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3 WILLIAMS ST - BUILDING INSPECTION (3) ldy .0 0 � IL. The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SA EM Mar evi Mar 2011 4t �� Building Permit Application To Construct,Repair,Renovate Or Demo One-or Two-Fmnily Dwelling This Section For Official Use Building Permit Number: Date Applie . Building Official(Print Name) Signature vf� Date SECTION 1: SITE INFORMATION 1/1 1.1 Property Address: aid 1.2 Assessors Map&Parcel Numbers 3 1, A 'r 2 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: U Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Requimd 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP[ ✓ 2.1 Owner of Rewrd: VA-1-)46n,erclz MA Name(print) City,State,ZIP :0-3 k '),II;Ai.ts 57 qQg- 94q- 26617 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 114 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) 1% Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work': o L r�•d�T'U' a�e^ M `r A l 1,4.�A�� r Vl�✓$s iJ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ ('3 J%ZbD , c-Z, 1. Building Permit Fee:$ j A, tJIndicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee C� ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ J c3Q 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ , ❑Paid in Full ❑Outstanding Balance Due: yi7 71it�` +0 �4 9r1 4 r4C�,o f( 5 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) '7 f7 O t7 i C� I AGAlA� L. License Number Expiration Date Name of CSL Holder L4 i ��C��lL� S; List CSL Type(see below) u No.and Street Type Description iMA�3 MBA ( � �I—J7 U Unrestricted(Buildings upDwellto ing cu.ft.) R Restricted 1a@2 Family Dwellin City/Town,State,ZIP M Masonry 2d� , RC Roofing Covering WS Window and Siding e NET SF Solid Fuel Burning Appliances 0677 I 1 Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement Contractor(MC) _ /2si /73 t�3o O 2��"2a�+ �C�+.J,S"'�'•3 C7]�5 ��-�— HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 7� �!' E t1�a,�i `TYL 2 No.and Street ,� email address eJ +t� Anp+ '7sSLG3g-�E7 G ci�c,*s , ^.47 - Ci /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 Co U o lam'+k L�L_ to act on my behalf,in all matters relative to work authorized by this building permit application. /ar_eenJ C rcrz o Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHO D AG DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information cMiA---�W n this application is true and accurate to the best of my knowledge and understanding. :/-e/�•-- .3; -4— T LeAI l 3 D 1 i')-- P er's or Authorized Agent's N e(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 MnLMgss.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 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 SM E14 NIASSACHLSETTS BUILDING DEPARTMIUNT • 120 W iSHINGTON STREET,Vo FLOOR \ 1$L (978)745-9595 FAX(978)740-91M KIMBERLEY DRISCOLL I iIMAYOR TiOALtS ST.PtERRB DIRECTOR OF PUBLIC PROPERTY/BL'II.DIING CO%WMIONER Workers'Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbers Applicant Information n Please Print Legibly Name(Business OrganizatioNlndividual): C-0 f2p_aa Address: t4- 12 1-I 1 Q4 La n)c� I �!'�Cc— City/State/Zip:MA MALe J14"Ait` Mn9y5 Phone#: 95-1- 6 9- 0 e J7/7 Are ou an employer?Check the appropriate box: Type of project(required): 1.a1 am a employer with / _ 4. ❑ 1 son a general contractor and 1 6. ❑New construction employees(full and/or part-tine" have hired the sub-contractors 2.❑ 1 am a sole proprietor Or partner- listed on the attached sheet.: 7. RRenuidtfing ship and have no employees These sub-contractors have 8. ❑Demolition workingfor the in an capacity. workers'comp.insurance. Y P�tY• 9. ❑Building addition [No workers'comp.insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c 152.§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] l3.