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18 WILLIAMS ST - BUILDING INSPECTION (3) 4 t r'- O � — ILI � ZI � coa � 69� rt�rF�I ) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF SALEM dl Massachusetts State Building Code, 780 CMR Revised 1far 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official'Use Only. Buildim>Permit Number: pate A ' d: ` P Z7 . uilding Official(Print Name) Signature Date SECTION 1:SITE'INPORD7 ON 1.1 Property Addre s: S'r v n r I 1.2 Assessors Map& Parcel Numbers �8 GJ tl � bc/yts L I n 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 R) Frontage(0) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.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 yes❑ • SECTION2: PROPERTYOWNERSHIP` 2.1 O�w.}}��ertoSSR__ec°°ffd: b n 12191,70 T�me(Print) City,State,ZIP AS30L ?!Y-- �r sS-' 5fK No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Buildin� Owner-Occupied ro Repairs(s) it I Alteration(s) ❑ Addition ❑ Demolition V Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Descri lion of Proposed Work'-: or( i�.v�-r/+en + r'��/r2 v Os e as r o m e btr a �) SECTION 4: ESTIMATED CONSTRUCTION COSTSJ Item Estimated Costs: Official Use Only Labor and Materials I Building $ �O ❑I. Building Permit Fee:$ Indicate how fee is determined: � $ D Standar . Electrical - d City/Town Application Fee- ❑Total Project Cost"(Item 6)x multiplier x 3. Plumbing $ 000 i, Other Fees: $ 4. Mechanical (l-IVAC) $ 0 List:. . L •Ef��i 5. klechanical (Fire $ Suppression) "Total All Fees:$ ` Check No. Check Amount: Cash Amount: • 6. Total Project Cost: $ J l-f 000 ❑Paid in Full ❑Outstanding Balance Due: CWi-� �� ( f SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor Liecnse(CSL) $ 0 9-r2eo AL 1 k7 B License Number Expiration • Nvnc of CSL Holder Lk 6� ' ,2 k7L/~� L List CSL Type(see below) No.and Street �/�'J AA 7/� Description VvAwtbl COS/ 1M# DI90/ U Unrestricted(Buildings s u el ing cu. R.) R Restricted 1&2 Family Dvvellin Citylfown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding - I _ SF Solid Fuel Burning Appliances ���df/�2.,3�' I t.�pJdP.�e�✓� ��]h7a� I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 7 yZ p Z� ,S 2 1 I iz 6,14 e Ser✓��� HIC Registration Number Expvatmn Date HIC Company Name or HIC Re ist nt Name JJAQjJu Lk No.an Street S 11 n W fo:l Email address N�Am CO /Y,// Ci[ /Town, Stafe,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'AP/IPLIES'FO R_BUILD IINGG PE RNI If 1, as Owner of the subject property, hereby authorize LIRVJO U"e S '6 c& • t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) 0 EFate SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below hereby attest under the pains and penalties of perjury that all of the information contained in this applicati t ' true a accurate to the best of my knowledge and understanding. °S b TPA - _9 I/3 Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 NLG.L.c. 142A. Other important information on the HIC Program can be found at www.mass,tgyov= Information on the Construction Supervisor License can be found at vvww.mass.,,ov/d -ss 2. When substantial work is planned,pro de the information below: 'total floor area(sq. ft.) too �a-� (including garage, finished basement/attics,decks or porch) Gross living area(sq. it.) Habitable room count Number of fireplaces Number of bedrooms 1 Number of bathrooms Number of half/baths Type of heating system err Number of decks/porches O Type of cooling system t✓L Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" • ' t PPage No. of Pages Pr Insured Litehouse Services License # 95280 Litehouse Services 67 Monument Avenue H.I.C. # 142824 Home Repairs Mode Easy Swampscott, MA 01907 _ litehouseservices@hotmail.com ut 'r Bob Pierce 781-864-5238 PROPOSALS BMI7TED fO/ PHONE STREET JOBNAME r#V S CITY,STATE AND ZIP CODE ' �� JOB LOCATION _ -]^!' w MA APPROX.STeRTINGPATE JOB PHONE 22 We hereby submit specifications antl estimates for. o oAllske,Zi lr� 2 k,drvams LI-r4n..