25 VARNEY ST - BUILDING INSPECTION k ,
The Commonwealth of Massachusetts CITY OF
Boar)of Building Regulations and Standards SALENI �
Massachusetts State Building Code, 780 CMR Revised.4lur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
ri One-or Two-Family Dwelling
This Section For Official Use Only
Duilding Permit Number: Date4(ppliedt
Building Otlicial(Print Name). Signature Date
SECTION 1:SITE INFORMATION'
LI Property Ad S. /0. —n1W t— 1.2 Assessors Nlap& Parcel Numbers
1.1 a Is this an accepted street?yes ty— 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(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(b1.G.L c.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 yes13
SECTION2: PROPERTY OWNERSHIP,
2.1 Owner�t�tf�4rtd�.n` GQV-ManD �� �^ E M �
�1me(Prin City, 5—State, P
tS ,
arvte� 9— tC.11�-73- l a 2 (0
No.mid Street 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. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Descripti Aof Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 3— 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(item 6)x multiplier x
3. Plumbing S P Other Fees: .S
4. Mcchanic:d (FIVAC) S List:
5. :Mechanical (Fire ,S 'total All Fees:S
Suppression)
U Check No. Check Amount; Cash Amount:
6. Total Project Cust: S 1 3 ❑Paid in Full ❑Outstanding Balance Due:
/ Y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisror License(CSL) b W?9b �-- f3 - !S
L (-,1)cI, �u� ` 'r, _ License Number Expiration Date
Name of CSL older i
1 D 7-O I E S T List CSL'Type(see below)
No. :md Sheet /{/ Type � _. � � � Description
fl _/ ,9 {�.S l� W ' ( G) 2 3 U Unrestricted(Buildings u to 35,000 cu. tl.)
�r V l R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
e hone Email address D Demolition
Registered HomtL
e lgtprov mtent ntr ctt r(HIC) L �- 7
yy` (�f� �1 Ag 4, f// r HIC Registration Number Expiration Date
H4 U l3tp,my L'7o 'TclC.N e"l
No. a{ S�te q3 Email address
City/Town,State ZIP - `i Telephone
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 t e Istuence of the building permit.
Signed Affidavit Attached? Yes ....... No........... ❑
SECTION 7a:OWNER AUTHORIZATION,TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT'
1,as Owner of the subject property,hereby authorize PA 0� )6 I ID d-4r/1 -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
S C- 00--k$-aW--f iz _ 22 -/Y
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 applicati n is true and accumte to the best of my knowledge and understanding.
Print Owner's o Authorized Agent's N;mie lectromc Signature) Date
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 got'have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
m
a
s
sgov:oca Information on the Construction Supervisor License can be found at w�ow.mass.��ox:'d.�s .
2. When substantial work is planned,provide the information below:
"rota[ floor area(sq. 11.) "A .(including garage, finished basementlattics,decks or porch)
Gross living area(sq. 11.) 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"
c a CS-034795,
EVANGELOS LUPiS
12 STONE STREET
DANVERS NIA 01923
0511 312 0 1 5
r '
Canz,
o� a ��Office of Consumer Affairs and Busine�J�rcLul�yss Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvem;tQontractor Registration
. Registration: 126893
Type: Supplement Card
THD AT HOME SERVICES, INC Expiration: 8/3/2016
MARK NIADNA --- -=------ -- --.__._.__
2690 CUMBERLAND PARKWAY SUITE 300
ATLANTA, GA 30339
Update Address and return card.Mark reason for change.
scn i c; aoMus n ] Address ❑ Renewal Employment 7 Lost Card
W.�
r%�r (jrnuiroarncrrl/�r/c.��irLrre�ruc/IJ .
4.1 -OfOce of Consumer Affairs&Business Regulation License or registration valid for individul use only
iT
q� OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
4v Office of Consumer Affairs and Business Regulation
Registration 126893 Type: 10 Park Plaza-Suite 5170
Expiration,-;8/3.12Q1.6. , Supplement Card Boston,MA 02116
THD AT HOME SERVICES INC:
THE HOME DEPOT;AT0 t,4ESERVICES
MARK NIADNA
2690 CUMBERLAND PARK)NAY S --6--�9.�_ —�'p1�^►{ i�
Xff-'AM%,GA 30339 Undersecretary l%pt valid withou signature
S
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 7� l- Please Print Legibly
Name(Btuiness/Organiza�tio—dlnd�ividual): r , 1/[�im eo l`I 7' &7-1t e- -5Q/
Address: 5— /CAS �rt'q�/22_� �rF�
City/State/Zip: "Vtl, 6A, 303F Phone#:
Are you an employer? Check the appropriate Ilox: Type of project(required):
1.❑ I am a employer with 4. M I am a general contractor and I
employees(full and/or part-time)' have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
working for me in any capacity. employees and have workers' y ❑Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions
myself o workers' co right of exemption per MGL
Y (N comp. 12.Q Roof airs
insurance required.] t c. 152, §1(4), and we have no td of
13.�Other
employees.(No workers' - - 1
comp.insurance required.] i,1 ijA
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this afridavit indicating they are doing all work and then hire outside conWxwrs mutt submit a new affidavit indicating such.
