60 62 WASHINGTON E ST - BUILDING INSPECTION y 0 ), o,
The Commonwealth of Massachusetts
Board ul'Building Regulations and Standards CITY
Massachusetts State Building� Code, 780 CMR, 7'"edition OFRerisrd S A L F M
+� Ju.rmvc
Building Permit Application To Construct, Repai , Renuvrte Or Demolish a ). :r1lAY
One-or u-Fumily Dwe ling
is S ion For 0fr
,lefal Use Only
Building Permit Number: ate Applied: 6 d-'b
Signature•
Building Curnl4issioned Inspector of Buildings note
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map A Parcel Numbers
I.I a Is this an secs 1 street'yes ✓ no Map Number Purest Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Ama(sq 11) Frontage(11)
1.3 Building Setbacks(R)
Front Yard I 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: 1.3 Sewage Disposal System:
Public'($ Private❑ Zone: — Outside Flood Zone' Municipal JIM On site disposal system ❑
Check if yesD
2.t Owner'of Record: SECTION 2: PROPERTY OWNERSHIP'
Name(Prim) Address for Service:
1 (0 n - S►,: c7
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) O Addilion ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelal Use Only
Labor and Materials
1. Building S I. Building Permit Fee:f Indicate how tee is determined:
❑Standard City/Town Application Fee
?. Electrical f ❑Total Project Cost'(Item 6)x mulliplier x
J. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) f List:
5. Mechattical (Fire S
tin ression Tu1al All Fees:f
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) jDOSa )
�6�{_ License Number Expiration Dale
Name of l'51.• I fur list CSL Type(see below) 1,
1"( f Descri ion
W ss U Unrestricted u to IS,oOo Cu.Ft.
LXJ. I U n(� ( � R Restricted IA2 F—il Uwellin "
Signal n�e M M only
RC Residential Roulin Coverin
I'dephwe WS Residential Window and Sliding
X-)( Cf��� �(.rL� SF Residential Solid Fuel Burning A liame Installation
C{ - D I Residential Demolition
5.2 Mitred Home Improvement Contractor(HIC) Sz Z
11 C, �ppan 7N I�Ilc `Reegistrantt Reyis//tr�atian Number
JJrc L Y lIH • 6)llrS `� /� S��'ObT/ �l- 1�2—
A Expiration Dore
Signature Telephone
SECTIO 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2. f 2SC(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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
[behalf.
i ure of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
at the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
Print Name ( _�_ �o� f D
Signature ofOwrter or Authorized Agent Date
lSisowd under the pains and penalties of 'u
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 IHIC)Program), will Rg have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.RS,respectively.
�. When substantial work is planned,provide the information below:
Total floors area ISq. 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 healing system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"may he substituted for"Total Project Cost"
Office o��on er A airs�-Baines" s RegulntToo
HOME IMPROVEMENT CONTRACTOR
Registration Y166522 Type:
Expiration �61912012 Individual idualWCE ONTRACTtFING�i:--- �,"I
ERIC CHASES # j
11 CROSS ST
,BEVERLY,MA Undersecretary
\Iasxttchusetis - Department of public Safeh
Board of Building Re!gukRions antl'Standartls
Constrpction Supervisor, Lickgse
License: CS 100531.
RAtricted to: 0
t ERIC CHASE
11 CROSS ST $
1 ;
BEVERLY, MA 01915
Expiration: 12/8/2011'
`, (',.,inin i+aiuntq• Trk: 100531
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ism:x:I:)xlilUl 1.
