72 VALLEY STREET - BUILDING INSPECTION (2) I� The Commonwealth of Massachusetts CITY OF
>a Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
�R Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
r
r, h 1
Building Official(Print Name) -Signature Date
SECTION 1:SITE INFORMATION
.l Property Address: '1 X VA/ y' S re4r 1.2 Assessors Map& Parcel Numbers
Map Number Parcel Number
I.I a Is this an accepted street9 yes_ no
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Prupusui Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
�mc rinl) I d
mek l 1/12lL✓�
Na (PnnO City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ NumberofUnits_ I Other ❑ Specify:
Brief Description of Proposed Work': l C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees:
A
nical (HVAC) $ List:
nical (Fire $ Total All Fees:ionCheck No. Check Amount: Cash Amount:Project Cost: $ 1 ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
_�'��,?� License Number Expiration Date
LNa of CSL Holder //
2,// List CSL Type(see below) —/ .— o
La On nr� M , [�Y1/1- )z
No.and Street Ty Description
U Unrestricted Buildings up to 35,000 cu.ft.)
Ctty/Towo,State,ZIP v� Restricted 1&2 FamilyDwelling
M Mason
Hnv Zr- r// /iJZQ Q/8 J 7,-2- RC Roofin Coverin
v WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
'fele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /l3 S�6'
L l"t h n`- ( r,it < 1 r!/'i7UP �Y I,l C CS HIC Registration Number Expiration
HIC Company.. ame N or HIG Registrant Name
N � LU
No and Street
&V-e t Email address
Cit /Town, State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 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...........
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
/Y I OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
//��� •�)11�ctM1 rf/I�G� 0�
I,as Owner of the subject property, hereby authorize A—ri Il n C� C OAS�r�G�/ci S P_rUI C-L(
to act on/my behalf, in all matters relative to work authorized by this building permit application.
— %�— fj -� p1 !/
Print Owne 's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties=understanding.
mation
co ed in this application is true and accurate to the best of my knowlet �y�-Y M o _ C Yi01 n rZ h/yPrint Owner's or Authorized Agent's Name(Electronic Signature) ate
NOTES:
l. 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. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"
CITY OF S:u.EM, lLAiSSACHL'SETTS
; .
a BUILDING DEPART\IEINT
' /<? 120 WASHINGTON STREET, 3'o FLOOR
TEL (978) 745-9595
F uK(978) 740-9846
KIMBERLEY DRISCOLL
lukYOR T HoNtAs ST.PIE➢RR
DIRECTOR OF PUBLIC PROPERTY/BU I'LDLNG COJLMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ahtilicant Information Please Print Le ib1Y
�nmt: (Businuss;Organization,lntlividual): 1.—Yi r1(I p�
Address: g8,3r Al L),t II1 6 roa,, (d lP`Y' C�
City/Sratc/Zip:_ [764t/ er L(It �A Phone #: ! tG—
Are you an employer?Check the appropriate box: 'rype of pr7. ,
red):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑Newn
,�..�( employees(full and/or part-time).* have hired the sub-ccntractars
2.D(J lama sole proprietor or partner- listed on the attached ahect.t 7. ❑ Rem
ship and have no employees These sub-contractors have 8. ❑ Dem
working for me in any capacity, workers'comp. insurance. 9, ❑ Buil
[No worker•'comp. insurance S. ❑ We are a corporation mid its
required.] officers have exercised their 10.❑ Elect or additions
J.❑ 1 am a homeowner doing all work right of exemption per MOL I I.❑ Plumbing repairs or additions
myself. [No workers' sump. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13,❑ Other
cutup. insurance required.)
•Anv apphcmi test dmcks box 91 mwt also Fill owl the section bclowshowing their work,,'compensation policy iolli malion.
'I lomeoanerx who submit this aftidivit indicating Ihcy arc doing all work and then hire outside cawnw,"m moat submit a new an7davil indicating such.
4:...into,that 0yixk this boa must anachcd an addttiunal sheet showing the mmne of the sub-conmcton and their workers'comp.policy information.
f unt an employer that is providing workers'cumprrtsmlan insurance for my employees. Beloly Is floe policy mod Jab gild
injonnatinn
Insurance Company Name:_.__
Policy N or Seif-ins. Lic.d: Expiration Date:
Job Site Address: City/Slate/Zip:
,\Hach 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 of%16L c. 152 can lead to the imposition ofcriminal penalties of a
line up to S1,500,00 und/or one-year imprisonment,as well as civil penalties in the farm of STOP WORK ORDER and a tine
orup to$250.00 a day against the violator. Be advised that a copy of this statement may lw forwarded to the OI'lice of
Investigations of the DIA for insurance coverage verification,
/do hrrrbr rrijy ar rhrpuirmdpenufirs ofperfury that dr injunrutlmr provided above is trot sud correct
Oates
Phone d
Official use only. Oa not virile in this area, tube cuntpleted by city ur town afjh iuL
City or Town: _..-.-.. . .__ Permitfl.fcensek
Issuing Aulhurity (circle one):
1. Board of Health Z. Building Departutent 3.Citylruwu Clerk 4. F.iectrical Inspector 5. Plumbing Llspecror
6.Other
Contact Person:- _ _ _ Phone Y:
/ryyr
;. CITY OF S:�LE,1I, AL S&wHUSETTS
BuLDLN(;DEPAR-I1 &NT
, t 130 WASHEYGTON STUET, V FLOOR
. .„ ah T�iL (978) 745--9595
RLe(978) 7-10-984d
!U1[BEltLcY DRISCOIl.
