44 WARREN ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALLhI
( ` Revised.t lur_'ill l
Building Permit Application To Construct, Repair. Renovate Or Demolis
One-or Two-Fonrih Dtr.11okq
This Section For w al Use Only
Building Permit Number: ate Applied:
�tr \ --9
Building Official(Print Nmne) Signatu Date
SECTION l:SITE INFORMATION
r1als
rty Address: 1.2 Assessors Nlap& Pa el Numbers
s an accepted street?yeses no Map Number Parcel Number
1� r�.'�3 Zoning Information: p _ 1.4 Property Dimensions:
! District Proposed l x l oning D Lot Area(sy It) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c. yU.§54) 1.7 Flood Zone Information: I.a Sewage Disposal System:
Public id" Private❑ Zone: _ Outside Flood Zone? Municipal$'On site disposal system ❑
Check if �es❑ li
SECTION 2: PROPERTYOWNERSFi1Pt
2.1 Owner'of Record:
tmo�&A,I-J r3i�5o►2[JSiN4Y.1 fir . I cp ot4to
N;ni'c(P-r-iint)��"�+-+ � City.State,ZIP
`/'
Nu. t`id Slrttt ` g �
P un t:nlall Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ EExisting Building❑ Owner-Occupied ❑ Repairs(s)�' Alterations) ❑ Addition ❑
Demolition ❑ ssory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 1A2G4 lapu
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
I Labor and � n
Iaterialsl y
I. Building s �D _ I. Building Permit Fee: E Indicate how fee is determined:
2. Glectrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
7, Plumbing 2. Other Fees: S
4. .%dcilumical (MAC) S List:,__ —
< \ledtanieal (fire
.tit trcssionl S 'rot:d All
Check No. Check Amount: _ _ Cash Annnutl:
G. Total Project Cost: S 0 Paid in Full ❑Outstanding Balance Due: _ _
/ P
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Number [Apiralion Date
Ninlc of CSl. IIulJcr -�
�,.�., � _ ListCSI.1)pc(see helowl
� _O ..------- -I s.pe Description
No. :aid Street
I Inrestricicd(Buildings up to 35.000 cu. It.)
ItRestricted 1&2 Family Duelling
iTnN 7rM%n.State.ZIP Ni Nlasonry
RC Rtwlin C'ovcrin
W'S Window;Ind Sidon
SF Solid Fuel Burning Appliances
I Insulation
felctillone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) t VIyOCF `� ZT 2AF
i IIC' Registration Number Ax1,i rat ion 1 ut
I IIC C'ompan ame Jr I IIC It islr Name
No. d Street _ Email address
Cirv/Town,State,21P fele hone
SECTION 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.
III Signed Affidavit Attached? Yes .......... la-' No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject pro erly,hereby authorize
to c on my behalf ' matter relative to work authorized by this building permit application.
Print Owner'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 of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
print Ottner's or:\uthorized,%gnn's Name I Electronic Signature) Data
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 Hume Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under NI.G.L.c. 1 q'_A.Other important information on the HIC Program can be found at
w,tts ;,r.l Information on the Construction Supervisor License can be found at t>�+y,mas�gip) dps
'.-When substantial work is planned, provide the information below:
Totai floor area(sq. ft.) I including garage, finished basement'atties,decks or porch)
Gross living area(sq. tl.) Habitable room count
Number oftireplaecs _ `umber ofbedroums
u
Nmber of bathrooms _ _ Number of half b.ttlu
l)po of he.tnng system Number of decks, porches.
I\pc ofcoolutu N%stcnl _ I nel sed . Open
3. "total Project Square Footage-may he substitulCd fur"Total Project Cost"
J w C
r
9'pT�P111VB
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX (978) 740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ _ Construction ❑ Moving
-12�, Reconstruction ❑ Alteration
❑ Demolition
❑ Painting
St na e
S 6 ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 44 Warren Street
Name of Record Owner: Miroslaw Kanwrosincki
Description of Work Proposed:
Repair/replace porch to replicate existing, reusing as much of existing materials as possible. No chanr_,Tes in
color, material, design, location or outward appearance. Non-applicable clue to being in kind
n urrntcncrnc•ch•eplcrcement.
