70 WEATHERLY DR - BUILDING INSPECTION (4) -ter
#/431 �
4. The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR SALE
Revised Mar 1017
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: A 'ed: d O it
J
Building O ial(Print Nam S' e
SECTION 1:SITE INFORMATION
1.1 Property Address: a0 1.2 Assessors Map&Parcel Numbers
0
L 1 a Is this an accepte street?yes_ no Map Number Panel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(R)
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 O Zone: _ Outside Flood Zone? Municipal O On site disposal system 0
Check if yes0
SECTION 2: PROPERTY OWNERSHIP'
2.1 er'of Record
.COL/A/& A I- EXOL•-' �i3Zc^F9
Name(Print) City,State,ZIP
ao 1��1�x.a_Y :be. (u l 3 SL`J 3Gio2
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Buildin Oaver-Occupied O 1 Repairs(s) ❑ 1 Alteration(s) O 1 Addition O
Demolition O Accessory Bldg.0 1 Number of Units_ Other O Specify:
Brief Description of Proposed Work :
�EPLACL= 91Tr/Ift'xs 1—' i&rt77A.J&-
/
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 99 cev . 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard Cayfrown Application Fee
�' °��' 0 Total Project Cost (Item 6)x multiplier x
3.Plumbing $a gam, 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
S ression Total All Fees:$
�. Check No. Check Amount Cash Amount:
6.Total Project Cost: $3 �� ' 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �7o7�g� •-/(��-aof.y
I.h YA1& '� a cso� License Number Expration Dale
Name of CSL Holder
y�_ List CSL Type(see below)
r�
T SFfz I� RlJ Type Description
No.and Street
A a/� D� yra U Unrestricted(Buildingsu to 35,000 cu.ft.
Akio,E �`7 R Restricted l&2 Family Dwelling
Ciry/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�y��{' SF Solid Fuel Burning Appliances
?8/c37.7 IVAY✓C&O-373e &,4n;;V420 I 1 Insulation
Tel hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) /)a5 3 �
+te •�
�// n / R ISC$ 67C)A; 5� .1-�/. HIC Registration on Number Expiration Date
HIC Company Name m HIC Registrant Name
SS '7NF S u �;tlFSc�PTy7tacu�3�3)T
No.and Street Email a ss
Sevar 00%r-oT 6�14_019d?— �4 B " 5
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..........O No...........O
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.
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 Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dus
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"
CITY OF SALEEM$ i LksSACHUSETTS
Buff-DING DEPARTNt&NT
• 130 WASI—INGTON STREET, 3" FLOOR
a TFL (978) 745-9595
F.4Y(978) 740-9846
K%{BERi FY DRISCOLL
' AYOR T HOatns ST.PtERRIi
DIRECTOR OF PUBLIC PROPERTY/BUnDNG CO-MUSSIONER
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 J
Debris, and the provisions of MGL c 40, S 54;
Building Permit # 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:
t �U/LSot/ .8/1O�;', Ce�t�7-
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility) -
A '�
signature of permit applicant
date
Jcbri>a�(ds
CITY OF Jiv=Nfl NI LA's&. CHUSETTS
`- BL•tmLNG DEP A EtTM&NT
120 WASHIINGTON STREET, 3°D FLOOR
�.e T EL (978) 745-9595
R+x(978)740-9846
KI BERi F.Y DRISCOLL THo& %SST.PtEua
MAYO;t
DIRECTOR OF PUBLIC PROPERTY/BlaLD6`IG CONMISS[ONER
Workers' CoinpensatIon Insurance Al idavit: Builders/Contractorv/ElectrictansdPlumbers
Almlicant information Pleas Print Legibly
NnnlC lUusin¢ss.Organira(iorulndividualY• 6Q6.) Ae-� C _Y� .-1-
n2 �._-. 7
� ^
Address: �— 7Xe-
City/Statc/Zip: jt0.9W0 // Phone tl: 76/ - 8yt/
,%�cc,�you an employer?Check t e appropriate box: Type of project(required):
I.L 1 am a employer with 4. ❑ I am a general contractor and
p 6. ❑New construction
mnployeea(till and/or p time).• have hind the subcontractors
2.❑ 1ama sole proprietor or partner- listedonthenttachcdsheett 7. emadeling
ship and have no employees These subcontractors have 8. ❑ Demolition
working.for me in any capacity. workers'comp.insurance. q
p ry. ❑ Building addition
[No workers comp.insurance 5.'❑ We are a corporation and its 10.❑Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152,91(4),and we have no 12.❑ Roof repairs
insurance required.)t employees.[Na workers' 13.0 Other
comp:insurance required)
;Any applicum that checks boa el must also nil out the saaim belowshowing their waked coma mudon Polley infumodon.
