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44 WARREN ST - BUILDING INSPECTION
as The Commonwealth of MaSSa ILISCUS Board of Building Regulations and Standards Cl OF 1 'I• ;, Massachusetts State Building Code, 780 C NIR SA EM N.�risrd / Building Permit Application To C'unsintct. Repair, Renovate Or Demolish a I h One-or Ttvu-Funiill Dwelling This Section For Off!•' I Use only Building Permit Number. D e Applied: _ UuilJing 011icial(Print N;une) Signature Date SECTION I:SITE INFORIIIATION I.I ,9ff-eM' r7` Property Address: 4 1.2 Assessor M1lap St Parcel Numbers w 1.la Is this an accepted street?yes_.11 no Map Numher Parcel Ntuot r 1.3 Zoning Information: 1.4 Property Dimensions: Coning District Proposed Use Lot Area(sq It) Frontage(II) 1.5 Building Setbacks(R) _ Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 116 Water Supply:( . I.c. 40.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check iY --1 Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' e� 2.1 Owner!of ecord: u�nme(P�—�h 294F 0,ate, - �-tv .Oil 7n ge.. S� uq.JWte,nP !� No.and Street 9 1r e d' �Q'0 relephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demulition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief D s iption of Proposed \Vork': � J SECTION a: ESTIRIATED CONSTRUCTION COSTS Item Estimated Costs: - Waborand.\laterialsl OMCIAl Use Only 1. Building S I. Building Permit Fee: 5 Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier i. Plumbing S 2. Other Fees: S - 4. .Mechanical III\':\(') S List: \ledianicat t Fire __ ------- - Su,*nssionl S Total :\II Fccs: 5 Check No, ('heck :\nwunt: C',uh:\mouln: � Total Project Cost: S ® o©- p — — ❑ Bala-- q ❑Paid in Full Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Cotlstructioll Supervisor Licellse(CSI.) Cis�Q^ /� _ q 11 (1z. License Nunnher —I I �-pii/,IuuutUnc Namc of C SI- Holder List CSI,1)P+'(ss below) I) Description _ _ YPC No. and Street ll UnreslncleJ(Buildings;ki'r,to I5,1100 cu. Il.l - _�pi�/-Qt�� R Ncstricted I&'_ Famil L M%cilin Citvi Foes,Stnte.L41' M Masoory RC Rootin C'ovcrin INS Winduw.md Siding SF Solid Fucl Burning Appliances I Iasulaeon telephone Finailaddress D Demolition 5.2 Registered Home Improvement Contractor(HIC) l � if IIIC Registration Numinr li. plrat m1YTulc IIIC'C'om 1 1ne a IIC 1 vtml Name N. ld- •.t � L'muil address ft- Ci /Town.Sate.ZIP rnic 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. Signed Affidavit Attached? Yes .......... ❑ No........... ❑ SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize 1JL±S1 y to act on my behalf,in all platters relative to work auth �ized by ibis building permit application. M1 V ai L lc7-`1-11 Print owner's Nmne(Electronic Signature) - Date SECTION 7b: OWNER' OkAUTHORIZED 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 myknowledge and understanding. /I/ f.+ ti li C�/ `� to`//- l/ Prim Uener's ar.\uthurired,\gcnt's Name Ililcctronie.Signauvel Dutc 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 no 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 ,,,,,, in.i.. +, o,.i Information on the Construction Supervisor License can be found at din, 2-7 When substantial work is planned, prov ide the information below: Total floor area Isy. ft.) _ (including garage. finished basement attics.daks or porch) Gross lining area(sq. It.) _ - Habitable room count Number of fireplaces...-- .-- _ - _ Number of bedrooms Numherofhadimmns Numbcrul'hall'hallu - I\pe of heating system Number of decks, porches I'\pC i,l iPUhllg s15lelll 1. "I'oial Project Stivare Footage-oun he substituted Ibr"focal Project Cost" Oct 04 2011 11 : 26FM HP LFSERJET FFX P41 NOTICE OF ASSIGNMENT EMPLWSR: �,..