Dated: August 23 201
— l SALEM H A IN[[SS[ON
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year From this (late unless otherwise indicated.
I HIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits lion die Inspector of
BUildings (or any other necessary permits or approvals) prior to commencing work.
CITY OF S.0 EMI AASSACHUSETTS
SULDLNG DEPA)MLENT
120 WASHNGTON STREET, 3iO FLOOR
TiL (978) 745-9595
FAX(978) 740.9846
K1NtHE.RLEY DRLSCOLL
MAYOR Diou'U ST.PlMit"
DIRECTOR OP PLBLIC PROPEATY/at:MDLNG COSMISSIONEA
Construction Debris Disposal Afttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l Debris, and the previsions of MGL c 40, S 54;
Building Permit Is is issued with the condition that the debris resulting from
this work shall be disposed of roerly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
/
(name of hauler)
The debris will be disposed of in
(name of facdity
210 ld an P 1() [J9 0
(address of facdity)
siynamre of permit applicant
D_
�.IfC
CITY OF SALEM
PUBLIC PROPRERTY
V r=
DEPARTMENT
i V�6 NI I YI 1AM l ql
\I%r.41
I!:\Vnrr n.�wa u.�i i a ecr • Jn l r w,M.w rsev,t o a f i r J I77:
Ihl. '/lp,'tS•riu3 • Fw.r v/x•7rC•'IMM
Workers' Cumpensaitlon ►nsurunce :\i0duvit: Uuilders/Cuntracturs/Elecirldvns/Mlumbers
� 1 Illcant In ormalio
?I riot u •bl
V:I ITI1J IIlua�krLi7r;{nlvninlYlnJlYnluall:_IaA �) .
City,Srarc.%ip 4,rw_ p�_
1'hunr 11:
•\re y nu an eugiloyer'l Check the apprnprlate box:
I ❑ I and a :mpluyur with 4. ]nh
tyM fit project(rcyulrrd):
enlpluyves(roll antUur purt•tinte).• a hove hiredbcoi,u aua�o rsr and l /i.
❑Now construction
'•❑ 1 ant a sole prnpriwoo or partner• listed on thhcd shout t �• ❑ Remodeling
ship and have no wnpsuyves These tub- tore have
wurking tier ma in any capacity, workers'cosurance. g' DemolitionI No workers'cutup, insurance J. ,�we are aeoion and iN 9. ❑DuiWing additionrequired.) nlYlecn havined their 10.[]Electrical repairs or additions
).❑ 1 am u hntncomwr doing all work right of er. par MIL 11.0 Plumbing rcpuirs or additionsmyself.INo workers'culnp. c. 1J2.j 1(4e hnva noinsurance required.!t CmPloyces.Irkers' 12.0 Roul'repairscrnnp insursuirvd.l 13.0 alltor�ntr� 1"Q LPQ`„�
•.r�q•;grLcar Ufa cheeYr ae•eb mop slat fill url iM.eclwu Iwlur awrruq rMir NrNYuI'ewln,IpnLNrlun INaier mriulnwiun.
th t ch w,s Itsis Ail amaNvil iMeL'Jline iAYr nr wine dl work.,Nl ihul Alm aW.idr rYrrrntrpr owl w1w14•new J(rdswil in,l(�,tinx wlhk,
'r'•.nlrhnNr Ihp tlwrk whir ke1 nIW1 Jrl;hid.IN Wall(uMl..hg1 Jluwine Ike naNN Or IIM IurlarrNliCIJn.1Ne Ikrr UYrkrle'rr"'�,(stilts iNaxrNa111M1.
irrf/urn un employer that h prul'1di"workers ru/nprnm//on Lrsurrmce/br iffy rrnp/eyeen Be/Div Is rho puB.y and/ul.rire
urrnutJrrra
Insurance Compaisy .14,11ii d
•+h.4r.cssQ_.
Policy 4 ur Scir•ins• Lie.n: Oq7 a ,;4
I .. . ERpiration Dare: A /L
Job firs-\tltlnss:
a . C'ity,Slateizi
p: �`9�I•,;••)\ttach cosy or the warken'cmnpanratloN Polley IleelaraNun pugs(showing this Polley numbur and expiration date).