�I,n+a L^-Wneuu:fU.XSTxEhI'* SAt Lsl,Msss.u:m a%rn 0197-
TI:i.,978.743-9595 • I:.sx. 978.74C-lx4G
Workers' Compensation Insurance Afrtdavit: Builders/Contractors/Electricians/Plumbers
J) 1llwnt Infunnation Please Print Leeihly
V81Tle Inucuw;�s/OrganiratinNlndlviduu4: wc-
1 �.as-� D3V� �sl.tasc- coc,�cac���
Address: I ccoss Sk
City,st:uc;Zip: xYs (a b1S1S Phoneb�c5'�0��
Are you an employer:' Check the approprlute box: 'Type or project(required):
I I :un a employer with� 4. m❑ 1 a a general contractor and 1 b. New construction
� ❑
employees(full and/ur part-tiolc).• have hired the sub-contractors 7. ❑ Remodeling
?.❑ 1 ant a cola proprietor or partner-
listed on the attached sheet.
" ship and have no employers These subcontractors have ti�Demolition
working for me in any capacity. workers' comp. ❑ Building insurance. 9, Building addition
I No workers'comp. insurance 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption r NIGL I I.❑ Plumbing repairs or additions
3.❑ 1 ;u;in,a homeowner doing all work c 5152, ¢1(4), and we have no 12.❑ Rouf repairs
myself. LNo workers' comp.
insurance required.] r employees. (No workers' 13.❑Other
romp. insurance required.]
-nny o;tphcaut that chucks box ill must al t,fill our Ihu section Wuw ahowiny choir wotkui uumpenstaio,1 pulicy inforncttlon.
'l lumeuwnen who itdsmil this nffidavit indicating Choy are duiny all work and dtcn hire outside cautweiam must.uhm:l a new al'ridav:t indi"my such.
-Cor%trxu,a that check this box must atachcd.m addiliunal-1heet showing Cho name of the sub+onlraeton and their wurkun'comp.ptdicy infutmatiun.
l nitr un employer that Le providirig Ivurkers'cainpen.Yaiion insurance jar iiiy employees. Belmv is the pulicy and Job.site
in n
f ormutio .
insurance Company _ _...---_.
( Expiration Date: �S O i
Policy A or Self-ins. Lw. n: ��-�d 2c��3�� -_-.. .. - ...._ P
Job site Address: b0 6a lA) C-itytstate/'Lip:
Attach it copy of Ilse workers'compensation policy declaration page(showing the policy number and expiration date).'
Failure to sccurn coverage as required under Section 25A ul'.'.1GL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisunmcnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lic adviwd that a copy of this statement may be forwarded to the Office of
Inccsllgaunns ul'thr DIA for insurance coverage seritic.nion.
l do hereby eerrify I Ier drr1 ain.s mad penaltiesWperjury that the Information pruwded abuse is true and correct.
C/—� Mite* /U� 10
tii�::,amrc
I h t ni 7� • �7�; �sC9-17
Of/iciul rise otrly. no tact Is•rite in this area, to be cronpleted by city or town o/fivial.
City or'I'own: _- Pcnnit/l.icense V._
issuing Authorily(circle one):
I. Iltrard of llvalllt 2. 1111ilding nvparunent 3.C.ityi form Clerk 4. L•'lectrical Inspector 5• Plumbing; Inspector
6. Oiher ----
Ctnttact t'crsou: _ _ Phoned:
Information and Instructions
.Massachusetts General Laws chapter L52 requires all employers to provide workers' compensation fur their employees.
Pursuant to this statute,an employee is droned as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined a"an individual, partnership,association,corporation or other legal entity,or any two or more
or the tbregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee ul :m individual,partnership,association or.other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
b1GL chapter 152, §25C(6)also states that"every state ar local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally. MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence ol'cumpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Ploasc fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s),address(es)and phone nui nber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for contimmation of insurance coverage. Also be sure to sign and dote the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any question regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate lino.
City or Town Officials
Please he sure that the affidavit is'compiete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill not in the event the Office of Investigations has to contact 3uu regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. in addition,an applicant
that must submit multiple pernit/license applications in any given year,need only submit one affidavit indicating current
policy information of necessary)and under"lob Site Address" the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he 0I lice of Invelligations would lice to thank you in advance fur your cooperation and should you have:my questions,
Please du not hesitate to give us a call.
The Daparnncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oiiflee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
iLCvi.cd 5-26-05 Fax N 617-727-7749
www.mass.gov/dia
�R CERTIFICATE OF LIABILITY INSURANCE O C:: JM DATE
91A SO 19 10
vROWCEt THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
John J Walsh Ina Agency, Inc HOLDER.THIS CERTFICATE DOES NOT AMEND,EXTEND OR
P 0 Box 4407 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Salem MA 01970-6407
Phone: 978-745-3300 Pax:978-745-9557 INSURERS AFFORDING COVERAGE NAIC8
INSURED INSURERA: Ponce-America Insurance Co.
dba INSURER& ¢eeniu eLt� Inwsenq m.
Eric Chase act
Chase ContractingINSURER C:
1BevailysHA 01915 INSURERD:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 HMIM IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LUATB SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS.
LTR PORN HYPE OF INSURANCE POLICY NUNBEIt POLICY
DATE TE a LYnB
GENERAL WaMTY EACH OCCURRENCE $1000000
A x COMIEACALCENr3ALLABIUIY PAC683394 09/17/10 09/17/11 PREMISES FJtoavam s 50000
CLAIMS MADE ®OCCUR NEED EXP ww me Paean) $5000
PERSONAL B ADV INJURY f 1000000
GENERAL AGGREGATE s2000DDD
GEN'L AGGREGATE LIMIT APPLES PER: PRODUCTS-COMPlOP AGO s2000000
POLICY JPRO-EcT El LOC
AUTOMME LIABKITY COMBINED SINGLE LAIR
ANY
AUTO (EN eaCMeni) s
ALL OWNED AUTOS
BODILY INJURY $
6CHEWLEDAiJT03 (PwPB1O^)
HIREDAUTOO BODILY INJURY
NON OWNED AUTO$ (PweoaftK)PROPERTY DAMAGE
f
Y
eoddwo f
GARAGE IABRTY AUTO ONLY-EAACCIOENT s
ANY AUTO OTHER THAN EA ACC f
AUTO ONLY: AGO s
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE f
OCCUR CLAIMS MADE AGGREGATE f
s
DEDUCTIBLE f
RETENTION f f
V"KMCOMPMOATM T LIMRS 6i
AND EMPLDVERE LABL17Y
B ANY PROPRIETORIPMRNEPoEXEcurrvy� WC002453069 05/05/10 05/05/11 E.LEACHACCIDENT s500000
OIf FFICERIAAEMBEREXCLUDEDT LI
(Y}�N1wUeary INN) E.L tNSFASE-EA EMPLOYE s500000
SPECIAL PROVISIONS UeIm E.LDBFASE-POLICYLBUT f 5D0000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VETSCLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE MWOOED POLICES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRIVTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO BO SO SHALL
City Of Salem IMPOSE NO OBLIGATION OR UJIMUTY OF ANY KIND UPON THE NBU ac{�yTS OR
Attn: Building Inspector RrrRESENrATIVEa J.WAp/ AT'INL��
93 Washington Street
Salem MA 01970 AUTHORIZED REPRESENTATIVE
Mark W. Bettencourt
ACORD 26(2009/01) 01989-2009 ACORD CORP TION. I d e d.
The ACORD name and logo are registered marks of ACORD reSI Bn
CITY OF SALEM
PUBLIC PROPRERTY
!� '• DEI'AKT'�tENT
,.I .. 0 �:' �� JII\i., `♦11�I.I r • \.\I I V,
` III' 'r�Y-'7;'h'i5 •,I �C: '1:'r511,
Construction Debris Disposal Affidavit
(1C(lui1Cd ILr all demolition and renovation work)
In accordance with the sixth edition ofthe State Building Code, 780 CMR section I I 1 5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit rf is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
— cs f s c�x>
Plante of hauler)
The debris will be disposed of in :
(narnr ul lacility)
• sw lactlit
(address .y1
ignauuc r(pcnnit.yrphcaut
,late