— COMl06D. sTATUSCPBMPLOYER NUZA ROOFING CORPORATION 000681805 Corporation 112 PATRIOT PRW1( COVERAGE GROUP REVERE, MA 02151 0928130 coverage under this assignment The Waiver of Our Right to applies to Massachusetts Recover from Others Endorsement operations only. For coverage in available on Pool Policies, outside of Massachusetts, contact Contact your agent for details. the appropriate Pool or Plan for that state. J~ 2ORLMDO, NCE COMPANY: AGENT FLAGSHIP INSURANCE AGENCY INC CAN ZURICH INSURANCE COMPANY OR DEBORAH L WAUGHTAL PRODUCER! PO BOX 40399 han Scharnbarg NNW BEDFORD, NA 02744 OR 3556 FL 32602-3556 453-9643 AOMOYFEN7 261489 79 9 _ CLASSYFICATION OF OPERATIOP CLASS ESTIMATED RATE EBTIMP+TSD CODE TOTAL ANNUAL PREMIUM ' REMUNERATION PAINTING OR PAPERHANGING NOC & SHOP OPERS, DR 5474 $0 5.09 $0 ROOFING-BUILT UP - YARD EMP & DRIVERS 5547 $10,000 27.07 $1, 707 ROOFING NOC & YARD EMP, DRIVERS 5545 $2,500 30. 99 $775 CARPENTRY-DWELLINGS - THREE STORIES OR LESS 5651 $0 9.68 00 CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 5645 $0 8.69 $a CARPENTRY NOC 5403 $0 9.61 $0 EMPLOYSRS LIABILITY 100/100/500 9645 $2,482 STANDARD PREMIUM $338 EXPENSE CONSTANT 0900 TERRORISM CHARGE 9740 $4 TOTAL POLICY MINIMUM PREMIUM $ TOTAL ESTIMATED PREMIUM $2, 824 24 DIA ASSESS. 5.99, - ---------- TOTAL EST. PREMIUM PLUS ASSESSMENT $2, 970 INSTALLMENT 6ASI8: Annual DEPOSIT PREMIUM: $2, 970 THIf M NOT A e8-L 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 this policy. An approved Form 153 - Affidavit of Exemption for Certain Corporate Officers or Directors - was submitted with this application. The Workers' Compensation Rating and Inspection Bureau of Massachusett 101 Arch Street• Boston, MA 02110 (617)439-9030• FAX(617)439-6055 •www.weribme.org ACORO® DATE(MM1/DD/YVVV) CERTIFICATE OF LIABILITY INSURANCE 9 2s 2011 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION AL PONTE I 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 617 492-7600 INSURERS AFFORDING COVERAGE NAIC# INSURED Nuza Roofing Corp INSURER A: C010nV Insurance 112 Patriot Parkway INSURER B: Revere, Ma 02151 INSURER C. NSURER D: INSURER 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. PISR NDDL POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSRD TYPE OF INSURANCE DATE MM/DD/YVVV DATE MMIDDIYVYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 DDD OOO COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $ 50,000 CLAIMSMADE C OCCUR _ MED EXP(Any one person) $ 5 000 A GL3669326 11/10/10 11/10/11 PERSONAL BADVINJURY $ 1,000 ,000 GENERAL AGGREGATE 8 2 000 000 GEN'L AGGREGATE LIMIT APPLIES PE : PRODUCTS-COMP/OP AGG $ 1 ,000 ,000 POLICYFI PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANYAUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Pet person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR C CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH - ANDEMPLOYERS'LIABILITV YIN TORVLIMITS ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ ' If yes,describe untler SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION City of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Salem Ma DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESEIJTATIV { / fir; ACORD25(2009I01) D 1981,2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT I!� \VnuuAaa uv Jls[A)' • Jau•w,M1Lh1,ra.ln a i n J177: I'h1. •�7Hli'ti'i! � f l.x vlx•7aC•'ixM )Workers' Compensation Insurance intlavit: Oull 1 )Ilcant In irtnation den/Cun tractors/E(ectr(c(yns/P(umben PI a+ Pr(nt Le 'AI Vi11TC 111uul,erait7raantrJiinNlndlrnluull: /�/ (tr Q..dL 20 r9 •� jt•i lr l'O,e N\ItIres.l: !