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70 WEATHERLY DR - BUILDING INSPECTION (6) 1 l ` 2 5 3 c+f),s T-ev-r The Commonwealth of5NfAWCAgvlas 4 Department of Public Safety p (�L Massachusettsstate Build in' I a=)F TXA Building Permit Application for any Building other a o ily Dwelling (This Section For Official Use Only) Budding Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block N and Lot N for locations for which a street address is not available) No.ami Street City/Town Zip Code Name of Building(if applicable) _(� SECTION 2•PROPOSED WORK Ca Edition of MA Stile Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ lChangLofoccupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review reyul i Yes ❑ No b Brief Description of Proposed Work: P�Cl'� a �, I &Le Y� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CIvIR 31) 0 Existing Use Group(s) I Proposed Use Group(s): SECTION4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION S.USE GROUP Check as a Iicable) A: Assembly A-1❑ A-2 Cl Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B. Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ - If: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-S❑ 1: Institutional I-1❑ 1-2❑ 1-3❑ FI❑ M: Mercantile Cl R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S•1 ❑ S-2❑ U. Utility❑ Special Use❑and please describe below: Special Use: SECTION fr.CONSTRUCTION TYPE(Check as applicable) - - IA ❑ IB ❑ HA ❑ 110 ❑ ILIA ❑ 1118 ❑ 1 IV ❑ I VA ❑ VB ❑ SECTION 7.SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal ClA trench will not be Licensed Disposal Site❑ Private❑ required❑or trench or specify: or indenti(y Zone: or on site system❑ permit is enclosed❑ Railroad rightof-way: Hazards to Air Navigation: \1A I listorin;•lnunictinn it_.i_•.,..I'rr�It..: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Bu0d enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per I:I,xwe Dacs the building,comain an Sprinkler System?: Special Slipulnlions: DPtf-2.eo-J -7 81 - ZKS� i ZoS U SECTION 9: PROPERTY OWNER AUTHORIZATION - Name and Address of P operty Owner ' P.?,�f'1�.' C>` Name(Print) No.and Street City/Town Zip roperty Ov t ct 1 domiat'ow, Title Telephone No.(business) Telephone No. (cell) e-mad address Iffaapplicable,the property owner hereby authorizes O' la N:vne Street Address City/Town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this buildin ermit a22lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less thin 35,M0 cu.it.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control. � - moo i�► g c s� X Name( islrant) Td hon No c mai address Registration Number ? a Q,, M -azu c� _J i Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 1)0,,[-`s`?Vl 9�v�V Company Name �a rr�IV\ Gf,�\ J Name of Person Responsible for Co [ruction Lice a Jo. and Type wif^ pplicable Street Address City/Town State Zip Telephone No. business Telephone No, cell mafl address SECTION 11:1V0RKF.KS'COMI'FNSAI"ION INSUKANCV,AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with thisapplication. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) TotalConstruction Cost(from Item 6)_$ L Budding $ 1XIS-00 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ 3 v - appropriate municipal factor)_$ 3. Plumbing $ ) exhanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Me hanical Other - $ Enclose check payable to 6.Tot Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, s•reby attest under the pains and penalties of perjury that all of the information contained in this application is true.md accur.tot the best of m cnowledge and understanding. Please print and sign none O e R�� U I Z,r� jitle �de0 i SE Date /�T-:yam—.�n.�n6Y\ I.J O a � 6�1� Street Address City/Town ,7 tote Zip -),.Q Municipal Inspector to fill out this section upon application approval• yjiO W " 'emu Name Da e Massachusetts Department of Public Safet• F p �� ; � Board.of Building Regulations unit Standards " 1 License: CS-02460 'sue i Construction Supervisor, DARREN J-GERRaf' _ 37 GREENINOOWA - WAKEFIELD MA�`01 r _ �� � , s ry ` - �/�-, Expiration: 1 Comissioner lot m 1 7/2 0 17 ..0 iy.. ; cT/ee�por.�reo�w.ealt/co�P/J�aaoac�livaelti "e OrrCe-'0f Consumer Affairs&Business Regiil6tion ` j !# t IMPROVE MENT CON istrabon '48988 ` Type: , �iiratfo - -4/9f2617 Intlividu$di i�S 1?'� fY 4 AVE'' :y ' 0188� '`�� i DARRGER-01 LCARLISO ��R� CERTIFICATE OF LIABILITY INSURANCE DAM(MMIDDNYrO 611 712 01 6 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 endomement(s). CONTACT PRODUCER NAME: Salem Five Insurance Services,LLC PHONE 933-3100 FaA1C! No):(781 933-9046 445 Main Street (AIC.No EXf):(781) 1 Woburn,MA 01801 nol RESS,insurance.servicesesalemfive.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Main Street America Protection 13026 INSURED INSURER B: Darren Gerry INSURER C 37 Greenwood Ave INSURER D Wakefield,MA 01880 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE­SEENUED 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 AffbE BR POLICYEFF POLICYEXP LIMITS LTR IN SD WVD POUCYNUMBER MMIDDIYYYY MMIDD/Yl'1'Y A X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ❑X MPS9048R 12/0712015 12107/2016 RENTS 500,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one Person) $ 10,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY❑ PRO LOC PRODUCTS-COMPIOP AGG $ 2,000,000 JECT $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _; aas:dent ANY AUTO BODILY INJURV(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accitlenI) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION STATUTE EORH AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICEWMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ (Mandatory In NH) U yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,my ee attached it more space is required) Weatherly Drive Condo Trust is listed as Additional Insured with regards to General Liability per written contract or agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Weatherly Drive Condo Trust ACCORDANCE WITH THE POLICY PROVISIONS. 