- /tV 1,41 rVob" J 'f lcken re oo✓t L/,A r Jiyt4vehJe l r ow reWdadel 3 ladL Ve Vropo8e hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: dollars ($ � Payment to16he asOnbws: 1/3 down, 1/3 middle of job, 1/3 upon completion t, All material is guaranteed to be as specified.All wodc to be completed in a workmanlike manner Authorized �— according to standard practices.Any alteration or deviation fmm above specifications invomrig Signat extm costs will be executed only upon written orders,and will become an extra charge war and above the estimate. Note:This proposal may be withdrawn by us if not accepted within days. Atteptante of Propagal—The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment Signature will be made as outlined above. Date of Acceptance: Signature - l CITY OF S. F-.\I, NLkSSACHUSETTS BUILDL\G DEPARTMEINT 120 WASHIINGTON STREET, 3" FLOOR TEL (978) 745-9595 FAx.(978) 740-9846 KIA{gFrzt EY DRISCOLL MAYORTHOxtrs ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/BUIMNG CONNISSIONER 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 It 1.5 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: t`{ t 6 U d-e (name of hauler) The debris will be disposed of in : / (name of facili ) a- _ 0o M� (addrg of facility) signature of permit applicant 13 date •lcbrisal Llx; CITY OF S:UE.%11 N-LUSACHUSETTS BL•ILDLNG DEPARTMENT !: t 120 WASHQVGTON STREET, 3"a FLOOR TEL (979) 745-9595 Ei%(978) 740-9846 KIS[BERt RY DRISCOLL Tlipb4lSST.PIERRB MAYOR DIRECCOR OF PUBLIC PROPERTY/BUILDING COSL\IISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly- ._ r Name(nusirtess,Organiratiorvindividual): [ kk—���_���t:� Address:--L-7 1AAo%riut "+ z^I2:S= City/Statc/Zip: Swaw r re 90`j Phone te:7 l �� 7 ��2 Are you an employer?Check the appropriate box: Type of project(required): 1.V I am a employer with 2 4. ❑ i am a general contractor and 1 6. ❑Now construction employees(ibil and/or part-time).' have hired the subcontractors II��11��,�, 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. Memodeling ship and have no employees These sub-contractors have S. Demolition workingfor ma in an capacity. workers'comp.insurance. Y P ty• 0. ❑ building addition [No workers'comp.insurance 5.0 We are a cc rpamtion and its officers have exercised their I0.❑Electrical repairs or additions required.) . 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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' 13.❑Other comp,insurance required.) •Any applicant that chltks box its meet alto all eurthe section below,showing their Woti ms'compenwton policy inf nmatiom '1 hwneownem who submit this affidavit indicating they am doing all work and then hire outride cantraaon must submit a mew alridavit indicting such. :Connoctoo that check this box meet attached an addidurud oheel showing IN mane of the sub-commdom and their workers'comp,policy infammnon. I urn an employer that is provldfng workers'conrpeasaden lnsuranee for my employeex Below/s the polley and job site Insurance Company Name: W (!J'� ff✓/ Policy 4 or Self-ins. Lie.�#: i ry r Expiration Date: Job Site Address: `!�'(6 / O �l (tfl/�r V City/StateJZipSilIm Mk 0 (?70 ,inacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 23A of NIGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonmm as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S230.