Palluru to wcure Coverage as required under Secliun J.IA ul'%IGL c. 152 tan lead to the""Position of criminal Penalties o/a
tine IT m.ILJIIOJN)anJ/ur une•year iinpn.r.nuncnr, ar well ar civil llcnalncs in the turul of STOP 1YURK ORDER and a lino
ofup rn i?JO.On is Jay IgainN life vLNanrr. 1leadvL+cJ thus a cuPy ufthis>tatcmens may br IurwarJed to the RDE ut'
Ins,atiga'I'nls uI';he DIA for m.nr:mcc:ovcr.l3a wcririuuun.
/du hereby r..rrily Iunler Ibe point,InJ prrrrdticr of prr/ffry that the iu/unffellon pre Yided Y�640rre is if rlrld l'Olrerl.
I)%/lciu/rut ulify, /)u nor wrier ire Ih/r ury•u, tube rump/.led by.iry up roiYn a//lridL
1 (ity ur I•n,rn:
` - Pcrmiul.lcvnvr e
I trains .\uthnrily (circle anc):
I. Ilya it Ilvvhh ). IludJinq UvP.lrnncul 1. Cis).'rolw C'Icrk 4. L•'ICctric.J Im Icclur ;,
G. 1)Iher
I Phnnbing Inryccrar
i
"-
-�_ I'hune 9:
Information and Instructions
roll In the service of another un,ler.Illy contract of hire.
�I,I,;Acltu;etts G:neral Laws chapter I i2 IegUlre7 all CIIII)IJyCf7 to pfOVIdO workers' CJinpeO%al1Un hl( their elllp JYCt7.
I'ursuanl to tills astute,an eetpli is Joined As"._every {>< .
,,Press or un PG:d, Jral Jr written." or an two or more
�n ernpluyer to defined as"an individual.P
urtnanhip,assOCII111 , corporation ut other legal 41 lu cr Jr the
.I the IJrequuld engaged m a Jutnl enarynsa,And including the legal representatives a c Ployees. However the
f the
(,%elver Jr trudge of.m individual, petmershtp,atsocnamoo or other legal endsid y.employing
Woos to do maintenance,CunstruCtion or repair work on such dwelling house
owner of a dwelling house having not more than three aPartnlents and who resides therein at the occupant e
.Iwe sling huusd of another who employ. persons
or on the grounds or building appurtenant thereto
shall nor because of such employment be deemed to be in employer.'
N,IGL chapter 152, i:SC(6) also 7larde that"even slag or local licensing agesey sbae withhold the lis for a or
crate a business air to construct ou
with thesin insurance coverage in the required
renewal of a ohaslicense or permit to c fable evidence at cutup political subtlivisions shell
;nypllcunt Nllo has not produced ace+D
additionally, -ii chapter 151. 3'-SC(1)"rates"Neither the cemmonwble a our any of its 1
corer into any contract for the Performance
of pub the con lic work �ract a author tyviddnce ol'cmupliwlce with the insurance
requirements of Ihis chapter have been p'
.applicants the boxes that apply to your situation and.if
lorts)Of
ple:n+a rill.rat the workers' cumpellsat"m aly davit completely,by checking
s addressles/aid phone number(s)along with their cartilfcucics other than the
necessary,supply pub controctor(s) llama(. ), LLP)with no employ
worker' compensation insurance. If as LLC or LLP doer have
insurance Limited Liability Companies(LLC)or Limited Liability partnerships
netmbers or partners, are not required to carry be submitted to the Deportment of Industrial
employees.a policy is required Be advised that this affidavit nay
accidents for confirmation of insurance coverage. Also be sun to ilea end Jute the u sled,n The affidavit show
ld
omit or license is being requested,not the DcpsAment of
ions regarding the law or if you ate required t, obtain u workers'
he retnnnred to rite city at town that the application for the pe allies should enter their
Industriul Accidents. Should you have any floods'ent st the number listed below. Self-insurcd comp
compensation policy, please call the Deptsrrfn
Self-insurance license number on the a ro riute line.