71 Weatherly Drive Salem,MA 01971 AUTHORIZED REPRESENTATIVE 1 trC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD C 17 Y OF SALEA4 A ASSAMBE 775 BunnnYGDaPAjmaxr 120 WASWW7MS71 W,3WROM TiL 078)7459595. Fi�1:(+978 7449846 %I1�ERLEYDRISOC)LL MAYOR TrIO�lSST1F DmEc7tm crPLMUCPFJ3MM/BUMDM03MMWCNM Construction Debris DisposaiAffidO it (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 coo, S 54; Building Permit B is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MAGI.c 111,S 156A. The debris will be transported by. (name of hauler) The debris will be disposed of in: Co k- � (name of facility) (address of facility Signature orippWcant Date Z\ The Commonwealth of Massachusetts Department oflndustrialAccidents l Congress Street,Suite 100 Boston,MA 02114 2017 UV www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITING AUTHORITY. Applicant Information Please Print Leldbly Name Business/Organi2ation/Individualy Address: w 1 City/State/Zip, Q r�l U t 9&0 Phone#: O I �>O �✓ Are you an employer?Check the appropriate bon: EE]Other of project(required): 1.❑1 am a employer with employees(full and/or part-time).* ew construction 2.®I am a sole proprietor or partnership and have no employees working forme m any capacity.[No workers'comp,insurance required.] emodeling I I ern a homeowner doing all work ] emolition ❑ 8 myself.[No workers'comp.iwurance required. t 4.❑I am a homeowner and will be hiring contractors to conduct an work on m ilding addition y prope ty. I will ensure that all contractors either have workers'compensation insurance or are sole ectrical repairs or additions proprietors with no employees. umbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurmmt of repairs 6.0 We are a corporation and its officers have axemised their right of exemption per MOL c. her 152,§1(4),and we have no employees.[No workers-comp,insmance required.] 'Any applicant that checks box#t most also till out the sec workers'compensation policy information. tion below showing their t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must soothed an additional sheet showing the tame of the subcontractors and state whether or not those entities have employees. If the sub= ntmcmns have employees,they must provide their workers'comp.policy number. I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation pokey declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c under the pains and penalties ofperjury that the information provided above is true and correct. Si nature: 11'1]` ate: / Phone M d 7 d v Ofclal use only. Do not write in this area,to be completed by city or town ogiciaL City or Town: Permit/License# Issuing Authority(circle one): (c 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person' Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an 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." MGL chapter 152,§25C(6)also states that"every state or 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 of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(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 confirmation of insurance coverage. Also be sure to sign and date 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 questions 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 line. _ City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you 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 permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job 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 filled out each year.Where a home owner or citizen is obtaining a license or pemut not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSA-FE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Cyndy Anselmo To: smurtagh@salem.com Subject: Unit#203, 70 Weatherly Drive, Salem MA 01970 Hi— Please be advised that the owners of the above unit,James& Kathy Heelen, have the authorization from the Weatherly Drive Condominium Trust to install new kitchen cabinets in the kitchen of their unit and to handle any additional remodeling work done on their unit. The kitchen is being installed by Darren Gerry of 37 Greenwood Avenue, Wakefield MA, and we have the appropriate insurance certificate. Thank you. Cyndy Anselmo East Coast Properties, LLC Real Estate and Property Management 400 Highland Avenue Suite 11 Salem, MA 01970 P: 978-741-2003 F: 978-745-9684 cvndv@ecpllc.net t 13- co- tog 3 Sally Murtagh 7 O b l� From: CyndyAnselmo <cyndy@ecpllc.net> v 27-z Sent: Tuesday,June 14, 2016 3:46 PM To: Sally Murtagh Subject: Unit#203, 70 Weatherly Drive, Salem MA 01970 Hi- Please be advised that the owners of the above unit,James& Kathy Heelen, have the authorization from the Weatherly Drive Condominium Trust to install new kitchen cabinets in the kitchen of their unit and to handle any additional remodeling work done on their unit. The kitchen is being installed by Darren Gerry of 37 Greenwood Avenue, Wakefield MA, and we have the appropriate insurance certificate. Thank you. Cyndy Anselmo East Coast Properties, LLC Real Estate and Property Management 400 Highland Avenue Suite 11 Salem,MA 01970 P: 978-741-2003 F: 978-745-9684 cyndyCcD,ecpllc.net 1