11 WILLOW AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
i Board of Building Regulations and Standards Ft)K
{ Massachusetts State Building Code, 780 C'MR. 7"' edition Sl,
Building Permit Application To C'onstiuct. Repair, Renovate Or Demolish a Rriv,c,l./,nor n r
One- or Ttru-Fumih• Dnrllin,C
=r)us
S This Section For Official Use Only
Building Permit Num r —
: Date Applied:
Sitn:uure: I O, ---
Building Commissioner Inspector of Buildings Date
SECTION 1: SITE INFORMATION _
LI Property Address: 1.2 Assessors M1lap & Parcel Numbers
Zvi//out five
I.Ia Is this as accepted street'?yes_._ no Map Number P:urcl Numher
1.3 Zoning Information: 11.4 Property Dimensions:
Zoning Jistriet Fropu:;cvl Use Lot Area tcu It) _ Fron!:itxe iltl
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required �— Provided Rcyuin:d Provided Requited Provided
i
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 ❑ On site disposal s stem ❑
Public ❑ Private❑ Check if yes❑ p I Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 OU/w/n/er/l'ofRecorrPWGGF�� 44 /FyC " 5
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ .Alteration(,) ❑ Addiiinn ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1Number of Units_ Other ❑ Specity:
Brief Description of Proposed Work': — -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)-
I. Building $ D� DO 1. Building Permit Fee: $ Indicate how fee is dete nnuQ7I
❑ Standard City/Town Application Fee
2. Electrical $ }
❑Total Project Cost (item 6) x multi r
Other Fees: $ —� x
3. Plumbing $ ?
4. Mechanical (HVAC) .$ List:
5. Mechanical (Fire $
Suppression) Total All Fees:
U Check No. Check :\mount Cash :\mount: _
1 b. Total Project Cost: $ �QQ. 0 Paid to Full 0 Outstanding Balance Due:_____
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) r)&S-12
q
�6gKf<<-S License Nunther I_vpir:pion Date
Name Ot CSl - Ilolder •� _
7 List CSL Ty)x(see haluw)
_20- 1, e Uescolnion
\ddrcas
C Unnstnucd uti to lS.(H)O('u. Ft.)
R Restricted 18c'_ Fant]h Duelling
S ignuwrc _ 7 r / _ \t Slasonry Only
b 5— RC Residential Roofing(',)suing
TrIcpIR c \1S ReSldellltal \Vindot, .inJ Siding— _
SF Residential Sol:d Fuel Burning \pplrmr: Ins).illauon
U Restdennal Demolition
5.2 Rl3 ed m,een[mrl.p ovement Contractor(IIIC) /OG 33
HIC Company Name or HIC Reg] trip `lame Registianon :Nuutber
Address 6r12 /
3s'131 Expiration Date
signatufeq Telephone
SECTION 5: 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 I
this affidavit will result in the denial of the Issuance a he building permit. —
Signed Affidavit Attached? Yes .._....... No ........... ❑
SECTION 7u: OWNER AUTII ! !ZAT!ON 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 bui]ding permit application. -
Suture of Owner �— Date
SECTION 7b: OWNER) OR aurHORILED AGENT DECLARATION —�
1, as Owner or Authorized Agent hereby declare
that the statements and information or. the foregoing application are true and accurate, to the best of my knowledge and
behalf. p
Print Name
p ` b^ �
Signature o wner or Authorized Agent Date
(Signed under the gins and^enahics oF-perjury)- t
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut 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 CNIR Regulations 110.RG and 110.R5, respectively.
'. When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.!_ (including garage, finished basementlattics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of hedraums
Number of bathrooms Number of half/baths
'rype of heating system Number of decks/ porches j
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
AcoRL�, CERTIFICATE OF LIABILITY INSURANCE DATE
/2°/2 a"
PRODUGER (781)438-5000 FAX (7911439-5029 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
New England Heritage Insurance Agency Group Inc. ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE
335 Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Stoneham, MA 02190
INSURERS AFFORDING COVERAGE NAIL III
WsuR® A B Carnes,Inc. mm)FARn Essex Insurance Co.
