7 WEST TER - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
>I }� OF SALEM
Massachusetts State Building Code, 730 C'MR, Th edition Revised Jan a ry
1, 1008
Building Permit Application TO Construct, Repair, Renovate Or Demolish a
Orr -or ' o-Furn"v Dwelling
his Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commission IInspecturo Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
7 i�):�� C1C�
I.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided 2ffTProvided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal El On site disposal system ❑
Public❑ Private O Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O ert of Record:
I€,fFR�i» ,
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction d Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Pr DSosed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
I. Building IIDD I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4, Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
6V r D ijnQ?s License Number Expiration Date
Name 1)ICSI.- I iIICr
W <)+l^i F</ PwY VlY List CSL 1.PC(see below)
' F\'PC De5crI tion
Address 11 Unrestricted(tip to 35.000 Cu. Ft.)
®RC
Restricted 1&2 FamilyINvOlin
Sire—
g lure �Slason Only
�✓� —337 l ` Residential Rootin CoTelephone Residential Window:aid SidinResidential Solid Fuel Rumin A liance Installation
Residential Demolition
5.2 Registered Home Improve r�eptCon tractor(HIC) ��`�` �
'T�}f. I1AP.YtW0e-x-- lv c
1 IIC Company NamC or 111C'Registrant Name Registration Number
Address
c Va74,
Cy(j -j}� -1Z06 Gspimtiun Date j
Signature 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 .......... ur No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, V ?///� - -' as Owner of the subject property hereby III
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Prim Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths j
Type of heating system Number of decks/porches
Type of cooling system Inclosed Open
3. "Total Project Square Footage" may be substituted lox"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.sat:x:1'Y:1XF'iCUl 1.
\I true U.-WASHING I ON5axEra' 5nU'N.M.vs.uan sha is 007C
11.r:979-7115-9595 o F.(s. 979•74C.9S46
Workers' Compensation insurance :\fftdavit: Builders/Contractors/Electricians/Plumbers
knolicant Information Please Print Leeibly
Name gnu<irxss QrganiratinNlnduv oluul): 1 Ryz HQ-�>
Address: 15 V�j
City,starci%ip: $ 4k Phone 0: Cu d7 ' 3 3 S'27,9,4,
\re you an employer? Check the appropriate box: 'Type or project(required):
❑ l d 1
1..�1 ;can a employer with � 4. 1 a n a genera contractor an
G. ❑ New construction
employees(full and/ur part-time).• have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 am a sole prnprictor ar partner- listed on the attached'sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q, ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical regain or additions
required.) oftieers have exercised their
3.❑ 1 ;can a homeowner doing all work right of exemption per NIGL 1 I.❑ Plumbing repairs or additions
myself.(No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) r employees. (No workers' 13.❑ Other
comp. insurance required.)
•Any;yphcuus that checks box 01 musi:Ilia Illl WI the iec goo Wow showina IhClf workl:rl cumpunsatiou policy inliumatiun
'I tomcawnen whu udumil this aff davit indicating nccy are doing all vurk and duel hire outside co ttmion must auhnno a new alraWvil indicating such,
-Conaacttus Ono check Ibis box muss atachcd an additional Aml hawing the name of the subrontraclJn and their workun'comp.policy information.
/ant un employer that k pravidinr workers'evalpen.sation insurance for uty employees. Belary is the policy and jab sire
iufortnutian.
Insurance Company Vmne: _..... -. --.-._--._..--------
Policy is or Sul Pins. Lic.tJ: __. . __...._ Expiration Date:
lob Site Address: C'ity,5late/Zip:
Attach is copy of the workers'compensation policy declaration pale (showing;the policy number and expiration date).
hailurc to secure coverage as required under Suction 25A ul•.\,IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to SL500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it Jay against the violator. Inc advised shut a copy of this statement may be lurwarJcd to the Office of
III\"illhaltOnx UI the U1A for in,ur:u:cc a,vcru�e (uric icatiun.
l du hereby certify under the pains and penalties u/perjury rhut the iufurtnurlon provided above is true and correct.
Date' l�/I 6w7
F
ay. Dd not m'rite in this urea, to be completed by city car town official.n: Permit/License 0-urily(circle tine):
lvalth 2. Ihlilding Deparuncut J. Cili four Clerk 4. Llectrical Inspector 5. Plumbing; Inspector
__. ..
Cmtlact l'cnuu: _ .. I'honc d:
Information and Instructions
.%lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their emptoyees.
