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0056 WASHINGTON SQUARE SOUTH - BPA-13-810 1 1 The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF SALENI Revised Mar Massachusetts State Building Code, 780 CNIR Revised 1 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Sectiori,Fo;'Official Use Only Building Permit Number:-_ Date plied> . 'f �3 Building Official(Print Name) ignature - Date E N : SITE INFORMATIO 1'.1 Pso erty Addrgss: 1.2 Assessors Map& Parcel Numbers rc1�Cr r- 52 S6z✓ j IN a Is this an accepted street?yes Map Number Parcel Number 1.3 Zoning Information: ` 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(fit) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Wate upply: (lA.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage D sposal System: Public c , Zone: _ Outside Flood Zone? Municipal Cn site disposal system ❑ Private ❑ Check if es❑ p p SECTION2 PROPERTY OWNERSHIP"' 2.1f Reco I-,AjJeriteoll rd: $ �4If'PA Q Naxfic(Print) City,State,ZIP s61, r:Sl^,; rSq , So,.�� ��� S'iz-sz�y cl�rc�,�tSF30z�`�/�a:� .Cv No, and Street Telephone Email Address SECTION 3: DESCRIPT19 OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building Owner-Occupied 0 Repairs(s) ❑ Alteration(s) &aj Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units / I Other ❑ Specify: Briefs escriptionofPropos dWork": PI%roc/ P c t/ cfr �,tc( �rtLTic f Zr l.Sirc `1ce /9K-ef !L`'l lf W SECTION 4: ESTIMATED CONSTRUCTION COSTS [rem Estimated Costs: Official Use Only.., Labor and Materials I. Building 1. Building PermitFee S Indtctite flow fee is determined: ❑ Standard City/'Gown Application Fee 2. Electrical $ �G i ❑"Total Project Cost ,(Item 6)x multiplier x 3. Plumbing 'S 000 2. Other Fees: S I. Mechanical (HV,\C) S List: 5. Mechanical (Fire S lbtal All Fees: S Sup ressrnt) Check No. Check Amount: Cash \mount l'otal Project L ost: S ' ❑ Paid in Full ❑ Outstanding B:d:mce D11c: SECTION 5: CONSTRUCTION SERVICES A101111 truction Supervisor License(CSL) e5'GG y6 Ct /9 Set P�u— __ License Number E.epiration Date L I folder V/�vrs t - • ��e� List CSL Type(sea below) NQ�nd Street . TYPa Description �ity) �t�r �tp U Unrestricted DuilJin s u to 35,000 cu. tt.) Ct ��� l `" ' �' V t a R Restricted 1&2 Famil DwellinCrown,State,ZIP` M Nlasonr RC Roo tin Covert lVS Window and Siding SF Solid Fuel Burning Appliances 1PM 'QPpv SNS,�o!'L I Insulation -rele hone Email address D Demolition 5.2JJ egistered Home mprovement Contractor(HIC) z 2;' '� S 's �4 HIC Registration Number E. pit ion Date 111C C�l'pa y Name r IIIC Ra stlant Name n f� �'b J4/�atiS cY.IL F - �.'1sQ.SS lrP'" I7PSt51�S�C��I�LI zed Street Email address � -( M4 o i 4 7 l/� 9zi-6G6G City/Town,State, 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 I, 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. Del�!G--A N Print Owner's Name(Electronic Signature) Onte SECTION 7h: 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 a ned in this application is true and accurate to the best of my knowledge and understanding. M C-'r;h asc/ y I� i3 a Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. :\n 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 toww.mas. uv�%oca Information on the Construction Supervisor License can be found at www.mass.,,o%dL 2. When substantial work is planned,provide the information below: -total floor area(sq. ft.) _ _ (including garage, finished basement/atticS, decks or porch) Gros, living area(sq. ft.) _ Habitable room count_ Ntunberoffi eplaces_ Number of bedrooms -- _-- Number of bathrooms N'mnber of halE'baths --------- — 1'vpe of heating system - --- -- _ Number of decks! porches -- — -- 1'ypeofcoolingsyiicnt_---------___-__-- Enclosed --Open _ ). `I Mal PI'ojeCt 1lhIa IV root:ige" may fie i1.Ibintutcd L11 -rntal I'10iCCt CO t" -- A1CORd® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 0 310 61201 3 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 holder in lieu of such endorsement(s). cpN�p PRODUCER 03181 -001 NA :CT W Gochis Insurance Agency Inc Pi1�CoME.1o.Eat: (781)272.8306 ram,No,; (781)272-1362 113 Cambridge Street Hghss: Burlington,MA 01803 INSURER($LAFFORpINGCCOff_RAGE NAICp INSURERA: A.I.M.Mutual Insurance Company I 33758 INSURED INSURER B_; _ Dana Salem NSURER C 10 Sallonstall Pkwy IN$yRER D Salem,MA 01970 INSURER E, INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 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,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE we POLICY NUMBER (hPir2 �SyvY) MM/D[j/YYYY LIMITS � GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE COMMERCIAL GENERAL LIABILITY RENSIETO RENTED $ PR MI ETOR RENTED nce CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL B ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: - - - - - PRODUCTS-COMPIOPAGG_ $ _�POLICV ECT LOC AUTOMOBILE LIABILITY F COMBINED SINGLE LIMIT $ ANYAUTO- " BODILY INJURY:(Per person)'.