AAYOA ngoaLU ST.PIEaRs
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONNISSIONER
Construction Debris Disposal At'tidavit
(required for all demolition and renovation work)
In uecordance with the sixth edition of the State Building Code, 730 CMR section 1 l 1.5
Debris, vid die provisions of VIOL 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�1GL c
I It, S 150A.
'fhe debris will be transported by:
y obi
name ufhauler)
The debris will be disposed of in
-- — (name of facility) —
Nddies.t of tacility)
signature of permit applicant
V Vl1V
11�r�o WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GS60UB-9662L85-8-13)
RENEWAL OF (6S60UB-9662L85-8-12)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
1, NCCI CO CODE: 10456
INSURED: PRODUCER:
ERINNA, RAMON DBA ERINNA M P ROBERTS
CONSTRUCTION SERVICES 1060 OSGOOD ST
583 NORTH BROADWAY NORTH ANDOVER MA 01845
HAVERHILL MA 01832
Insured Is AN INDIVIDUAL
Other work places and identification numbers are shown In the schedule(s) attached.
2. The policy period Is from 11 -17-13 to 11 -17-14 12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
m= Rem 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
�= C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
u�
N�
O�
D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required Information Is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 11 -07-13 WC ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: M P ROBERTS 28SGF
005347
NORFOLK& DEDHAM MUTUAL FIRE INSURANCE COMPANY
SPECIAL BUSINESSOWNERS POLICY
RENEWAL DECLARATIONS
Policy# R0618253A
Named RAMON ERINNA DBA Agent M.P. ROBERTS INS. AGENCY, INC.
Insured ERINNA CONSTRUCTION SERVICES
583 NORTH BROADWAY Phone (978)683-8073
HAVERHILL MA 01832 Agent# 20045
FORM OF BUSINESS:
INDIVIDUAL
Policy Period: 1 YEAR from 03/01/14 to 03/61/15
This declarations page together with the policy jacket, the policy form and any endorsements, completes this policy.
Coverage begins at 12:01 A.M. Standard Time at the covered residence premises.
I. POLICY PREMIUMS AND CREDITS
Basic Annual Endorsements State Taxes Total Annual AdditlonaURetum
Premium Pre iu or Fees Premium Premium
$1,102 $1,102
II -, IN:S:URE.D - PREMIS 5 ..
Building/Location 1 583 NORTH BROADWAY HAVERHILL MA 01832
Address if Different
Mortgagee Information
Business Description CARPENTRY
III: t'< ,':P:R'OP'ER'TY.:.CO.YERA'G E S .r
Premium
POLICY DEDUCTIBLE $250
OPT.COV.1 EXT.BLDG GLASS DEDUCTIBLE $500
BUILDING (COV A) Limit
ACV OPTION (Yes I No) NO
AUTOMATIC INCREASE (%) 8% Included
BUSINESS PERSONAL PROPERTY Limit $10,000 Included
IV: " : O P7,l ' L" ; , V'ER'AGES
Premium
OUTDOOR SIGNS Limit
EMPLOYEE DISHONESTY Limit
MONEY&SECURITIES Limit
ACCOUNTS RECEIVABLES Limit
VALUABLE PAPERS Limit
FORGERY&ALTERATION Limit
TOTAL PREMIUM PER BUILDING $1,102
V:..,. B :Y: AND : M:.Ep, C L AY EN.TS.
EXCEPT FOR FIRE LEGAL LIABILITY, EACH PAID CLAIM FOR THE FOLLOWING COVERAGES REDUCES THE AMOUNT OF
INSURANCE WE PROVIDE DURING THE APPLICABLE ANNUAL PERIOD. PLEASE REFER TO PARAGRAPH D.4 OF THE
BUSINESS LIABILITY COVERAGE FROM ILI "'PREMI
LIABILITY&MEDICAL EXPENSES
OCCURRENCE $1,000,000 Included
GENERAL AGGREGATE $2,000,000 Included
PRODUCTS COMPLETED OPERATIONS AGGREGATE $2,000,000 Included
MEDICAL EXPENSES $5.000 Included
DAMAGE TO PREMISES RENTED TO YOU $50,000 Included
VI' "_-END'OR.SE-MEN?TS. .. .. ;.
Premium
SEE ATTACHED PAGE
NOTE: THE POLICY PROVISIONS REQUIRE THAT A$ 550 COUNTERSIGNED BY AUTHORIZED REPRESENTATNE
MINIMUM PREMIUM CHARGE NORMALLY APPLIES. IF YOU CANCEL
PRIOR TO EXPIRATION DATE,WE SHALL RETAIN AT LEAST$300
ncr_�en,eec ne reeu
f Vlee%pam+nspi mvwlllc b Q'ffieadaC�[[drtLl
f Office of Consumer Affairs&flusintss Regulation -
ii VMEIMPROVEMENT CONTRACTORgistration 135503 - - Type:
p1ration ,4/9/2016`a DBA
t ERINNA CONSTRUCTIONSE.RVICES
Ramom.Erinna-
t. 583 NORTH-BROADWAY �;�
HAVERHILL,MA 01t132i ���-'''
Undersecretary
i
3
}w 4
. 's ; of Kwlduc xwancp .�d S+
Construction Si penisor A ''
License CS-066182 1 r,
RAMON M ERINNA q
583 N BROAD WAY%
HAVERHILLMA 01832 '.*
Expiration
Commissioner 04/1 612 016