/2 /�� )`/�D1` p lL cl ,stal :ir e(i G � 824FoGo � a q s b�� Phone N: '� ` I .lire y nu an employer:'Chvek the appruprlule box: 1.Q I ant a empluyur with 4. Q 1 am a genera)ununetor and I I yl"of proJuet(reyulred): ampluycvx(full Jnd/ur pun-lime).a have hirvi the.aub•cunaacwrs f' Q Kew construction 2.0 1,In1 a sale proprietor or partner• listed on the anached.rhect )• ❑ Remodeling ship and have no cmpluycv's These subcontractors have working Air me in any capacity. ,vorkers'comp, Insurance. V. Q ntmolirian I NO workers'cutup, losurance J. (� We are a colporxtinn and its 9, ❑ Building addition ).QnyuireJ.) lt)iecn have exereisad their IO.Q Electrical repairs or additions I and a halrn:uwner doing all work right oruaemption put M1IC6 I I.Q Plumbing rupuirs ur additions myself. .) rr;nrken'comp, c. l Jl,§I l4).arts we Mira no imuranco required.) r employees, (No workers' I�•Q Rnol'npuin ernnp in.urancomyuired.J IJ.QUdter •ln/.,,phroe Iha1 chcha Doa el muY:Ilan rill cut the arcnan Wow"Will$lism wwkwi cunlyanwttwa policy nlliu111arIwA 'I14nhn,wrwn she"Alma this an anvil irdlaalind that'us,loins all Vurk ins IAaI him awa14/cwernelpra Mimi aah,nY a new J104sait Inaicalinx vwA. r,Mlrwhe9 Ihsl t.haek'his Arx Missile JnaAes,In.aaiiiwYl,Ap,,Aawiue Ills nanM CrrN 111r1•eontracWra and Thee oudew'c".plllay In/effll,p,juL/am If.vrrpluyrr that/r prvvlJ/nx ivorArra'rutnprnration hlrurvnre/ur my r/np/uyrrr. Bdmr is rhrpu/I�y unr//u1 ails inr/urinutGan, InauranccC'umpaty Vane: I'nlicy 4 of Sul Gins. Lic.M; (r/3 (' -�--. loll )its ,\ddn•ss:��- � !/-r<f�'� j� C11ytstaler Zip: .Saac.Utach a crlpy of Ilw workers'cumpenxatlnn pulley Juclrrallun puye(showing the policy number and explrallun date). PJilur: to ucum coreruge as required under Sucliun 'JA ul'JIGL c. 151 eau lead i'J M to the imposition ol'criminal penalties o/a Arse till ro S 0 A1 10 Jn r .1 Jay Igd/ur uae-year hnpris,mment, Js troll J.e civil pertain"in the lunn of a STOP WORK URGER and a rtne V up ro uinat the vialJhv. Ile advi.a,•d that a copy urthis.dulvmunt may be turwarded la the oil Ica of In\'e,rll�Jllutb al :he UI,\ :or nl.ur rce enrcrJyc ,exilic Jhun. /du/arrAy r rrli/y larder the paint and pnrnhiee of pn/nry/but the hi unnullow/ yrvridrrl ubuvr/x true"I'd rom Clit 7:___rile ncO pI/.i llrlh uurceaa, iclvn'fryletrPJc bryln oiuilyl.Iuery/ntaier oY nClerk s. Cluor iac/./)l Il rlrouLy rccrur i, rh//m,b iny Imyecror Vt i i information and instructions v s non m the service of another miler.lily conlmct of hire. \LuiJ:hLL+ens l,:neral Laws chapter I i2 ,cyturcs all eugiloyers to provide workers cu�npensaunn tat their cnhV uyees. I`ursu.uu to tills.lituld. an rmOlorre is dettneJ as every P• : ,,press or implied. oral or wnnen." oration or other Icgal cntiry,or any two or inure he �n eon;,oluper,+detincJ as"an Individual, Partnership,assoecsnuo,carp ,,t the lrego,,,g engaged J to In vm loyees. However the vd m a milt enterpnsa, and including the local gal en tily.c es lO a deceased employc4:V t ,center at uuatee ul'.u, iudivldual, pe,menhtp, assocwtioo or other legal entry,amp Y g ' ant of the Woos to do maintenance,cunstruction or repua work on such dwelling house owner of a dwelling{house having not,pore than thrt o apartments and who resides therein,or the acts ,Iwcll,ng Ihuuid of another who employ. Pe or,,tt ,he grounds or building appurtenant thereto shall not because of such employment be deemed to be an e,nployer.' \mGL chapter 152. 425C(6) also states that"every state or local Ilcensleg agraey shall withhold the Issuance or urged: renevrul of r Ilconsa ur peril{to uyarafe a business or to coestruet bug mO Nigh the la tha insurance coverage cal suolootabdivisions i lis for any shall ;,ppllcunt wile has not pprodu produced acceptable abl esr'Neiniher the onct of unonwo lath not MY of its Political required." \aditionully, -,IGL chit ter 15_, I- enter lino anY contract for the perfomsanec of public work until acceptable evidence u1'cunlpliwlce with the uhsuranca roquiremene of this chapter have been presented ro the contracting{authority." Applicants to our situation and if y checkin the boxes thtuaDP1Y Y adJresilee)and Phone numlter(s)along with their cartiAcate(s)of Please rill out the workers' compeusarion affidavit completely.by with no employers other than the necessary supply suit-contractor(s)nana(s), Insurance. Limited Liability Companies(LLCworken'Limitcom pensa oed Liability e insurance.