City air Town Omclol.
The Department has pruvided'a space at the buc��
the app
Please be sure that the affidavit is complete and printed legibly. hcant
.If the Affidavit for you to sill out in the event the Oliiee Jf Investigations has to contact your in
p lications in any given year, need only submit one Zcutiuiflifinvn iadicotine current
I'I:ase bd+ore ro fill in the permiUlicarse nwnber which will be used as a reference number. In addition, it upp
dell mutt submit multiple PenniUlicense applications
p be provided ro the
policy information(if necessary) and under"Job Site Addtesi'the LAPPlicant shnuW write":Ill lucutiuns in (cnty or
ruins." A copy of the uf7ldevit that has been officially stamped or marked by the city or town may P
town)
as proof that a valid affidavit is on file for future Pel'"i at licenses. A new affidavit must m tilled nut each
applicant Jar, is a home owner or citizen is obtaining A license at permit not related to any business id commercial venture
dug license home
a Permit to burn leaves etoJ said person is NOT required to complete this atfi�uo how.m uetuems,
I he I>itice ut Inveaigatiuns Iwuld Itke to think you un advance Fur your cooperation and ShuulJ y Y 4
Meese du nut hesimrd to give us a Call.
ncc u:parnncnt's Addfdls, telephone and fax number'
The COM MOnwealth of Massachusetts
DePaMent of Industrial Accidents
Office of feveadQadons
600 Washington Street
Boston, MA 02111
'ref. )$ 617-727-900 6CXt 17 702 of 1-977-MASSAFE
;.In.us www,mau.gov/dis
Rug 25 2011 11 : 24MM HP LRSERJtT FRX p, 1
NOTICE OF ASSIGNMENT
EMFLOYL^R `' COMBO 1.0, RTATUO OF EMPLOYER
NUZA ROOFING CORPORATION 112 PATRIOT PHWY OpOB81805 Corporation
REVERE, MA 02151 COVERAGEOROUP -
0929130
The Waiver Of Our Right to Coverage undor thin m2signment
Rocovor from Othora Endaracmcnt applies to Massachusetts
is available on Pool policies. OpeXaLiona only. For eoveCageOuL"Ide Of NassachuneLLa, COOLacL CcnLacL your' a9enL for ds Laile. the appropriate Pool or plan for
that state.
AGENT FLAGSHIP INSURANCE AGENCY INC INSURANCE COMPANY:
OR DEBORAH L WAUGmrAL AMERICAN ZURICH INSURANCE COMPANY
PRODUOER: PO BOX 40399 Sonachan Scharnberg
NEW BEDFORD, MA 02744 P O SOX 3556
ORLANDO, FL 32802-3556
AGENCYFMPN:261469799 (800) 453-9843
CLASSIFSCATIOA• OF pPERATION CLA89 ESTI?4kTED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
REMUNERATION
PAINTING OR PAPERHANGING NOC a: SHOP OPERS, OR 5474 $0 d 09 -
ROOFINU-BUILT VP - YARD EMP & DRIVERS 5547 $0
ROOFINU NOC & YARD-EMP, DRIVERS __ _ $10,Ou0 17.07 $1,707
"CARPENTRY=:DWELLINGS - THREE STORIES OR_LESS - 55 554745.sl $2, 500 30.99 - $775 --. -.
CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 5645 $0 8.66 - $0
CARPENTRY NOC 80 8.68 $0
EMPLOYERS LIABILITY 100/100/500 5403 $0 9.61 $0
STANDARD PREMIUM 9845
EXPENSE CONSTANT 0900 $2,482
TERRORISM CHARGE $338
TOTAL POLICY MINIMUM PREMIUM 9740 $4
TOTAL ESTIMATED PREMIUM $500
DIA ASSESS. 5.93 $2,624 .
$146
TOTAL EST, PREMIUM PLUS ASSESSMENT - ----------
INSTALLMENT BASIS: AnDua3. - DEPOSIT PARMWMN $2,970
TNIS IS ND7A ILL
COMMENTS
Coverage effective 12:01 AM on 08/19/11
Subject to 09/23/11 Anniversary Rate Date.