r 1t,"eownem who submit this affidavit indicating they an doing all work and then him uv4iek,cm o gom must submit a new anbb,,il indiaine such
:Gmooctun that chok this box meet anachod an adabluma shoo showing then=*of the subacntractors and their wurkeo'comp,policy Information.
l our an employer that/s providing workers'campensardon Lust rancejor my employees Below Iv the policy and fob rlfe
injonnaQom insurance Company Name:'/ '/nl/G
iaolicy 4 or Sclf-ins.Lic,d:AyL2 -&?3� eB42 Expiration Date:
Job Site Address: o-4208 city/State/zip:
,ktiaeb a copy of the workers'compensa lan policy declaration page(showing the policy number and expiration date).
Failure:to secure coverage as required under Section 25A of,LIGL c.`152 can lead to the imposition oferiminal penalties of a
tine up to S1,500.00 undl/or one-year imprisonment.as welt as civil penalties in the form of a STOP WORK ORDER and a line
Of up to SM.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of3ice of
Investiguiiuns of dtc DIA for insurance coverage verification.
l du hereby cerf under die pahts and penahles aftIer/ury that the btfornrurlon provided above is true and currrcL _
I
Date: 9
I'I•nne 3: Zr�2/
OJ/icial a se auly. Do not write in ildi area,to he cautpleted by city or town a/)lrlaL
j
City or Town: Permit/Llcense.4
ksuing Authority(circle one):
I. hoard of health 2. Iluildlnq Ilepartment 3.Cilyi Town Clark J. Electrical Lupector S. Plumbing Otapeeror
6. Other ._.
on
Ctact Person: PA°n¢Ih.
i - .. _ ..._._ .._
I
y
�` ''✓ CERTIFICATE OF LIABILITY INSURANCE 8/28/2
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).
PRODUCER NNAAMSp Thorna6 Quinn Jr
Quinn of Lynn Insurance Corp. - PHONE _ (781)581-6300 1FAX N :(7e1)Sa1-solo
152 Lyanway Suite 1D A L$$:toMKluinn@aluinnoflynn.com
P.O. BOX 789 INSUR S AFFORDINGCOVERAGE NAICS
Lynn LID 01903 IMSURERA:Safety Insurance Group 9454
INSURED INSURERB:Travelers Insu dace
Wilson Brothers COnst. INSURER C:
55 The Greenway INSURER D:
INSURER E:
Swampscott MA 01907 INSURER F:
COVERAGES CERTIFICATE NUMBER' L1382700728 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.