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do/remby cerdJy rat er dar pubs ad poll allies of perjury that the hylurmatlon provided above * sere and correct. Si'miluro: A.,— Dare' lililgz Phone A; Y SL & r7J 1cial use mdy. Do not write in ildi area,to be completed by city or town ojjlclast City oe Town: _ Permit/I.Icense X Lcsuing Authority(circle one): --- I. board of ilculth 2. nuiiding Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone ti: I 08/19/2013 MON 10: 31 FAX Farquhar and Black 0002/002 DATE(MmmDIYYYY) A CERTIFICATE OF LIABILITY INSURANCE 6 19/2013 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: N 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 center rights t0 the Certificate holder in lieu of such endorsements. PRODUCER CONTACT Christopher Kennedy NAME Farquhar & Black Insurance Agency, Inc. PHONE FAX (7B7)599-220_0 IALq ).(7B1)591-3940 85 Exchange Street - Suite 101 E-MAILAD . MA s:Chris@FandBlnsurance-cam PRODUCER 00031842 _ CUSTOMER ID A: _ L MA 01901-1475 INSURER(S)AFFORDING COVERAGE MAIO0 INSURED INSURER AITrayelers Insurance Cc '39357 INSURERS Safety Insurance _ 39454 Litehouse Services LLC INSURER CAssociated Employers Insurance 140959 _ 67 Monument Ave wsuRERO: INSURERE: __ Swampscott MA 01907 INSURER F; COVERAGES CERTIFICATE NUMBER:Oity of $alern REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED_ NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DE$CRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CTR� TT PEOFINSURANCE �R WVD POLICYNOMBER MMLDICDYEF MMLIDPOCYEXP LIMITS GENERAL LIABILITY EACH OCCURRENCE § 1,000,000 I X:COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED r� : PREMISES(Ea oecurlence) E 300,000 A CLAIMS-MADE XOCCUR 6a0-4C723935-12-42 10/17/201220/17/2013 MED EXP(My one peroon) ,8 5,000 j PERSONAL B ADV INJURY $ 1,000,000 _-- GENERAL AGGREGAIE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIOP AGO '$ 2,000,000 - !X I POLICY I I PRO- 7 LOG _— !AUTOMOBILE LIABILITY COMBINED SINGLE UMM Is ANY AUTO (Ea accldenl) --B ! ALL OWNED AUTOS 6204939 Sl/12/2012 p BODILY IMURY(Per Person) I$ 100,0001/12/2013 __. BODILY INJURY(Per acaden0 E 300,000 X SCHEDULED AUTOS PROPERTY DAMAGE I X' NIRED PUTOS I I I F(Perauidenl) �S 100,000 X. NON-OWNED AUTOS Unheured molollat Combined '$ Undodnamd mWop*I. S ._ I CLAIMS-MADh it i EACH OCCURRENCE i$ UMBRELLA LIAR !OCCUR EXCESS LIAB ! AGGREGATE $ 7DEDUCTIBLE g RETENTION § ! § L.�II WORKERS COMPENSATION WC STATU IOTI t. AND EMPLOYERS'LIAGRATY Y I N ANY PROPRIROIWARTNEWEXF,CUTIVE E.L EACH ACCIDENT_ $ 500,000 OFFIOERIMEMBER EXCLUDED? ❑INIA (Mandatory In NH) �aCC5009958012013 5/7/2013 5/7/2014 E.L DISEASE.Gt3.1PLOY[E$ 500,000 D SCRIPTION OF GPEMTIDNS aHGW ycnbo under I E.L.DISEASE-POLICY LIMIT S 500 0 ECNIP I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attxh AGORD IM,Additional Remarks Schedule,X mme space is raVulied) ". CERTIFICATE HOLDER CANCELLATION i (978)740-9846 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. Attn Building Dept.93 Washington Street AUTHORIZED REPRESENTATIVE Salem, 1-% 02970 Marian Cruz ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(2009091 The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY.INSURANCE 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 BETWMN THE ISSUING INSURERIS), AUTWORIUD REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER, IMPORTANT: If the ce to balder Is an ADDITIONAL INSURED, the polley(lee)must be endorsed. If SUBROGATION IB WAIVED,SUbloet to the terms and