Loading...
12 VISTA AVE - BUILDING INSPECTION (3) i ' y The Commonwealth of Massachusetts W Board of Building Regulations and Standards CITY OF ALEM Massachusetts State Building Code, 780 CMR SdMar Revised Mar 20/1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Nu ber: Date Applied;. f V O O , Building OtTicial(Print Name). - a[ure Date SECTION 1:SITE INFORMATION 1.1 Property Address• 'c L2 Assessors Ma &Parcel Numbers A/ P Y �Z �1 VCR- p //�� 1.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP[ 21 wn tof cords war e GL r P S�/o7 �J mitis,� t� A/ e(Prin City State,ZIP II"1 � PZh, l Ve 74V 1 V No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief D s ription of Pro osed Wo•k2: .d5 /a /09 SECTION 4: ESTIMATED CONSTRUCTION COSTS . Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ r Q 1. 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: $ - - 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ �. Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 3z261 0 Paid in Full 11 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �077 G /r//C//J ��Q/� License Number E✓xpirationgDate Name of CSL Holder f List CSL Type(see below) y No.an Street Type Description x. U Unrestricted Buildings tip to 35,000 cu. R. R Restricted 1&2 Family Dwelling jlV Cityfrown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances/1 lJI Insulation Telephone Email address D Demolition 5.2 gi/sjere Ho a Improv tent Contractor(HIC) �7/Z- � L HIC/Registration Number/ E7piration Dnte F C aule r am r�Tm /, ey ftt N $tr et m� � UnEma�il Aaddress AP ��. City/Town,Stat ,ZIP 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 the Issuance 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 PERMIT 1, as Owner of the subject property,hereby authorize 2%771,e IK 0-6 `t�aactt on my/behalf, tiinniall matters relative to work authorized by this building permit application. yUGI17C1�/ 61,ok �yiC1 0 l Print Owners Name(Electronic Signature) IDate 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 bes f my knowledge and understanding. \}/� A " 6z4� S /9 Print Owner's or AuthorizedAgent's Name(Electronic Signature) Date l 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.govioca Information on the Construction Supervisor License can be found at www.nta s.,>ov/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" Page I of 1 The Commonwealth of Massachusetts Department of Industrial Accidents uv;�, Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gorldia Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers Applicant Information !Please Print Le bh } Name(nusiums/o ganizatim/Ldi ddual t Address: Cit /State/Z) /Q Phone#: J5U CY6F/ C 111565- -- Are you an employer?Check the appropriate boa: Type of project,(required): IA am a employer with�_ 4. 0 I am a general contractor and I 6. New constructionemployees(full and/or fiart-time).• have hired the sub-contractors I 2.0 I am a sole proprietor or partner- listed on the attached sheet ?,MRemodding These sub-contractors have ship and have no employees � S. E]Demolition working for me in any capacity. employers and have workers' 9. addition [No workers'comp,insurance comp'i"A rance t 10.❑Building 1�rma:al repairs or addii required.) 5. 0 We are a corporation and its 3.0 I am a homeowner doing all work officers have racereise d their I l.0 Phnnbing repairs or addil myself.