tContractors that check this box mast attached an additional sheet showing the name of the sub-conuactors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide tbcir workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information. q f 5{I/
Insurance Company Name: Mew /7�� i!'r- -ZNY 00 ,
Policy#or Self-ins. Lic.#: (21 0 j 0 g 8 02 Expiration Date: 3`/ 1 6-
Job Site Address: D S �0 S f City/State/Zip: (S t7) f`�V�-- t "I 0
Attach a copy of the workers' compen ation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL 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 the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coveraae verification
I do hereby cent' under the
//pains and penalties ofperjuty that the information provided above is true and correct
Signature: ,t.. 'l Date:
Phone#
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
� r � CERTIFICATE OF LIABILITY INSURANCE
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 INSUREP.(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les)must be endorsed- If SUBROGATION IS WAP/ED, subject to
I the terns and conditions of the policy,certain policies may require an Endorsement. A statement on this certificate does not confer Tights to the
certificate holder in lieu of such endorsement(s). _
FRODUCER CONTACT
MARSH USA,INC. NAME :FAX 1
TWO ALLIANCE CENTER PHONEAH:No Exl- (AIC Na>:
3560 LENOX ROAD,SUITE24C0 ADDRESS' _
ATLANTA,GA 30326
' MSURER 57 AFFORDitiG COVERAGE ' Ng7C9
100492-HOMSD-GAW-14-15 INSURER A:SleaCad Iruance Conpa,"Iy '2c:57
INSURED INSURER B:Ztetc 1 AInPIIQn hwtdalce Ca 78535
THDAT-HOME SERVICES.INC. --
'08A THE HOME IvaAT-HOME SERVICES INSURERC:NSWHam aMWCO �235'1
2455 PACES FERRY ROAD INSURER D:111inos National Inwmnm Corrpany Ie..817
ATLANTA.CA M339 '
INSURER E:
_ I INSURER F:
COVERAGES CERTIFICATE NUMBER: - ATL4)03242665-01 REVISION NUMBER:3
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 NTH 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 POUCHES.LIMITS SHOVVN MAY HAVE BEEN REDUCED BY PAID CLAJMS.
IL7R TYPE GF(Y.SURLHCE IA D U POLICYEFF POUEVEXP
I POL!CYNUMBER MM/DD MMIDDIYYYY LIMITS
A GENERALLIABIL11Y - GU0488Tt14-G4 0310112014 031D12015 EACH OCCURRENCE S 9,GM OM
X PREMISES EaDmare S
CO!dtAERCIAL GE?!ERA.LIAE:�i!
CLAR.:S-tuG= L `' iCCCI:a LIMITS OF PIXIGY XS MED IXP(Any..moon) S EXCLUDED
OFSIRSIMPSOCC PERSONAL&ADV INJURY 5 9'�'�
GENERAL AGGREGATE 9 9�'wo
GENT ACGREGATE LI?fAFF!IES Fc::. PRODUCTS-COMPIOPAGG 5 9,000.0w
I X f-0LICY' I FR0. r1 LCC S .
J=CT
B AUTOIlpBILE LIABILITY BAP e'LJ38863-11 0310112D14 0MIM15 Ea IHNEDNSMCLEUMr S 1,Om,000
An
NY AUTO BOOILY INJURY(Petpersanj S n
ALLOWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY WNRY(Per accident) 5-
AUTOS AUTOS
NW,-OWNED PROPERTY DAMAGE 5
HIRED AUTOS AUTOS
Pe a
s
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAR C(AIMS44ADE AGGREGATE 5
OED RETENTIONS
C WORKERS COMPENSATION WC04910/882(ADS) 03101201d 0?A12015 �CSr1�TU-
AND EMPLOYERS'LlAaNER Vld W00491016M(AK.A2,VA) 0=12014 0OWO15 EL EACH ACCIDENT $
1,000.000
C ANYPROPRIETOR/PARTN.=R/J(ECUTNE N NIA
0 O InN )IXCLUOEO? WC049101863(FL) 031012014 031012DI EJ-DISEASE-EA EMPLOYEES
f'..,d(mandatory. In NH)
DYee,RIPTION antler E.L.DISEASE-POLICY LIMB S 7'7100'ODO
DESCRIPTION OF OP_ZiATI099 Ce:ow
C WORKERS COMPENSATION WOM101885(KY,NC,NH.VT) 031012014 0310/2015 (EL)LIMIT L00D.Om
C WCD491018M(NJ) 03/012014 031072015
DESCRIPTION OF OPERATIONS!LOCATIONS i VEHICLES(ANach ACORD 161.AdEIllanal Remarks Sched k_Lr"M.P.-""Uked)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT4DME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DBA THE HOME DEPOT AT-HOME SERVICES THE r=xPIRAmoN DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS
ATLANTA.GA 3OM9
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
- - Manash7 Mukher)ee
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
CITY OF SALEM3 MASSACHUSE M
a
BUILDING DEPARTMENT'120 WASHNGTONSTREET,3'mFLOOR
7'EI_(978)745-9595
KI1vBERLEYDRIS0OLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUII.DING 00M[vIISSIOmR
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 c40, S 54; Building Permit#t is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
)n cq k ,<\- I I-e-
n
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
4 /
at o
Signure of a plicant
� 2 23 , /c�
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