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63 VALLEY ST - BUILDING INSPECTION (5) 1'he Commonwealth of Massachusetts � Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Akir 2011 One-or Two-Family Dwelling - This Section For Official Use Only Building Permit a ber: t Date Appli d: 'J wilding 0 icial(Print N, e). ` Signatu..to., Date SECTION I:SITE INFORbiAT10N L( Pro eW Ad/r i 1.2 Assessors Map& Parcel Numbers Lin Is this an accepted street9 yes_ no Map Number -- Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zuuing District Propose)Use •e Lot Area(sy tt) Frontage(d) 1.5 Building Setbacks(ft) reJ ui Re Front Yard Side Yards Rear Yard q Provide) Required ProviJed Required Provide) 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: Public❑ Private❑ Zone: _ Outside Flood Zone? L8 Sewage Disposal System: Check ifyes❑ Municipal❑ On site disposal system ❑ 2.1 wnert of Recor SECTION2: PROPERTY OWNERSHIP' d:/ t I thm ,( Ne(1 nht) r dvti 1 �f pGm �' r r^I CJ.I )0 /3 'et I � City,State,ZIP No. mtJ Stre Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Brief Description of Proposed Work Other ❑ Specify: a SECTION 4: ESTIMATED CONSTRUCTION COSTS Itcm Estimated Costs: Labor and,Materials) Official Use Only I. Building $ lc�,6_D V R I. Building permit Fee:$ Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee 3. Plumbing S Cl Total Project Costa(Item 6)x multiplier x $ d. �AIcchmtical (FIVAC) S 2. Other Fees:List: 5. ,\fechanical (Fire Su «ssiun) S rutal All Fees:S 6. Total Project Cost: .S /Z�6 Check No._Check —Cash r\mount:_ ❑Paid in Full ❑Outstanding Balance Due: FTC 1 r 0 I t f ; Q SECTION 5: CONSTRUCTION SERVICES pp © l��lb i j•1 true lot Superviso nse(CSL) LicenseLicense Nun Expimtio Date ��VV�n�'pp�� Name of CSL Holder L List CSL Type(see below)_�-- �/ C'0 �/J-j�� 1 "type . -,. Description No.: td Street U Unrestricted Buildin s u -to—,000 cu. ItJ Resvicted 1&2 Family Dwellin Mason Ci yfro vn,State,ZIP I Roofin Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation of ' " �'•� �- p Demolition Tele hone Emau auuress U 2. 5.2 RegistereJ,Home Improvement Contractor(HIC) FIIC Registration Ninie r Expvutio Data l_.[ IYMr I 11,11v,, HIC Corn :my ume or HIC egistra Name mull address No.an trees _ l —_ Tele hone CA JTiAvn,State,ZIP R$'.COMPENSATION -PENSATION INSURANCE AFFIDAVIT(M.G L.c. 152.Q 25C(�),. SECTION 6:WORKE Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the ls3uance of the building permit. Signed Affidavit Attached? Yes .....ER No........ ..❑ SECTION 7a:OWNER AUTHORIZAT[ON:TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit ap at�L l / Vale I Frin vner's N• ectronfc Signature) 7W AUTHORIZED AGENT DECLARATION SECTION b:O Rt OR 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 understand Date Print Owner's or Authorize Agent's line Iectronic Signature) NO'f ES: I. An Owner who obtains a building Permit to do his/her own word,or an ol'In'r v not have ho tac access toires an u the registered tractor [he arbitration registered in the Home Improvement Contractor(HIC)Pro ram), rtant ormation on program f vsv aml r,guaranttyl nforlm,t under on on the Constru tioon Supervisor License can be found atthe CvProgram �S nms�M10 b IL and at When substantial work is planted,provide the information below:(including garage, finished basement/attics,decks or porch) total floor area(sq. a.) Habitable room count Gross living area(sq. ft.) ,lumber of bedrooms Number of fireplaces Number of half/baths Number of bathrooms Number of decks/porches�— Type of heating system Enclosed Open Type of cooling system 3. "Total Project Square Footige"may be substituted tor-total Project Cost" CITY OF SM-EM) NLISSACHUSETTS l i t UU-0ING DEPARTJL&YT 120 MASHNGTON STREET, 3i°FLOOR r ? TtEL (978) 745-9595 FMX(978) 740-9944 lU103F_RLEY DRISCOLL L ILYOR T Ho.%.tu ST.PiERRa DIRECTOR OF PGBLIC PROPERTY/HCILDLNG CON a(I5S[ONER 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 1 11.5 Dcbris, and the provisions of N1GL c 40, S 54; Building Permit k 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 t,VfGL c 111, S 150A. The debris will be transported by: y (nameofh uler' ) fhe debris will be disposed of in (�me of tacdity)�-- -- (add As of tacirity) signnaat_ureeoo�fpermitappli _ -//� —� ate 1LIVV/4V14 ' ' CERTIFICATE OF LIABILITY INSURANCE '�VYA facoRd. DATE(NMmlrvrw, 12 9/12 THE CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THE 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), AUrIDWZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT; B