[No workers'comp. right of excropdau per MOL 12.0 Rod repairs insurance required.]t e.15Z§1(4),and we have no employees. [No warkus' 13.0 Other coup.inaumce regnireed.] .11 'Amy applicant that creeks box el most dao 9a out the section below showhagthelr woken'compeasation policy infamatiou. t Homeowcan who submit We a>sdavh indicating they ice doing all work and then hire ouhlde contradors mud submit a new affidadt indicating such. ' 1Cnnkacton that check this box must attached an additional shed showing the came of the subcontractors and state whether or not these entitles have employees. Mthe sibcoMndors have employees%they mud provldetheir workers'comp.poaey member. I ant an employer that isprera7/777-fcao 'comPeirsapioa insurance for my empoyees. Below k the policy end job sib brfsnnatbn. j InsranceC®panyNa�: �lcs y/ �G✓Vl�.ri Policy#or Self-ins.Lic.#: ( /��i /SJ�I� ..7 �/ �g70/d? Expiration Date: Job Site Address-. l� I(/e, City/StatefLip: Sr�h' l CJiJ7o Attach a copy of the workers'compensation policy declaration page(abowhtg the policy number and expiration dai Failure to secure coverage as required under Section 25A of MOL c.152 can lead to the imposition of criminal penalties c fine up to$1,300.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and 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 coverage verification. - I do hereby cee(rtiff�y/�render the poins �i�i��, penalties of perjury that the information proridedpabore is hue lord eomeeL Signature: �"(,ep ytr�i: -4l Date: � / �7 Phone#: /�a8 S gl 8 5s_ 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 Americans rmaMl vc http://img.docstoecdn.com/thumb/orig/l0386444.png 4/5/2013 ACORO OP ID: M CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) ¢ 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 holtler in lieu of such entlorsement(s PRODUCER East Dougglas Insurance Agency 508�76.2107N. T 'PO Box 1370 508.476.129 Douglas, MA 01516 Ert):._ - F ----- Marc Larocque - -- __S:ER -------"ERmp;UNITE51INSURED INSURER(S)AFFORDING COVERAGE United iced Hog Company, IOC A Western World Insurance CO. NAIC e dba United Home Experts - _. .__8:CommercelnsuranIo- ompany 3.4754 200 Butterfield Drive,Suite I _ _ Ashland, MA 01721 INSURER C:Scottsdale Insurance Company - - - ----- INSURER o:America EuropeanlnsuranceCo. _ INSUREREoCN- _,_ Com an -- COVERAGES CERTIFICATE NUMBER: INSURER F: ------ ----__. THIS A ED NY 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEITION OF N ISSUED 70--THE NAMEREVISIOD gBOVEB OR.THE POLICY PERIOD CERTIFICATE MAY BE ISSUED OR MAY PERTAIN ETHENT TINSURANCE AOR FFORDED BY 7HEONTR CONTRACT R OTHER DESCRIBED HEREIN IS WITH RESPECT ALL T HE . j EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CH THIS _.. LTR TYPE OF INSURANCE ApOL30BR _ POLICY NUMBER POLICY EFF POLICY EXP -"----- GENERAL LIABILITY MM/DDIYYYY MM/ODrvYYY ' LIMITS A X COMMERCIAL GENERAL LIABILITY NPP8O23401 EACH OCCURRENCE $ 00 I - 04/15/13 04/15/14 DAMAGE-TOFRE 6 ------- ..CLAIMS-MADE X OCCUR PREMISE Eapc ace g0 Sl 'MEO E%P AnY One person) $ OOPERSONAL 8 ADV INJURYOOGENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE g . 0PRO- _-..POLICYLOG PRODUCTS-COMPIOPAGG $ 0_.__ AUTOMOBILE LIABILITY � $ B ANY AUTO : COMBINED SINGLE LIMIT -- - BOGTON 04/15/13 04/15/14 Ea accnaenp S 1,000,00 -" -.- ALIOWNEDAUTOS rSerI S ._—______- _ _ BODILY INJURY Per person! S - X SCHEDULED AUTOS - '- - - - ---.