INSR TYPE OF INSURANCE POLICY NUMBER MMM�EFF PMOMLICYEXP LIMITS
GENERAL UAINUTY EACH OCCURRENCE $ 1,000,000
8 COMMERCIALGENERALUABILTTY PREMISES Ea-ccun $ 100,000
A CWMSJdADE ®OCCUR SMA0005321 /16/2013 /16/2014 RED EW(Any one person) $ 10,000
PERSONAL S ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 2,000,000
X1 FuucY PMa LOG $
AUTOMOBILE LIABILITY (bMBI rftSINGLE LIMIT 500,000
A ANY AUTO BODILYINJURY(Perperson) $
LL A OWNED M
SCHEDULED 003111 1/19/2012 1/19/2013 BODILYINJURY(Pera.M rd) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
g HIRED AUTOS AUTOS Por=kInn[
8
UMBRELULIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMSRADE AGGREGATE $
QED 1 1 RETENTM $
B WORKERS COMPENSATION X I U.INGSTATl TS
BE
OT14
AND EMPLOYERS LIABIMTY YIN
A PROPRIETOR,PARTNERID(EWMVE� MIA E.L.EACH ACCIDEM 8 100 000
NY
OFFICERMEMBER EXCLUDED? 6341Y78823 /5/2013 /5/20:
( oiy In NH) EL DISEASE-EA ENPL $ 100
Mar 000
Ifyes descd0eunder
DESCRIPTION OF OPERATIONS Oebw EL DISEASE-POLIOV LIMIT $ 500,000
DESCRIPMON OF OPERATIONS I LOCATIONS I VEHICLES (Avach ACORD 101,Addinonel Rem-rk-ScM1eduN,N more-pace is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
1 Salem Green -
Salen, MA 01970 AUTHORIZED REPRESENTATWE
ACORD 26(2010105) 9)1988-2010 ACORD CORPORATION. All rights reserved.
INS0251minms1 nl Tr.n ACflRiT nnron amr loon aro ronicfnrM mar6e of Ar-nRn
ADDITIONAL COVERAGES
Ref# Description Coverage Code Form No. Edition Date
Uninsured motorist BI split limit UMISP
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
250,000 500,000
Ref# Description Coverage Code Form No. Edition Date
Experience ModE EXP01
Limit 1 Limit Deductible Amount Deductible Type Premium
221.00
Ref# Description Coverage Code Form No. Edition Date
DIA Assessmen DIASMLimit 1 Limit Deductible Amount Deductible Type Premium
$488.00
Ref# Description Coverage Code Form No. Edition Date
Expense constant EXCNT
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
$338.00
Ref# Description Coverage Code Form No. Edition Date
Premium discount PDIS
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
-$88.00
Ref# Description Coverage Code Form No. Edition Date
Terrorism Prem TRWCL
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
$44.00
Ref# Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref# Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref# Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref# Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref# Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
OFADTLCV Copyright 2001,AMS Services,Inc.
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All dimensions Sze designations This is an original design and must Designed:3/31/2012
given are subject to verification on not be released or copied unless Printed g2g/2013
job site and adjustment to fit job applicable fee has been paid or-job
conditions. order placed.
jpm miranda kitchenl All Drawing#: 1
From:East Coast Properties LLC 978 745 9684 09/04/2013 13:12 #625 P.001 /001
PROPERTY
EAST
® MANAGEMENT
EAS ll COASTPROPERTIES, LLC NATIONAL SECTION
NATIONAL ASSOCIATION OF REACTORS 6
September 4, 2013
City of Salem
Building Department
120 Washington Street
Salem MA 01970
Re: Unit #208, 70 Weatherly Drive, Salem MA 01970
Dear Sirs:
Please be advised that the Board of Trustees has approved the construction work to be
done on Unit #208, 70 Weatherly Drive, Salem MA 01970 (i.e. kitchen remodeling,
replacement of carpeting and flooring). We also have the appropriate certificates of
insurance on file with Wilson Construction, the contractor doing the work.
Very truly yours,
EAS CQ T PROPERTIES, LLC, Manager
BY: C/
Cyn y Anselm
Cc: Board of Tru tees
REAL ESTATE AND PROPERTY MANAGEMENT
400 HIGHLAND AVENUE,SUITE 11 email: EastCOastPro@aol.com Phone: (978) 741-2003
SALEM,MA 01970-1777 Fax: (978) 745-9684