cond sons of the polloy,cortaln Policies MIRY Nqulfe an andorsamallt, A Statement 011 this Certificate duos not confer dgTne to the cartMORts holder In Neu of Such en lorsome e MONONA Matthews Insurance Agency Inc 102 Parker St oxs (gT�881-1112 " (578)865- 055 wL Lawrence.MA 0180 Fss` P+evMwsl aiFOROx+e caveMoe ���_ INBURaa 0.1 AtNntiG Casualty INSU EB Michael Capeiess I aEBe: AMells 105 Tyler St — Methuen,MA01844 INSURER b: SURERF: T- COVERAGES CERTIFICATE NUMBER: FIEVISION NUMBER: THIS IS TO CERTIFY T14AT THE POLICIES OF INSURANCE UST80 BELOW HAVE BEAN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY.PERIOD INDICATED, NOTNAYHSTANDING ANY REQUIREMENT,TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT MTN 1`185PECT TO WHir n THIS CERTIFICATB,MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TIIRMB. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BBBN REDUCED BY PAID CLAIMS. . T"t Or MBuw *E: P 0Y P LIgT9 GENERALUA11IL11Y G AMM; s T,000,OOO cGMNBnqutesNBanL unelurY L143000684 03107/2013 01IN1772014 Srgg�g� S,eBppL f 100,000 CLANS MME 7 OCCUR P one PMML— t 1,000 RODNAL A AN INilyrty_ 1,00000 S+ENERALA08"AAjg_._, f 1,000,000 OEN'LA00NlGATEUMn A;MLM PER. PRODUCTS. ACID i,DOD,D00 POLICY M TA F7 LbC f AIROROBILE LIAe1LIN NOTE LIMIT ANYAM HG357357 OBWZ012 0=012013 BODILY INJURY"rpwii" S 300.000 ALL OWNED SCMLOULSD AVTOS NON D�VYNED BODILY INJIIRY(Per rpalnrnq f 300,000 hIlRt:p AVr06 AUM A s 300.000 t�LA�.a�,19 p UMBRELLA UAe OCCUR eACH RAN } f,00D,000 VIOESSLMB ClA1MS•Mgea A1111463 2/23/2013 0212312014 AGGREGATE f 600,000 !Nn } WOMRSCWPENSATION ST�77uu ANO MAKOYHIB'LIABILr1Y lelCLBK 8 ANV PROPRI6TORPARTNeRpecunveffl 8909f1.OB37858 11/17/2012 11/17f2013 E.L.eArJanDcmRNY tl)D,00tl 1Mob MMAM NM1 WWDDPPo''11 NIA fI 1 E.L.as s i 100,000 ° T a. Y uMD a 500,000 DESCRIP11011 OFOVEIRAMONS I 10CATON9 IVEHeLIS(Aftdl1 ACORD 1O1,AdeNeA�r ArmrNlr EaMIIA0,Span BpA IA("alrod) Heating or combined heating and air conditioning systems or equipment,Installation.SeMeing or repair,plumbing CERTIFICATE HOLDER CANCELLATION Itanbc Coast Homes 48 School St 02 SHOULD ANY OF THU ABOVE DESCRIBED POLICIES HIS CANCELLED BEFORE SSHm.MA THE EXPIRATION DATE T1gItBOP, NOTICE WILL BE DELIVERED IN - ACCORDANCR WON THE POUCY PROVISIONS. AMRIrtmea MAMEN TIVA ®1988.2010 ACORD CORPORATION, AN rights rtegerved. ACORD 28(2010108) The ACORD name and toW are ragl Oaredmerkz of ACORD gs / / 35 FORT AVENUE 247-14 pis a- 6324 COMMONWEALTH OF MASSACHUSETTS Map: 142 Block: CITY OF SALEM Lot ag 10084 Category REPAIRJREPLACE Peril„t# 247-14 BUILDING PERMIT Project# JS-2014-000583 Est. Cost: $0.00,_; Fee Charged: $25 00 Balance Due: $.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Expires: Use Group:.. A&A Services Inc. CONSTRUCTIO SUPERVISOR-57733 Lot Slze(sq: ft): 7450.0668 'a Zoning: Owner: SZYMANSKI JOSEPH J,BARBARA E Units Gained: _ Applicant: A&A Services Inc. Units Lost. 5.:AT: 35 FORT AVENUE Dig Safe#: 'ISSUED ON. 19-Sep-2013 AMENDED ON. EXPIRES ON. 19-Mar-2014 TO PERFORM THE FOLLOWING WORK: REPLACE FRONT RAIL ON DECK WITH FIR;REPLACE TWO (2) GARAGE WINDOWS WITH VINYL REPLACEMENT DEADLITE WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Undergiou ul: Underground: Underground: Excavation: Scrvice: Meter: Footings: Rough: Bough: Rough: Foundation: Final: Final: Final: Rough Frame: FireplacNChimncy: D.P.W. Fire Health Insulation: Meter: Oil: Final: House# Smoke: Treasury: Water: Alarm: ASSCSSOr Sewcr: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: CheckNo: Amount: BUILDING RFC-2014-000586 19-Sep-13 1561 $25.00 i I6eol'D1S02013 Des Lauriers Municipal Solutions,Inc.