30 Arrowhead Farm Rd. ISSUItER
wRER : AIL AMERICJIN INTERNL GROUP INC
Soxford, NA 01921 URER c
INSURER
R
E
THE POLICIES OF INSURANCE USTEDBELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REOUIREMENT.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.
DM TYPE OF INSURANCE POLICY NUMBER PDUCTERZ:cnVE POUCYEIUIIRATRON DATEOUNWOrM UIMS
GENERALLL40UAY TED 03/18/2008 03/18/20M EACNocaunEmm $ 1,000,001
X CNDIERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ so,OOI
a./WS HAM OCCUR _ WED EXP(Any one Pasa,) $ S,ODI
A PE4SONAL&AM1PUURY S 1,000,001
GeRgaL ACGREGATE S 2,000,001
GENT_AGGREGATE LIMIT APPLES PER: PRODUCTS-CONPJOP AGG $ 1,000,001
POLICY LOG
AUTOWmL F LIABILITY
ANY AUTO (Ea t) LE LINK S
ALL OWNED AUTOS BOUILY BaNRY
SCHEDULED AUTOS Pe,pa ) S
/M710 AUTOS BODILY DUURY
NONOVAIEDAUTOS olerawderd) S -
PROPERTY DAMAGE S _
(Pe,erackXl
GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT S
ANY AUTO
OTHER THAN FA ACC S
AUTO ONLY. AGG $
EXCESSAIMBRELLA LIABILITY - EACH OCCURRENCE $
OCCUR 0CIMYSMADE AGGREGATE S
S
DEDUCnBLE S
RETENTION S S
WORKERS COMPENSATION AND WC 844-90-76 03/31/2008 03/31/2009 137 STATuff,I oTH-
EMPLOVEW LIABILITY
g ANYPROPRMTORUPwmNEWEXECUTWE EIEACHACGDENi S 1,000,00E
OFL�FIC, gVNEWBEREXCLUDED? EL DISEASE-EA 2n2 ,
S 1,000 00(
MIMPROVL 6beb, EL OISEAsE-POLICv LARK I S 1,000,00(
OTHER
ESCMPTMNOFOPERATIONS/LOCATIONSIVDNCLMI ADOMOT ISPECIAL PRONSIDIS
ntractor Subject to terms, conditions, endorsements and exclusions on the Policy.
E
SHOULDANY OF THE ABOVE DESCR®FD POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATETtEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL
1O DAYS"MrTEN HOME TO THE CORIFICAM HOLDER NAMED TO THE LEFT,
BUT PIULURETO MAIL SUCNNO ICE SHALL IMPOSE NO OBLIGATION OR UABRJiY
"PROOF OF INSURANM COVERAGE ONLY" OF ANY NI®UPON THE OICIW9L ITS AGENTS OR REPRFSENTATIVM
SPE@IEM COPY ONLY AUFMCIRUNDREPRESENTATIVE � I
William Kell
ACORD 25=1418) rAAenon CnwonDATInN 4002
CITY OF SALEM
PUBLIC PROPRERTY
DEPAIZT'�1ENT
'.I i •I: I', A,,,!II\i 1.41.) r • \.\1I M. %I.\"NI I .
II I v'3 'l;.);v; • 1\Y: 1i78.'4:_ 64n
Construction Debris Disposal Affidavit
(reLluired lbr all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 CMR section 1 1 L5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit H is issued with the condition that the debris resullin.- from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I ( 1. S 150A.
The debris will be transported by:
(Name of hauler)
I he debris will be disposed of in
(11 tPe u1 facility) _
ST
Iaddrdres u(lacilitvl
i
Yignawrc of permit applicant
'late
��
CITY OF SALEM
` , PUBLIC PROPRERTY
a' =r; DEPARTMENT
?,moo
.I\nL K:I'Y:)KM V(I
\1.\Y\at IBC W,vstuMt ION SI RLhT 0 SAL IzNl,bl.sisnG It it.rn GI970
'ft.I:978J45-9595 • 1'.\x. 978.741C.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Al ilicant Information �{ - Please Print Leeibiv
Name l0ucincssi Organir:.uioNlndl\iI(uu�ll;���fJ �„��
Addross:
City,State,Zip: c
Phone i': 5�3
Are sou at I oyer? Check the appropriate box: 'Type of project(required):
4. ❑ m I a a general 6.eral coulractor and 1 New construction
I. am a employer with ❑
employees(full incL'ur part-tints).• have hired the sub-contractors 7. ❑ Remodeling2.❑ I and a sole proprietor or partner- listed on the attached sheet.