Add endorsement WC 00 03 08 to thinpolicy. An approved foam 153 - Affidavit OE Exemption
for Certain Corporate Officers or Directors - was Submitted with this application.
The Workers' Compensation Rating and Inapeotlon Bureau of Masseohusetts
101 Arch Sbeat• Boston,MA 02110
(617)439-9030- FAX(61T)439-0035•www.wcdbmB.org
08/29/2011 11: 39 61735404011 PONTE INSURANCE PAGE 02
ACOKC7" CERTIFICATE OF LIABILITY INSURANCE DATE(M9/2111
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Al. POINTE INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
819 Cambridge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Cambridge, MA 02141
(617j492-7600 .. _ INSURERS AFFORDING COVERAGE NAIClF_
INSURED Nuza Roofing Corp INSURER A; COlOnV Insvrance _
112 Patriot Parkway INSURER B: „- ..
Revere, Ma 02151 INSURER C: .-_
INSURER_D: _ _ __
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWDTHSTANDING
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. _
ILTR SR POLICY NUMBER P ICYM?DDB�E POLICY
ATE MMID�RA LIMITS
LTR SRO F D
GENERAL LIABILITY EACH OCCURRENCE S 1 o00,000
COMMERCIAL GENERAL LIABILITY PREMISES(Ea PPF 'L.j_ S 50 ,000
CLANSMADE I_IOCCUR MmEXP(my anaPSrEDn( B 5 ,000
A -., _ GL3669326 11/10/10 11/10/11 _PERSONAL&ADVINJURY S 1,000,000
_GENERAL AGGREGATE S 2,900-,.000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPCP AGG $ 1�000�000
POLICY P O- LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANYAUTO (ES emldwt) S
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per peraan) B
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Par Acedanq $
PROPERTY DAMAGE B
(Parecadent)
GARAGE LIABILITY AUTO ONLY;EA ACCIDENT 4
ANYAUTO OTHER THAN EA ACC S
AUTO ONLY: ADO B
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR �I CLAIMSMADE AGGREGATE S
S
DEDUCTIBLE $
RETENTION S
-_ -
WORXERS COMPENSATION WOS'rp1V-
AND EMPLOYERS'LIABILITY IN TORY.LIMIT9
ANY PRDPRIETDRmarrmEwENEcuTrvE Y� EL EACH ACCIDENT S
OFFICERM.EMEEA EXCLUDEO9 -'
(MaaaANNy In NMI E.L.DISEASE-F-p EMPLOYE S
IIy�a deealbn under
SPE61AL PROVISIONS OFIOP E.L.DISEASE-POLICY LIMIT S
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLPD BEFORE THE EXPIRATWN
City of Salem
Salem Ma DATE TNEREOP,THE ISSUING INSURER OVAL ENDEAVOR TO MaR 1O DAYS MITTEN
NOTICE TO THE CERTIFFMIL HOLDER WMEO TO THE Lg".MUT FAILURE TO DO 90 SHALL
IMPOSE NO OBLIGATION OR UARIUTY OF ANY KIM UPON THE INSURER,ITS AGENTS.OR
RvIansnNTAT
AUTHORIZE RE N IVE '
ACORD26(2009101) 9 -2009 ACORD CORPORATION- All rightsreserved. I'
The ACORD name and logo are registered marks of ACORD
44
ty�* s� w'*� a`;qn 54,. Ilid REICi(q�`e
Construction Supervisor tcense
� �Licer�se CSy100572 � � ��+ •,'�
:. Reslnct N61�00
IUIS Nl1NEZjt '
112'PATRIOT WAY°
y REV 6E;MA 0215-1 - x
,t { , t ,t
Exparanor! 3/1712012012 J;
�—,= irealfle ro�,✓C�.o4usc%emeCk
y-ns� Office Of COosumeseAftairs&B smess Regulation
- IU
, HOME IMPROVEMENT CONTRACTOR -
Registratlon 154045 Types
Explration: 2 5=13' Private Corporatio
N ROOFING
112 PATTIOT PKWYZ
ccvcoc sse noss�"