(if an)LLC or LLP does have nemban ur p,nnan, an not required to carry be submittod to the Departmennt of Industrial enhpinyeas,a Volley is required Be advised that this altidavit,ttsy \cciJents for confirmationrequire of insurance coverage. Also ba sofa to raga and Jula the ufpdavn The affidavit shoal tustioas regarding the law ur if you are required to obtain s a should enter he rammed to die city or town that the application for the permit or license is being requested, not the 9 workers' of Industrial ,%"{dents. Should you have any y compensation policy,pleas•call the Department at the number listed below. Self•insureJ companies should enter then ,elf-insurance license number an the a ro riute line. city or.rawe omelets tunl oil to till out in the event the Office of Investigations has to contact you regarding the applicant. please he aura that the affidavit is complete ;Ind printed legibly. The Department has provide)u spud at the t cant Of file affidavit for y I'l.asu be surd to till in the pormit/licenss neunbe-r which will be uied as a reference number. In addition,in is aPD current or lea must submit multiple Vennit,'lica,tse applications in any given year, need only submit ono at)i iun indicating w(cil policy iul'm mutio f the uftlda the vityh11 rt has been Jobe d tinder"Job S ally s mped or marrkedlby+I a city or town truly be p o l' Y tuwn)•" \copy permits or licenses. A now alliduvit must be tilled nut each applicant as proof that a valid affidavit is on file for futon P ennit not related to any business ur comnnerc"l venture )ear. Where a hums owner or citizen is obtaining a license or p (i, !. a d ns dug license tit permit to burn leaves ctc.)said person is NOT required to complete this afftda utha,d.m udluous, I he I)dice tot Inveaigatiuns wuuld like to thank you in advance for your cooperation and shuulJ y Y 4 hlda,e du nu, hesitate to dive us a call. f he U.parnncm's address, telephone and Th of number: umb rnwea)th of Mossaehuset» Department of Industrial Accidents Onles of IavaU4ations 600 Washington Street Boston, MA 02111 fel. p 617-727.4900 ext 406 or 1.877-MASSAFE Fax M 617.727.7749 d 211 www,mam.glov/die CITY OF SM-EN4 AASSACHUSETTS 9t.'[ mm, DEP.1RTtwr 1 0 W-tSHLYGTON STREET, Ya Rocit TIEL (978) 74&9595 F.kx(978) 7�984d Kl\®ERLfiY DRI3COLL MAYOR no.+cu sT.PM"A DIRECTOR OPpLaLICPROPERTY/9t:m C4GCOUMISSIONER Construction Debris Disposal Aff1davit (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 M is issued with the condition that the debris resulting from 1 11 work shall be disposed of in a pro I 1, S I SOA. perly licensed waste disposal racility as defined by MGL c The debriswill be transported by: p (name of AGUIev The debris will be disposed of in : (name of faci Y) .. ' (�ddraa oY f�cili�y) �iyn�mrc of permit applicant /O . ,,ace coso'IA. 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 Reconstruction ❑ Alteration ❑• Demolition ❑ Painting ❑ Signage ❑ Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemption's 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: as Warren Street Name of Record Owner Mirodlaw k to;oclnski ''2- Description of Work Proposed: Replace existing 3-tab asphalt roof with new 3-tab asphalt roof(black or charcoal gray). Repaint house to replicate existing colors. No changes in color, material, design, location or outward appearance. Non- applicable due to being in kind maintenance/replacement. Dated: September 6, 2011 7;7 L COMMISSION By: The homeowner has the option not`to commeiice the work (unless it relates to resolving an outstanding . All.work commenced must be completed within one year from this date unless otherwise indicated. violation,) _ THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work.