the ce ease holder is an ADDITIONAL INSURED,Me poliey(fies) must be endorsed. N SUBROGATION ,e Jeet to the terms and aondidons of Um policy,certain policies may require an Endorsement A Slatemem on this cordficals does not Ganbr roll;to the eertiteats holder In lieu of such ordorseme PRODUCER Sabatino Insurance Agency Ngee - I 17) 397-7466 (617) 361-9168 364 Broadway j AD s: Everett, MA 02149 _-- - Ins s AFFORDING COVERAGE MWO I RER RAVTLE INSURED 1 REI6: Now Ri-79-Inc EBc Saulo Sampaio INSURER : 22 Reed Ave M2 R Everett, D41 02149 I EAF� COVERAGES I 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. N07WTHSTANONG ANY REOUIREMENT,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 TIE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM. IN TYPEOF INSURJrNCE AIMSM In P MWi CY I PIE MSN UNITS A L¢NEAALUANLJTY 680-7242RO03 8/11/12 8/11/13 EACH OCCURRENCE '3 1-000,000 ' DAAMCE R { 0 00 COMM ERCW.GENERAL LABLITY C44UB AADG Q OCCUR I,E�D W ero rim f 5,000 PERSONAL&ADVINIURY { 1.000.000 GENERAL AGGREGATE GEN'LAGOREGATELMITAPPUESPER PRODUCTS-COBPIOPAoo { 2,000,000 POLICY M T I I LOC { AUTOMOMLB LIARUTY GV can INHEI nII PINY PUN BWILY INJURY(Par PNPD) t AILOWTED SCHEDULED eW0.Y INJURY(Pal avtlenU f AUTOS AUTW HREDAUT06 gN��WNEO N DAAM t 3 UMBRELLA UAa OCCUR EACHOCCURRSNCE S EXCESS LIAR CLAIMS-MADE - AGGREGATE 1 DED RETENTION A m"KERSa RSATION NDB7597R601 9/il/12 B/li/13 •T - �• AND ENPWYERS•LABILITY VIM OµFFVIRR°PAIeMB[-R E�UDED?ECUTNE ^T NJq .EACH gcare Nr 100 000 QRaMs"'YIIpnppNH) �l E.l. EASE- AEWUDY F RIPTIONQ RATIDN66obw ELCISPABE-POLICVLHR f 50D 000 D[SCmP71W OFOPeRA710N8/LOCA7�NE I YFwpFl7 IIMANI ACORD tO1,Ar3NUaIW MIroR°Schodub,S aANa apca b roRUnAtI CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OESCmBED POUCIEB BE CANCELLE D BEFORE THE EXPIRATION OATS ARE OF. NOTICE WILL BE DBUVERED IN M Hussey Contracting ACCOR ANCE WITH 7HE P IDY PROVISIOMB. 490 Washington St. Lynn' lda 019D1 AY REPRESDITArn 19 0JOB -2010 A RD CORPORATION. All rights reserved. ACORD 26(2010106) The ACORD name and logo are reglatered marks of ACORO Ptrone; Fml: EMAIL CITY OF S.1I M, INL-1SSACHUSETTS BUILDING DEP:♦RTNIEINT k t� I?O VflASNCVGTON STREET, 3'a FLOOR TEL (978) 745-9595 F.kY(978) 740-9846 iCI.,,IBERLF_Y DRISCOLL MAYOR DIRECTOR Sr.Pt>✓aRs DIRECTOR OF PUBLIC PROPERTY/BuILDiNG COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Natne (0usincss,Orgnnizmiom'Individual): Address:._ 41 City/State/Zip: hone ft: �� Are you an employer?Check the appropriate bo • Type of project(required): L❑ 1 am a employer with 4. ] ;on a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 ana a soic proprietor or partner- listed on the attached sheet. �• ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition . working for me in any capacity. workers'comp. insurance. 9• ❑ Building addition [No workers' comp. insurance S. ❑ We are a corporation mid its required.] officers have exercised their 10.0 Electrical repairs or additions ).❑ 1 tun a homeowner doing all work right of exemption per MOL I I.❑ Plumbing repairs or additions myself. (No workers'cutup. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. (No workers' 13.❑ Other comp.insurance required:] -Any applicant dut checks box sl must also fill um the action kluwshowina thcirwrioco compensation pulicy inlinmatiun. s I Lemoownexx who xuhmll this affidavit indicating they arc doing all work and then hire outside contractors most suhmit anew affdavil indicating such. :Canincwrs that check this box mat attached an additional sheet showing the none of the sub-contraetun and their workers'comp.policy information, l ant an employer that is providing workers'contpeusadun insurance for my emplayees. Below is file policy and fob site information. Insurance Company Name:_._._ Policy 4 or Seif-itts. Lic.d: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in fhe form of a STOP WORK ORDER and a fine of up to$230.00 a day against the violator. De advised that a copy of this statement may bee furwarded to the Office of Investigutions ofthe DIA for insurance covcroge verification. l rho hereby certify under the s and penalfles of per' that the information provided above is true nVid correct ajDL l n • Date: /� Phoned: 6 O ic•iat use only. Do nor write in this area, to be completed by city or town ofJic•lat CirvorTown: _.....„ _ .__ PermRfJ,icenseN Issuing Authority (circle uric): I. Board of Health 2. Building Departatent .I.Cilyfrllwn Clark J. Electrical Ltspector S. Plumbing limpector 6. Other Contact Person: . .... .. _ Phone 1R: