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65 VALLEY ST - BUILDING INSPECTION (2) 'rhe Commonwealth of Massachusetts } Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR. T"edition OF SALEM Revised Jurnngv Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 10011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: 340Signature: Building—Commissioner Building-Codimissionerl Inspector ol'Buildings Date �— SECTION 1:SITE INFORMATION 1.1 Proper Address:( 5a ' LZ Assessors Map& Parcel Numbers L I a Is this an accepted sire °yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(it) Front Yard Side Yards Rear Yard Required Pmvided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: . Zone: _ Outside Flood Zone? Public❑ Private O Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of R or �Cl <��-t �s �2(� CO 5 /0.11zs._ 5� t v (e.w �✓d Nu�rint) Addrcss for Service:: ( Signature Telephone SECTION 3: DESCRIPTI OF PROPOSED WORK?(check all that apply) New Construction❑ Existing Building Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.O 1 Number of Units_ Other ❑ Specify:WI-J Ace Ss«a AS Brief Description of Proposed Work': c - - o `C — SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building Is 1 I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S �p o Check No._Check Am unt: Cash Amount: 6.Total Project Cost: S ❑Paid in Full O Outstanding Balance Due: S r- t�iv� SECTION 5: CONSTRUCTION SERVICES 5Ell censed Construction Supervisor(CSL) � I �DGJa� s�� License Number lispimtion Date N• a o�SL-I_ er List CSL'type is"below) �• t sk rype Description A ss - U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling tiiµnat t-c M Masomy Only RC Residential Routing Cuverin Telephone WS Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Horn Imp�ro�vemrct Contractor( HIC) // L g f IIC Company Nart)e.or 1111CC.Regislmnl`Name Registration Number '6 v v_ L_ ✓oil/A'JS r�f ' Expitutiols Date Sign re Telephone S CTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I —5:�d--`L" as Owner of the subject property hereby authorize —J to act on my behalf,in all matters relative to work authorized by this building permit application. 4-� . i atuteof net Date SECTIO NERt OR AUTHORIZED AGENT DECLA_ ION as Owner Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to f-my-cknowledge and behalf. Print Name J�.. � /6f .aof Signature of Owner r Au ed Ag t Date Si ned under in and rattles 'u 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 api have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 10.116 and 1 IO.RS, respectively. 2 When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics.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 of heating system Number of decks/porches / Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" z CITY OF S.UZINI, AASSACHUSETTS aLmDoiG DEPARTMIUNT 120 W.%iHLYGTON STUgT. 300 FLOOR TgL. (978) 143-9595 FAx(978) 7410-9811411 ICINIBEA"y DIUSCOLL TiOMASST-1i'M IRC MAYOR DIRWMR OF PL eLIC P1t0PERTY/8L:MDNG C0'%OI/S510'%FA Workers' Compensation Insurance AlRdavit: Ouilders/Contractors/ElectriclanslPlumbers A 111c2nt Inform2doa Pleats Print Legibly VtlMe Itlunne+aOrhhanunionrttabvtdutl): ��V�'� ��� Addrew cily/state/zip: -y��'r � . Array to emplayer?Clock the appropriate beat Type of project(regWr"IN t am a cmpioyer with�/ s. C3 I am a penenl contracmr and I & ❑New construction employees(fall and/or part-time).• have hired the subca owlicull 7. Remodeling eior tx artnev listed on the anachod shM 2.[] 1 ip a sole pe no P These sub-cone seta s have g• O Demolition :hip and haw rp empbyeO working loge me in any capacity. workers'comp.insurance' 9. O Building addition (No worker'comp insurance 3. ❑ We ate a coepoesdam and is Io.O Electrical repairs at additions requiraL] otllcas haw eat rcised their ri of clam ion MOL 11.❑Plumbing repairs or additions ).❑ I am a homeowner doing all work IlM Pt Pa myself.[No workers'comp c• I5Z f 1(4),and we have no 12.0 Roof repsiro insurance required.]t ernpbytm.LNG workers' 13.0 Otha comp insurance required.] •Any appacass that chocks is el more air no well the arsine helse shawbu tksin lism 'CoMP MA M Polk?iNAWWAd&L 'l l..wtuwsr corm submit thin allldva ineltat gig they rA tan%in wait ad saw him OMAN eaanacton matt submit a now amdoeit odieMi4 maw <'.nYra�w I the cheek ibis ban mud aeshaa m addttfitttd Jet Jmwtn%tti err a!the dAsaMramwe one tMr.eeasto'taM7.Palter inranrtls /use ote eseptloyo that ls p oviline workers'romprnmnba lmsarrot ro jar ANY esep/eyars sehw b rAe pd/cy swal p1 a/br infortwWlota � - s Insurance Company Name:_� a^'� I`� 5 5r-vc�j{ L e- 5 C� n�tJ oO�S�-'� Policy is or Self-ins. Lie.M: Expiration Dab: `5 yo f e Job Site Addrew G,�5- V c City/Statwzip: ,l t, O /C R ,itrtack a copy of the werharo'complasslillin policy dotlustlem pap(showing the policy number and expiration dste)6 Failure to securs coverage as required under Secelos 23A of h1GL e. 132 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 the form of s STOP WORK ORDER and a Hoe .if up to S230.00 a Jay aaoinsl the violator. Iu advi+al that a copy of this statement maybe rorwurdcd to the Office of in vcvu gat ium ol•tile DIA rorinsurance coverage v wificatiom 1,10 herrby Corr! 4er the s YIII penYI I Y/'per/ury Mar r 'nforseallon proriJaf uubTbove is true end correct I)ara• y�y �,O zc� P'•nre a' g � O/Jlrie!use Yel/v aW write in/A&Yreas to be.urnpiad by miry or tawtt a/1wini I City orruwn: ParmiUl.)censel__. Ivwing.whurity Icircte line), I. ituard of llealib 1. HuOJing Deparimant ). Cityrrown Ciark A. Electrical lntpeclor S. Plumbing Impeeror Phone e: t s CITY OF SALEM Ali PUBLIC PROPRERTY DEPARTMENT Kit) L•l'T 0).\I I'\I, 979.74(y1446 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 q _ is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in pcuneut au ny a - (address of lacility) signature 31'11 it appli no 2-0 1-0 date Ichi i vl l d,K L r ACORD CERTIFICATE OF LIABILITY INSURANCE DATE / ) 06/1717/20102010 PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rose Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC 9 INSURED INSURERA:Nautilus Ins Co. Serven Construction Company LLC INSURER B:Guard Insurance 14 Gri£fen Terrace I INSURER C. N SURER RE D: L n MA 01902— INSUR E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADVL POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY) DATE I Ni LIMITS A GENERAL LIABILITY MN007523 03/16/2010 03/16/2011 EACH OCCURRENCE S 500000 DAMAX. COMMERCIAL GENERAL LIABILITY PREMISES TOEa occurence $ 50000 CLAIMS MADE [::] OCCUR / / / / MED EXP(Any one person) a 5000 PERSONAL&ADV INJURY $ 500000 GENERAL AGGREGATE a 1000000 GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 1000000 17 POLICY PROT LEE / / / / NOWND AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT S (Ea accrpM) ANY AUTO ALL OWNED AUTOS / / / / BODILY INJURY (Per person) S SCHEDULED AUTOS HIREDAUTOS / / / / BODILY INJURY S (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) S GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO / / / / OTHER THAN EA ACC q S AUTO ONLY'. AGG $ EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE S S DEDUCTIBLE RETENTION $ $ B WORKERS COMPENSATION AND SEWC131747 04/01/2010 04/01/2011 TORY LIMITS DER EMPLOYERS'LIABILITY 1000D0 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 5 OFFICEPJMEMBER EXCLUDED' / / / / E.L.DISEASE-EA EMPLOYEE s 100000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Mr. and Mrs. Scott Gately FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 65 Valley Sreet INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHO EPRESENTA E / /`/efS /�/', Salem MA 01970- (c/��� ACORD 25(2001108) ©ACORD CORPORATION 1988 INS025(ofoe).Ds Page 1 of