- - --- BODILY INJURY(Per am,aenn s j X HIRED AUTOS ---- PROPERTY DAMAGE X NON-OWNED AUTOS iPa acc,Cenp $ UMBRELLA LIAR XOCCUR S X EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE _g 4,000 gg - XLS0087858 AGGREGATE j_ DEDUCTIBLE 04/16/13 04/16114 '---- _;,g _ _ 4'000,00 RETENTION 3 - WORKERS COMPENSATION '$--- AND EMPLOYERS'LJA8IWTY WC STATU- D ANY PROPRIETORIPARTNERIEXECUT,VE YIN ____1WC T TL IT X T OPFCERIMEMBER EXCLUDED' I NIA WC'C5010274012012 08/15/12 08/15/13ER IMI MMatory in NH) L— E L EACH ACCIDENT - S -_ ...._ SOO,OO If yes Essence ureer DESCRIPTION OF OPERATIONS Delaa _E L.DISEASE-EA EMPLOYEE S_ _ SO0,00 iA Personal Property NPP6023401 E.L.DISEASE-POLICY LIMIT $ 500.00 04/16/13 O5116/14 PERS PROP 93,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES IAEeCN ACORD tat,AEEitional Remarks ScheEWe,R morc apace is repulreE) ('Supplemental Name' (CUnited Painting Company,Inc.DBA United Home Experts&United Painting ompany,LLER CERTIFICATE HOLDER CANCELLATION UNITP02 LD ANY OF THE SHOUEXPIRATIION H DATE VE DESCRIBED THEREOF, NOTICE POLICIES ILL CBE CELLED DELI DELIVERED BEFORE 11 IN United Painting Company, Inc ACCORDANCE WITH THE POLICY PROVISIONS. 200 Butterfield Drive, Unit 1 . Ashland, MA 01721 AUTHORRED REPRESENTATIVE Marc Larocque f�G ACORD 25(2009109) ©1988.2009 AD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CITY OF SAL.EM, INLA SSACHUSETTS • BCILDNG DEPARTMMNT k 130 WASHLNGTON STREET, 3° FLOOR TF-L. (978) 745-9595 F&x.(978) 740-9846 Kl-%jBFRT RY DRISCOLL MAYOR THot�L+s ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BCILDNG COOLiIISSIONER 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#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 MGL c 111, S 150A. The debris will be transported by: �Z -21 e�w r��5 /(name of hauler) The debris will be disposed of in : �_..__. (-nammee of facility) (address of facility) signature of permit applicant date JcbrisaiF.J=x Off iee of Consumer A I 17a its&mhus B / mTIMM -, iness Reguiali,:1 015OME IMPROVEMENT CONTRACTOR Registration: 157108 Type: Expi;ation. 9/5/2013 Suppleme!jt UNITED HOME EXPERTS MICHAEL DUDLEY 200 BUTTERFIELD DR STE I ASHLAND, MA 01721 Undersecretar), kill Ecato ot Bullclinc Peaujpli—'n� ;n') lldofas License: CS-1000' D6D' MICHAEL K LEY 137 CENTRAL STANI't 3' ASHLANDMA 01121, Comm'ssi one, Expiration 05/06/2014 6 NFRC` la::cznt_cr.: .cioblt y 1 cet.:ii:a de - National FeenU aea . e CLass r e;,yna Ci Rat Council® •. y i.g ,%,lass ! __`. No Carta _ r Lias A11 tt- Gri•'•s RATINGS ENERGY PERFORMANCE EVALMOON DE RENDIMIEMO ENERGERCO Solar Heat Gain Coefficient U-Factor Cceficiente Gan ancia de Ehergla 5olar Factor-U t ICI I rti tl ba " ADD flONAL PERFORMANCE RATINGS EVA W ACION SUPI.EMEMARIA DE RENDIMIEMO Visible Transmittance Tmnsmision de La Visible ;; • 41 NMMEWWEEMWM�Manufacdrer,tpubtasthatthese mfirgs mmoaato applicable NFRC PreceduresfordelemliNFR don�e Dom, ,MM1my.NFRC Mangaare demaniaed forafaed ser oI env1eMM dW condlboaa end aVeCfic Productsie;. jaa, M,inotrecommend Pef"oe"t and does a dni'Mried f mitebild setol a Dioducte,ImomtecHiC uS<+e+.nfm.er9 anumcmrers lileramre mramer DroductPedarmance t ,Mat Eyre mbrmenm esapula Sue eslos valetas m,,Im conlwpr dimOymaPlimbilde NFRCpmdeWm"el rendimiematotal del ue el produclosea ademado paraw use esw ffiae.Consulte mn el prfabr1 Los�amreauszdos Wr NFRCsen determiredoa per un Mjuneo file tle eaniiciones embiemalea Y Datorwo de Made especalcD.NFRC M rec eendafollnetodel l8bdcant0 a aprfi°piado tle esm Praducto.w nfiaurg L t r gca11Y-ca T"= Not th �'o.+^F - Can coal. go.+ihcrn' IP�N�Y STAR La uniaaC ca iii ica pars is lsl 3TC: NiA ' ¢ ` ragi6i; s) STIRC,CY =TAF-+t;act`_ .�su .t•. t;i,. N_r'- Cif icel, our _ _ S:vh: Fa i;, v'C JCl zss 1. - Tastad Taxiaiio Ocobado: 1°1.s �M > 273.2 cm Tat y. pC? so-artfk'V . To team mare v¢itvrxw.enelgysmcgov r ov. Reep this label for pmstle ENERGY STAR®rebNeil Goggle amefiqueto pom posiMes reembolms ENERGY STAR®Pem mnorer mds acara de node Zeevraw.energysm.q