-.S ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS , :.. AUTOS .. -. -_. - - - ( ) HIRED AUTOS-' """" NON-OWNED_._ PROPERTY DAMAGE $ -' ...__ _ ._._... _ ... ..- . . ,. _._ Per acgd.nt1 _ AUTOS --� ' — UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED I I RETENTION $ WC gT u $ yyppl(ER5���1P�C$'�'14f'1• X TORY LA�ITs °J�' AND EMPLOYER$ IA I A ANVIpq�Pq�ETpR�ppppgqTTNEERR//EE ECUTIVE YIN NIA VWC6014389012012 5l7/2012 SI7I2013 E.L.EACH ACCIDENT E 100,000 OFF CPR/MEMBER EXClUOED.+� I(Mandtlatltteosrcyf In NuurHn.aa)er E.L.DISEASE-EA EMPLOYEE $ 100,000 DtD�RIPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,B more space Is required) Job Location: 21 Victory Road,Salem,Me CERTIFICATE HOLDER - CANCELLATION CITY OF SALEM 120.WASHINGTON STREET SHOULD ANY OF THE ABOVE DESCRIBEOPOLICIES'BE CANCELLED BEFORE SALEM,MA-01970,,,. -,--------Y_._,� __ '_ THE EXPIRATION DATE THEREOF,-NOTICE" WILL BE DELIVERED IN -"--"-—" -' ------— - ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD CITY of SiU_ENI2 11WSACH SEM ) BUILDING DEPARTUENT 120 %VASHLNGTON STREET, 3'a FLOOR ' TEL (978) 745-9595 FA_%(978) 740-98-f6 M.\mFRT FY DlUSCOII MAYORT)io6tAS ST.PIERRs DIRECCOROF PUBLIC PROPERTY/OI:ILDLNG COSLMISSIONHR Workers' Cotnpensadon Insurance Affidavit: Builders/Contractors/E(ectricians/Plumbers A s slicant Infortnatinn Please Print Le ihl Muni:tausin�Ns.orylniratiurv/individual): 11,Sl"eI J�'/ VO^- Address:/6 Ja CitylStatc/2ip3e, (P/K, Liz., G �cfad PhoneM: Are you an employer?Check the appropriate boxy Type of project(required): I.o I am a employer with 4. 0 I am a general contractor and 1 S. 0 N construction employees(full and/or part-time).* have hired the suMs:ontractors 2.❑ I am a sole proprietor or partner• listed on the attached sheut t y emadeling ship and have no employees These sut►contractals have il. 0 Demolition working for mein any capacity. workers'comp.Insurance. 9, 0 Building addition (No workers'comp.insurance S. ❑ We are a corporation and its required.( officials have exercised thdir t0.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MOL 1 I.0 Plumbing repairs or additions myself.(No workers'comp. c. 152,11(4),and we have no 12.0 Roof rupairs insurance required.) r amploy"%LNG workers, 13.0Other comp.insurance rcqulrcd.J •Any appll,am aW,hwks boa t I must alwr all uut Ihs u',liva hdow thawing rhs4 warkan'compntutun pulley intutmollon '1f,meuwnm who suilnlil this antdavit indiewina ihcy ore china an watk and Ihee hire a Itidscantnatort must tubmk a new arndavil indicting such. !C mir wears that,bmil this has most machod an addluunal'haet thawing the vane alibi Mbla.anlraatars and(halt wutksn'ramµ policy lnramatloo. I arm an enrptayer that Is provldlgr iverkers'rorrtprntadam hlsuranee far ANY armplayerrs Below Is the pollay and fob site infertmatlon. InsumnceCompanyName; Pulic 4 ur Self-itis. Lic,n: V V''C(6)t]j�c7('JIZ O/Z J g y ' / Expiration Dote: r Job Sit*Address: r6 �S/nt~3�N,5� City/State/zip, Attach a copy of the lvorkers'componsatlon policy declaration page(showing the policy number and expiration data). t'ailuru to securu coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of s tine up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of it STOP WORK ORDER and it line of up to S250.00 a day against the violator. Ile advised that a copy of this matemunt may be forwarded to the 011icu of Invesiigatiuns of Ilia DIA for insurance coverage vurificaliun Ida lrrraby cetd/y turd rr uaJ prnuldas u/par/ury r/rut rkdGr�unnurlwa provided�b�v�e it�ru�e rrd fdrrect / re- Chore 4 l0 O/jiclul acts only. ------------- Do nor Wild in r/dr ufe,4 to Se complridd by city ur lawn owletal I i City orl'ulvn: Permft/J.icensed Gsuing Aulimrily (circle one): -- -- - I, Quard of Ilcahh L. IluihllmJ Vellartnlent .1.Cilylfnwn Clerk J. Cleetrlcal Inspector 5. Ilumbing Inspector i Phone 4: I CITY OF SiU EM itiWS 1C HL'SETTS 7 O :LWLNGDEP.IRTNLEVT t ( 130 WASHNGTON STREET, .3"' FLOOR TEL (978) 745-9595 FAX(978) 740-934b (C!J(BERiEY DRISCOLL A+LAYOR THOXU ST.FIERAR DIRECTOR OF PL BLIC PROPERTY/aLM.1304G C01Nl55[ONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of ILMGL c 40, S 54; Building Permit fx is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal racility as defined by MGL c l 11, S 150A. The debris will b�eitrutsportcd by: (name or'hauler) J The debris will be disposed of in ! ' O�IC� $ iclP Ccit� i� (name of facility) &J';M5Cis �J- (ZCA Sg Ie/k C(- tJduress of taaihty) s"'aluce of permit applicant plate - .I �Il.11i.�.M1 II