❑Other `Any appliram that checks box A most also all out the section below showing their wafluns•compensation policy infumutioo. t I hsmetrmess who submit this affidavit indicating they art doing all work and them hire ra6ide Cmmlaetets most submit a rtew affidavit indicating em'a. :Comm ton that cheek this box most anachod an additional sbsss slowing are more of en subconuacton and their woraas•comp,policy informative. I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site information. \ Insurance Company Name: /a✓'] 2J�o (Z[^ cias L1a-LrJ Policy#or Self-ins.Lic.#: rrAxa' 08W GT LAC,y2 Expiration Date: () [, �1 Job Site Address: e r.t,'r 'w,�_City/StatdZip: `A) ef-iN rVIA D 1990 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c_ 152 can lead to the imposition of criminal penalties of a fine up to S 1.500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 it day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Invosligations of the DIA for insurance coverage verification. I do hereby c der the pains and penalties ofperlary that the information provided above is tree and correct. gnature Si _�j ' - / /�s �— Date, 0 OJjrcial use only. Do not write in this area,to be completed by city or town ojJiciol City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3.Citylfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Perinn• Phone#• CITY OF SM.E.M. N'WSACHUSEM lw • BUILDING DEP.AA['m&N mo 120 WASHLNGTON STREET, 3"O FLOOR TEL (978) 745-9595 FAX(978) 7400846 KmBERL.EY DRISCOLL MAYOR THoatas ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER 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 111.5 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: Q�(Jp(�t4 ri)tS; L nJG - (name o hauler) The debris will be disposed of in N b lZi�i C A`'Lzw 6. (name of facility) E g�-- sla ki-\ ;Yuri 0/ 9' 6 (address of facility) signature of permit applicant date Jcbris�r.i�S 0-2/28/2012 15:47 FAX 978 532 2217 CROSS INSURANCE Z 001/001 " CERTIFICATE OF LIABILITY INSURANCE 2/28/2012 °"'E'MM°°"" ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOTIVELY ON 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(im)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 ce tificata does not confer rights to the cerUBcate holder in lieu of such endorsemen s. PRODUCER MEAN@ Tapr9a GD1 Cross Tnsuranoe-Peabody PHonE - (978)532-5445 R (97e)5M-2227 139 Lynnfield Street E•LW .lgoldman@orossa ®a g CY_ccmm INSUR AFFORDING COVERAGE NgICO Peabody MA 01960 MURERA:Hartford Ins Co INSURED INSLRERe;RartfOrd Casualty Ins Co 9424 Corporal construction Inc. wsuRERo; 46 Shepard Street uISUBER D: N91 RER E Marblehead tRi 01945 MSURERF; COVERAGES CERTIFICATE NUMBER:CL0 622 612 634 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- N9R LTR TYPE OFINSURANCE V6IVDPOLICY NUMBeR "MYYY M/0o EIIP LIMITS CENERALUAWLIIT EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY R Aw $ 1,000,00 0 A CLAIMSMADE ©OCCUR SSBPW353E /1/2012 /1/201.1 MEDEXP we PerseA s 10.000 PERSONAL&ADVINJURY S 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS AGO S 2,000,00 X POLICY PRO- LOC S FAUTOS M081LEDABILIry co aamdeNYAUTO BODILY INJURY(PA PN n) 5 LL0MEDSCHEDULEDNON-OWNED AUTOS BODILY IWIIRY(Fu aaedanV S IRED aU705 AUTOS PROPERTY DAMAGE & $ UMaftEL1A LIAR OCCUR EACH OCCURRENCE S E1{CE89 LLAB CLAIMS -MADE AGGREGATE § DED RETENTIONS B WORKERS COMPENSATION $ AND EMPLOYERS'LIABIUry WC STATU- OTN• ANY PROPRIETOR/PARTNER/FJ(ECUTIVE YIN OFFICERIMEMBER EXCLUDED? NIA E.L.FACN ACCIDENT S 5OO 000 (Aten4al NH) 8WEC1a0042 /3/2032 /3/2013 Ifya5RI;a Peun4er EL DISEASE-FA EMPLOYE S 600 000 OE$DRIPTION OF OPERATION36eow EL DISEASE-POLICY LIMB S 500 p00 PESCRIPTION OF OPERATIONS I LOCATI°NSI VENICIES(Amcl ACORD 1D1,/1VWDOAaI Remgdq SrDe4ldq M mOn spew ly RWlnd) CERTIFICATE HOLDER CANCELLATION (978)740-9846 SHOULD ANY OF THE ABOVE DESCRIBED pOL1L'Icc BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Salem ACCORDANCE WITH THE POLICY PROV6IONS. Attn; Building Department One Salem Green AUTHORED REPRESENTATIVE Salem, MA 01970 �p y y Timothy Tramonte/L64 14-0 ec, ,GLcvnrvrlZTe+ ACORD 26(2010106) ®IVUB-2010 ACORD CORPORATION. All rights reserved. INS02612Dro°&),oI The ACORD name and loco are renistared mnirc nF Arnon