These subcontractors have K. Cl Demolition
ship and have no employees
workers' comp. Insurance. 9. Building addition
working six me in any capacity. ❑ b
[No workers'cutnp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
right of per tvIGL I t.❑ Plumbing repairs or additions
3.El I ❑m a homeowner doing all work S exent Lion P P'
myself. (No workers' Lump. C. 152, §1(4), and we have no 12.❑ Ruuf repairs
insurance required.] t employees. (No workers' 13.❑ Other-
comp. insurance required.]
-Ai i phcant that chucks box rrl mull atso till out the section twluw showing their workers compc(oatiorh Policy inlurma(iun.
o.
' I lematwrwn who submit this affidavil indicating they are doing All work and then hire outside contraeton must-uhmil A new alfdavit indiuong auch.
-f m(ncluA(hut check this box metal attached An additional sheet showing Iho name of Ill.subtontractora and their wurken'comp.policy inib manon.
loin an employer that is prowiditig lvorkers'c•ornpe(rsntiolt iusaratsce fa•ary eutploj'ees. Below is rite policy ant!job knee
information.
InsuranccCumpauy Name: _..__ p
-- ._ Expiration Date: / r
Policy a or Self-ins. LiC.-!?:—��) � _`.�6 _ .---- P
l
Job Site Address:�r G111 G�D�✓S __-- - - - L'ityistateizip:
Attach It copy of life workers' compensation policy declaration pale (showing the policy nuruber and expiration date).
Failure to sceuru coverage as required wider Section 25A of>IGL c. 152 can lead to the imposition of criminal penalties of a
tin. LIP to S1.5110.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00:t day against the violator. Ile ad"d that a copy of this,tutcment may be forwarded to the Office of
III\'illi�ut1011] ui the UL\ for iosuratxc utvc c \crification.
l rlo bert•by c:riifv antler the pains'an penolriev of perjury that the information provided above is Noe and correct.
O[Jiciul use wily, Do not write in this area, to be completed by city ur town )JjiLiaL
Cilv or Town: . Permit/License d._ . _-
Issuing Aulhorily (circle line):
1. Board of licallh 2. Building mpartmcut 3. Citliffown Clerk 4. L•'Iectrical Inspector 5. Plumbing Inspector
6.O(her
Contact l'cnoal; _- . ._. Phone 1:
Information and Instructions
Vassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Phrsnant to tills statute, an emplgree is defined as"...every pei:son in the service of another under any contract of hire,
empress or implied, oral or written."
An einplayer is defined as"an individual,partnership,;tssociatioa, corporation or other legal entity, or any two or more
„f the tore_goinb enraged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of :i in 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(rouse 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, :b1GL 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-contractor(s) name(s), address(es)and phone nuniber(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 confimlation ol'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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permio'license 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 affidavit must 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 burn leaves etc.)said person is NOT required to complete this affidavit.
I he i 1fice of Investigations w'Ould like to thank you in advance fur your cooperation and should you have any questions,
Please do not hesitate to give us a call. -
Me 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. # 617-727-4900 ext 406 or 1-877-NIASSAFE
Rev;sed 5-10-05 Fax # 617-727-7749
www.mass.gov/dia
r. J Boar o ui dmg egulatdon`4/i' tan a�
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 100733
TVpe: private Corporation
Expiration: 623/2010 Tr# 267195
A. B. CARNES, INC. --
Barry Cames T---- -
30 Arrowhead Farm Rd.
Boxford, MA 01921
Update Address and return card Mark reason for change.
(l Address ❑ Renewal 0 Employment ❑ Lost Card
ovsca� c �wiror-xaeso
oBaits of 0ailaing Hegulatie an0 Smndnrds
Construction supervisor l.,xmm .
License: C5 68139
Expiration: V1412010 Tr# 12607 r
t R"hictiorc 00
' � t
e
F�
i KENNETH R CARNES
8 DORIS STD
M GROVELAND, A 01834 - �
. _ Cammissiaae+ .�_