8 WEST TER - BUILDING INSPECTION (3) a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised Jumrury
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-F mily Dwelling
This Sect' n or Offtc' 1 Use Only
Building Permit No er: I IJAWAIpplied:
Signature: ' " "' ti � 90
Building Commissioner/Inspector of Buildi gs Date
SECTIO 1/SIT I/SIT9 INFORMATION
LI Property Address 1.2 Assessors Map& Parcel Numbers
to baer.� J rl . -
1.1 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 11) Frontage(11)
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: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Me 4 tAM< 14)ke lieu SnM�
Name(Print) Address for Service:
9 79 - 7Y(-i-07a r'_
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building V 1 Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ Number of Unils__I_ I Other ❑ Specify:Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ORtcial Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determiIned-
2.
❑Standard City/Town Application Fee
Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
6. Total Project Cost: S oe, Check No. Check Amount: Cash Amount:
/ 7 $O0 ❑Paid in Full ❑Outstanding Balance Due:
/d�j• o�
P13
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
�lJl ll•/fM l..b�/fu s I.iccnsc Number Expiration Date
Namr of /SL- I IulJer / List CSL Type(see below)
lrL�s`1i:9... (�7/7•St — f. Description
.4JJmss u Unrestricted(up to 35,000 Co.Ft.
�fAe�th-3( f! R Restricted 1&2 Family Dwelling
Signature:�„ , / (/7/��' M Mason Onl
C.ZZ2&� V' RC Residential Roaring Covering
Telephone WS Residential Window and Siding
q
/ 7 Residential Solid Fuel Burning Appliance Installation \I
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) a Paa (e!�L
I IIC Cu y Name or fllC Registrant Name Registration Number
Address os— v CF6'a Es trution Date
tt 3 GJ/ra/rr�,� .. S 97�-i'G
Signature f Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ..........0 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Signature of Owner Date
SECTION 71b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed 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(HIC)Program),will W1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.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.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hal0baths
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 S.U.E.NI9 iSSACHUSE"ITS
OCQOLVG DUARIMLN r
110 10.%MMTON ST%w. Y'FLOOR
TM. (978) 745-9599
is F.%X(971A 7449NW
Kl.N®EALEY DaMOLL Tuab"lSLF3RRs
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Workers' Compenssilon Insu►2nc0'%MdaeiM OuildwWContractor/EleetrielrnalPlumbers
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Address: AG,L /114tw S s (JA"'
CityiStaiwziF h/eeev
�r roe on empbW Cbeer the spp►eprlaq be= Type orprgleat(r.qube¢
e. ❑ 1 am, contractor ad 1
I. 1 am a unpla)m with ll d IL ❑Nor conatuctim
Cmpleyew(Add aod/ae Paradrrr}c have hind the m►.meracau 7. RertotMlin 2.01 am a sof proprietor ur partner` liased an low otwhed ahea .i ❑ d
.,hip and how no ampbyaaa This ar►.amraeaara haw a ❑f?amolirior
workind the me in any capacity. werbtnt'comp.insentoon. 9. Q lyuiWLy addhior
RNo alas•comp•inwranco r. ❑ We aw a carpaMlan an/it I O.Q EbenieN repair or additimee
Mks halve eatwciwd pleb
).❑ 1 am a heretao~doing ail work riaw ofewomption per MOt, t t.Q plu M td repaint or adelklotr
royal[(Yr Worlme'Camp. c. 1S2.11(4).aml we how no 12.❑Roefrepaim
insurance!required)t :tnp' 2 LNeworkma' 1).❑Otbae
comp`inourwom reeked.)
*roar�Yrar,ler al,waa as el a.ta sir r1a w uw.wa.6dw Ar.l.y,atb wbw'ohm peaoy larr.rrl..
'I gwwawwao wW aabwa cab datYrk ieslsa.y,he/>w,IoY,d aerlt a.e,bm bier writ awtaattsse Cerro witab a aw aleieil idlerine aaaR
f..+,.,w owi bob,W w.nr,werw an slau.d ANN r..re a.,..e.rlr dub4moso"w Juk.w6w.aw¢Pwfiw la"Mi i
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:n/arnrrde�
In,uranca Company Votee (�y?i AN r F e
Fnlicy e or Self-ine. Lie.N: Expiration -D 6 !�
)ob Sire Adtheae CiWStatrZip:
.tetaek a copy of tbe warners'compoanMn patsy dimbrelbr pap(abowbeg tba pelt number an/eapindsn 4fe16
Failure to seclul coversp an required under tamtae 31A of MOL a. 132 can led to the imposWon ofcrimbw pe"ds are
ring up to S 1.)00.00 afww one-year imprisonment,L wog as civil peaawi it the form ore STOP WORK ORDER and a floc
.)f up to s_7o.00 a Jay ayainsl the violator. IN advi.*W that,copy of this statemene maybe forwarded to the Otl?eo of
htrc.nymiu,ts„f the nIA for insurance cowmp wYilkativa
/Je Aereay cerd/}r an/N tko psins rand prno/il"elpequq rAw tM is trw and.•erred
V`are a•
rLOUIAPICIf
are aa/p Oe rod wia io thia arre;tr Ir•utw0/dn/I)'cilyW/aver n/�ft•int
Cityorturn: errmiul.lcrnse a— ---
Aurhor,ty (circle une):
u(Ilrillb 1. quddlaa Ilepartmene I. ('tlrtrown Clerk 1. flectrical Imprctor 1. rlumbtnd Impeetor
_
� tenon: _ than. l:
�\ CITY OF SALEM
PUBLIC PROPRERTY
�; I DEPARTMENT
1'.It: Nlfl ^Mlv .`ll
.1.a t!Q�T�•1 IL\t..��V)I Ntr r •5.111�I, �t•i��r t ltN4 1,•:1't':
1'rt:va.�+47'y! •t'tr:97a, s'
Construction Debris Dlsposal Affidavit
(required Iur all demolition:uid renovation work)
In accord ante with the sixth edition of the State building Code, 730 CMR section 1 11.3
Debris, and the provisions of MGL c 4U, S 54;
is issued with the condition that the debris resulting from
Building Permit Mom. - rl licensed waste disposal facility as defined by MGL c
this work shall he disposed of in a Properly
111. S 150A.
The debris will be transported by:
Ills of hauler) -
I'he debris will be disposed of in int-p-V L✓h ��
-
� 7D
(nartleul act my
taaarefNurfaedityl
aanature of permit applicant
date
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
03/30/2010
PRODUCER 978,374.6352 FAX 978.521.5127 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
COSTELLO INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
2 South Kimball St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 5248
Bradford, MA 01835 INSURERS AFFORDING COVERAGE NAIC#
INSURED Valley Siding Wholesale LLC INSURERA: Nautilus Insurance Company
185 South Main Street INSURERB: Arbella Insurance
Unit B INSURERc: Granite State Insurance
Newton, NH 03858 INSURER D:
INSURER E:
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.
NSR
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMMD DATE MMIDDPOLICY EFFECTIVE POLICY EXPWM LIMB
GENERAL LABILITY TO BE ISSUED 03/30/201U 03/30/2011 EACH OCCURRENCE $ 1,000,000
COMMERCIAL GENERAL LIABILITY PREMISES Ea occurre nce $ 500,00
CLAIMS MADE OCCUR MED EXP(Any one person) $ 1,00
A PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE1-IMR APPLIES PER: - PRODUCTS-COMP/OP ADS $. — 2,000,000
POLICY PENT LOC
HJEC
AUTOMOBILE LABILITY 1000046352 03/11/2010 03/11/2011 COMBINED SINGLE LIMB
ANY AUTO (Ea aoddent) $ 1,000,000
ALL OWNED AUTOS BODILY INJURY $
X B SCHEDULEDAUTOS (Per Person)
MIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGO $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION E $
WORKERS COMPENSATION TO BE ISSUED 03/30/2010 03/30/2011 1 TORYLIMITs I I ER
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNER/EXECUTNED E.L.EACH ACCIDENT $ 100,000
C OFFICER/MEMBER EXCLUDED? — E.L.DISEASE-EA EMPLOYE $ 100,000
(Mandy ry in NH)
Ifyyees.desenbeunder E.L.DISEASE-POLICY LIMIT $ SOO,OO
SPECAL PROVISIONS btlaw
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYSWRnTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
City of Haverhill IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Attn: Blding Inspector REPRESENTATIVES.
4 Summer Street AUTHORIZED REPRESENTATIVE
Ha erhill , MA 01830
ACORD 25(2009101) FAX: 978,374.2337 01988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Nlassacbuscns - Dcperthncnt n1'Public Safct% .
Board of Buildin_ Remilations :uul Standards
Construction Supervisor License
License: CS 16201
Restricted to: 00
WILLIAM P CHASE
15 KINGSBURY AVE
HAVERHILL, MA 01835
o—
� 'y��` Expiration: 11/16/2011
0...miisvi„ner Tr#: 9840
Boafffli(SatPAtBE10Ef�of�9n8gP�S{7Ed( t
HOME IMPROVEMENT CONTRACTOR
Reration 118838
Expiration.',
xpixplragon 4/26/2011 Tr# 282244
+ Type Private Corporation
J
HI TECH WINDOW&.SIDING_INSTALL INC
WILLIAM CHASE,��
143 WASHINGTON STk�'-� /
HAVERHILL,MA 01832 :. �:c%� Administrator
lop