,6'®t7 , 00 ---- __. ._ 0 Paid in Full 0 Outstanding Balance Due. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(C'SL) 4931g _ MI NAL z� .YD(�US(C( _____---_.-_-- License Number — -- F-cpva(mn Date N4amc o(CSI. I Inlder List GSL 1)pc(see below)_�W 47 A$h}U a! --- - --- --- f pe Description No. and Strect —Dd U Iinmscted J 2Ii mi ys Li to 75,11110 CU. tt.) 1Li dl9 j R RestnctcJ I&2 Fumil Dsccllin r C iblfown.Slate.ZIP bl Masonr RC Roofing Covcrin _ - W'S Window and Siding ��"" SF Solid Fuel burning,%pplianccs lf Vi—gli —2(016 52tpt Af;1 )'y)(�S_dr,.� 0 Un�nn�Vew 1 Insu lation 'felt hone !— Finail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) (FiE?OOP" 1(7 �+ �i Alva lit u IIIC Registration Numl er lixponu)n Date IIIC C'nmpmp N:une nr i IIC' Registrant Name PP pp Llrit / f15AVSC �t S7 u17(i lsK{Lr YYIe' /[/(fl LthJ. Nu. a:J Strect Email address City/Town.State,ZIP "relc hone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 15C(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........... Cl 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Nmne(Electronic Signature) 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 application is true and accurate to the best of my knowledge and understanding. W141 L n Print Owner's or Authorized Agent's Nantc IPlectrunic Signature) ate NOTES: 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 Contractor(HIC) Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 112A.Other important information on the HIC Program can be round at Information on the Construction Supervisor License can be found at\%\sk%Jmn,s!�o� Vp, 2. When substantial work is planned, provide the information below; Total floor area (sq. ft.) (including garage, finished basement'uttics,decks or porch) Gross living area(sq. fl.l - - _.._ Habitable room count Number of tircplaces _-_ -_- _ Number of bedrooms Number of bathrooms Number of half hadis l\pe of heating system . _ -_---- -- _ Number of decks, porches h)pcofcoolings)steln I711ilosed ---Open 1 "I owl Project Square Footage- ma)- be SubSlltufed for"Total Project Cost** CITY OF SALEM it PUBLIC PROP RERTY DEPARTMENT %Ittlw 12. NVnvu.�t:fu.�itstbr• S.tu•W, Mn»st.ul it i nJ177� )Ip71YKnS • f t.r 97t•74C•'It4e Workers' Compensation Insurunce .vndavit: Uullders/Cuntracturs/Electricluns/Plumben \ e )Meant In nrmatlo �` PI •rs Meet Le 'hl N'linc I Iluune,sil7rgylvninw Indn.,luull: MI U(If L 'Z / f'L,/ Addre.w O '¢5_ Y Sf- City,.Srtrc,%ip _f�i¢/Y//L7 /V ` Monet/: /tJ/- 9r3 —26/� .\rr)ou tut emyloyer'!Cheek the approyrloa box: 1.❑ I;fin j emplu)er with ❑ I ,fin a general conuaetor and,4. I')Pe of pru)oct(required): 1 Ljnys4lf. )'eek(toll nttl/ur part-lime).• have hired thu soh-clintractors rl' O'Kew construction a tale pmprietnr or partner- listed on the anached sheer. r 7. FiRernodelling nd have no onpluyucs These subcontractors have ng her me in any capacity. (corkers'cmnp, insurance. a' O Demolition orkers'comp. insurance 1. 0 We are a cnlperstion and its 9, ❑ Building addition d.) otrtcers have erereined their 10.0 Electrical repairs or additions homalnrner doing all work riyhr arerennplino per NICE 11.❑Plumbing repairs of aJJitiane .(t\'o workers'cutup, c. 1S7,¢I(i),and we hnvo noco required.) 1 :mployccs. (No workers' I�'❑Ruul'npuirs crnnp, insurance rt:quircd.) 13 0 Othor •.1,q.ggd,aue this cWcks bus el must Jlatl fill wl the.emml Wier iwk - I tunynwnM why,ubndl this sI1lJevh i,Wluline tMry+re Joins JI vuurrk and lik velligerhim va side eullrncron moll.u'hnil ltw a1RJavir indfusine.,Nk. 4',m,ew4tn 1hM Lht'ck this by ni Jli;had an ttWlfharl rhesf'h"ven"I IhY"an"of the IYklbineeWn ued IhfM wYAM•tanlly,tenpin mrbrina ,ve/urn on rtrtpleyer that If prul-id/gr workers'curnpenrallon htrarance for/ay anp/agree Be/ov/s tAePu/ley and/mo sty %IIlYf/IIY/M16 Insurance C'tintpuny Nnme:._ _. I'nlicy letter Sulr--ins. Lic.it: - .._ Expiration Date: tub Site -\titres: \ouch Is ntyy of the workers'eumpearatiun policy duelarutlon puge(showing thslpoliey nunibur and"plratlun data). Palluru to xcurs covera as ge as require)under Seaton 2!A ul'MU c. 152 can lead to the imposition or criminal yenalties of a. tint;up to.l't 500.1y)andlur uoe-year imprisoutnunt, Js wull 4-4 civilpenulhus in the turn era STOP 1VORK URGER and a Rns of up fit i210.i)n a Jay.tguinst the violater. He Jdviecd shut a copy irthis alinement may be Iurw JrdcJ to lho Otlico vr IIIV�a1t�Jln lfb of Illa 1)IA for unuruxe:.,vcrJ,e,ar il4ilmn. /du hereby t rrrifY afider the pfi%nr mIJ pat,dNer u�prr/nry/her die infufmsNon prurtJed uba ce is true find correct. �l•1a.nnta �(- � ti o 20l rj� - It)//1r;a/,r,e Holy. ran,Inc it Pill,In rht.arva. tube rumplcred by city of,rotrn )Ilh tot (7/r fir Town: _ Permit/Lleenre nl I„ving .\ulhnrily (circle noel; I, Ih. G ,e nrI1eJltb !, IAher Iluddill$ Dcp,trfhle" I. t:il,.'1'Will Clerk J. Llectriral Inliec0or 5. Pluulbin I . y In,yccrar I � l'"nl.t cl 1't nun: I information and Instructions v n in the ecrvice of another wider any conlrIct of hire. �t.u>.tchu:cln,a +t,W10, in rmplurra is defined AS'Ile Icryo� n so to provtJe workers cumpenrrhon IiN their cusp oycfs. I unu.ult to ;%Press of unp6cd, oral of written. ' oration or other legal cnliry,or any two or more aAnenhip,assoeiatton,cory er or the kn einpluyrr i t dctincd as"an individual,p lu in �m loyeee. Nowavor the a ,hc I,,regutng engaged In a Join' a^Wtnenhlp Idassocialloo or other legal andty`empo yes 0 erplo tesenj occupant of th@ ,el:elver of 1ruflCe uI .a1 IIIdIvIduJI, p eons to Jo maintenance, cun%ruction or repair wurk in such dwelling house owner of a dwelling hcus@ having not More than three aparemenu and who resides therein,or the ,Iwelling houia of another whoparemploysPe or on the grounds nr building appurtenant thereto shall not because of such employment be deemed to be an employer. �tGL chapter 132, �'_SC(6) also state,that"Ivory seat@ or local Ilcensiag agraey had withhold the Issuance or till for any table evidence of cumplleac with the insuran¢t coverage required: renewal of r Ilccnst or Pernslt to operate a buslneu or to eoaslruet buildings la the clients political subdivisions ii i ens.+hall typlleaat vI has not prmducad-Acceptable of its AJJitiunally, �ICiL chupar I S_', ,1?SC(7)stales"Neither the conurtonwcaa a not any enter into any contract 01 for the Perfomwn e ntedbo the untilcontracting lItabI�ityv��nce of cunlPli;mce with the insurance requirements of this chapler have been p' Applicants the boats that apply to your situation and.if: addre„(es)and phone number(,)along with their certi8catt(s)Of PIa:I:Ie rill out the workers' compensation affidavit completely,by checking with tin employees other than the necessary supply sub-contrretor(s)n mo(s), workers' compensation insurance. if an LLC or LLP doe,have insurance, Limited Liability Companies(LLC)or Limited Liability partnerships(LLP) strial members or partners, are not required to carry enlplmyees,a policy is requite 9t advised that�i,3lyidavil may be Also be stare to sign and Jule he allidavvIIL 1114nt of lAir' it should Aceidens for Confirmation town n that h cc co cation for the permit or license is being requested, not the WP,remunt of tain a workers' he rclllmed to the city you have any 4cesnoas regarding the law ur if you an required toanies should enter their InJustriul Accidents, Should Y ent at the number listed below. Self-insured comp compensation policy. plcasAl call the Departm self-insuranes license number on the aROMPI line. Clry or'rown Offlclals You to till out in the avant the Oil of Investigations has to contact you tenanting the applicant Please he sure that the affidavit is complete and printed legibly. The Department has Provided u rding h the bottom cam of the affidavit fur y iberw c any given year, need only submit ono