Pursuant to this statute, in emplt ree is defined as"...every person in the service of another under any contract of hire,
e,cpress or implied, oral or written.-
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
,,t the lbregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,:ssoctatioa 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.,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
%IGL 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 subtfivisions shall
enter into any contract for the perfomiance of public work until acceptable evidence of conrpliunce 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-contractor(s)name(s),address(es)and phone numbers)along with their certificata(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 he 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 pennit/licerse number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilice se applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and tinder"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 affidavitnrust be filled 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.
t he 0ilice of Investigations would like to thank you in advance fur your cooperation and should you havc:my questions,
please du not hesitate to give us a call.
the Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
R:riscd i-26-05
www.mass.gov/dia
,. CITY OF S UI ENI, tiIASSACHUSETTS
• BUIL.DING DEPAR-r%l&NT
130 WASHNGTON STREET, 3" FLOOR
TEL (978) 745-9595
FAx(978) 740.9846
Kl�tgFRi EY DRISCOLL
MAYORlliO.tilAS ST.PLERRB
DIRECTOR OF PUBLIC PROPERIY/BCt=%L G CONWISSIONER
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 I 11.5
Debris,and the provisions of MGL a 40, S 54;
Building Permit# is issued witfi 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
I11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature T
applicant
lO
date
11-18-2010 03:49PM FROM-CLEMENT ARCHER INS. AGENCY 978-922-9276 T-424 P.001/001 F-035
ACORD,,,, CERTIFICATE OF LIABILITY INSURANCE 1118/201D DATE CERTIFICATEPRODUCER (978) 922-4600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ARCHER INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
271 CABOT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BEVERLY MA D1915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A.WESTERN WORF5D INSURANCE
Frederic Hopps INSURERS:HARTFORD UNDERWRITERS
15 Walcott Rd. INSURERC:SCOTTSDALE INS. CO.
NZRER O'
Beverly MA 01915- INSURER
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,
INSR ADO'L POLICY EFFECTIVE POLICY EXPIRATION
L'TR INSRPI TYPE OF INSURANCE POLICYNUMBER DATE(MMIDDI" DATE(MWDDIYY) LIMITS
A GENERAL LIABILITY NPP1167103-2 04/24/2010 04/24/2011 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES eemrronee $ 50,000
CLAIMS MADE ❑ OCCUR / / / / MEDEXP(AJMamP on) . $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENL AGGREGATE UMITAPPLIES PER PRCOUCTS-COMPIOPAGG S 1,000,000
POLICY PELT F7 LOC
AUTOMOBILE LIABILITY / / / / COMBINED SINCLE UMIY $
ANY AUTO (Fa acdnmq
ALL OWNEO AUTOS / / / / BOMLYINJURY $
SCHEOULEOAUTOS (PaTPafaan)
HIREDAUTOS / / / / BODILY INJURY $
NON.OWNEDAUTOS (Para 4-nt)
PROPERTY DAMAGE
(Par occident) $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHERTI-AN EA ACC S
AUTO ONLY AGG $
C EXCILWUNISRELLA LIABILITY XES0008303 05/17/2010 04/24/2011 EACH OCCURRENCE a 1,000,000
X OCCUR 17CLAIMS MADE AGGRFGATE $ 1,000,000
a
DEDUCTIBLE
RETENTION S I $
13 WORKERS COMPENSATION AND 6S6LTB9620M71-9-10 04/08/2010 04/08/2011
EMPLOYERS'LIABILITY MI
AIVY PROPRIETOWPARTNER/EXECUTIVE ELEACHACDIDENT S 500,000
OFFICEWMEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ 500,000
E 0 SPECIAL PROVSIONS 6NOw E.L.(NSEASE-POLICY UMYT $ 500,000
OTHER
DESCRIPTION OF OPERATK)NSILOCATIONSMCHICLE$IEXCLUSIONS ADDED BY ENOORSEMENTISPECIAL PROVISIONS
JOB SITE: 7 WEST TERR. SALEM, MA. 01970
CERTIFICATE HOLDER CANCELLATION
( ) ^ (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POUCIE$ BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WALL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BITT
CITY OF SALEM FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE
120 WASHINGTON ST. INSURER ITS AGENTS OH REPRESENTATIVF9,
AUTHORIZED REP AT VE ,
SALEM MA 01970-
ACORD 25(2001108) ®ACORD CORPORATION 1988
�,^INS025(0108).a$ ELECTRONIC LASER Tj ORMS.INC.-Mm)3 Page 1 of 2