aflidnvit indicating current ,if til a be suro to till in the paout in o number which will be used as s reference nunlbar• In addition,an rPD that must submit multiple pennio'and Uldl,o applicationsbe provided to the Policy iul'ormatian lit necessary) and a^der"Job Site Address"the applicant shaulJ writes"all lucatiuns in (coy or town)• r town " \copy,,(at the utYlduvit that has been officially star^ennits uped or t marked es`IA now l@ city o4illduvit must be r11W out each applicant as proof that a valid affidavit is on file far Notre P ennit not related to any business or commercial venture y ecu. \Yhare a hums owner or citizen is obtaining a licenses or p tic. Jug e a hui ld Owner permit to burn leaves coo.)laid petiole is NOT required to complete this affida a hat a.m uesuons. .je 1 h< 1)II1Gv 1,1 I,Ivacttgatiuns would ilk@ to dlallk you III JdvalKa fur your tOUPerallUll and should y Y 4 plea,- do nut hesitate to Wive us a call. File Ucp'•uuncnt'4 aJJte+f, telephone and Es,t number: aldf of)vtassaehuxtp The Comm Deparmaent of industrial Accidents 011fee of Iavesdgadons 600 WL&I-d IBton Street Boston, MA 02111 ref, p 617-727-4900 ext 406 or 1.877-MASSAFE Fax M 617-727-7749 J ns www.maw.8ov/dies CITY OF S.V�&Nfj Alss.xCHUSETTS OLMDLNG DEPARTMl&NT 130 W.1iHLVGTON STREET, 3*0 FtOOg I-EL (978) 745-9599 FAX(978) 74Q9&9 K1J®t.1tL.EY DRL4COLL MAYOR THO..mu ST.PmjU DIRECTOIOPPCBLICPROPERTY/Bu DLVGCONNISSIONER Construction Debris Disposal AtEdavit (required for all demolition and renovation work) i 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 Al is issued with the condition that the debris resulting from 1 11 work"] be disposed of in a pro I 1,S 1 SOA. perly licensed waste disposal facility as defined by N1GL c The debris will be transported by: COP)TRacmR CDUmn YR1�1�� (name of hauler) The debris will be disposed of in 6- �1�Cto -1 4b5pEQ (name of facility) Zo3 E. mAl UV �� Gs'nRf Ef7ul1N Ja7„� ' (address or raclhly) signature ofpWrmit applicant Ob' 3f3 A0 / IIJIC hnuJ•bw krom: Steve Hick r'aXlll:y'/t3'/'/'/y:iy4 Date:8/30/2011 08: 41 AM Page: z of 2 OP ID: SR ACORO" DATE""'I CERTIFICATE OF LIABILITY INSURANCE 08/30/11 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 Ileu of such endorsements. PRODUCER 978-777-9394 CONTACT Dan Hurley Insurance Agency NAME PHONE FAX Chestnut Green,Suite 24 978-7773306 AIC No E AIL No): Seven Federal Street EMAIL - Danvers,MA 019233620 PRODILI ER ADDRESS: Daniel J Hurley CUSTOMERIDr:SZYDL-1 INSURERS AFFORDING COVERAGE NAIC0 INSURED Pionarch INSURERA Preferred Mutual 15024 Michal Szydlowski DBA INSURERS: 450 Asbury Street INsuRERc: South Hamilton, MA 01982 INSURER 0 SURER 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. LTR TYPE OF INSURANCE INSR POLICY NUMBER rUU1Y Ell MMIODIYYYY MMIDDIYWY LIMITS GENERALLIASILITY EACH OCCURRENCE $ 500,006 A X COMMERCIAL GENERAL LIABILITY CPP0150587114 05/22/11 05/22/12 PREMISES(Ea occu«ante $ 100,000 CLAIMS-MADE Fv,77 I OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 1,000,00 X POLICY PRO- CT OC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY IPerpeacH) $ ALL OWNED AUTOS BODILY INJURY(Per accitlenry $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Pei acciiI $ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE - AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION - WC STATU- OTH- AM)EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETORIPARTNERrrXECUTIVE OFFICERIMEMBER EXCLUDED? NIA - E.L.EACH ACCIDENT $ (Mandatory in NH) - EL DISEASE-EA EMPLOYEE $ If yes describe under DE SC RIPTION OF OPERATIONS below E.L.DISEASE-POLICYLIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) As per policy. CERTIFICATE HOLDER CANCELLATION CITYOFS 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 Inspector 93 Washington Street AUTHORIZED REPRESENTATIVE Salem,MA 01970 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD