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35 WILSON ST - BUILDING INSPECTION ,22 .�if The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM 780 CMRd C Build ing State tate ung Code. Revised filar 2011 VJ Building Permit Application To Construct. Repair. Renovate Or Demolish a One-or Two-Family Duelling This Section For OfficiWXse Only Building Permit Number. Date Appplied: I. Building Official(Print Name) Signature Date SECTION l:SITE INFORMATIO 1.1 Property Address: 1.2 Assessors Map At Parcel Numbers 3.5 Ill 1.1 a Is this an accepted street?yes no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sgil) Frontage(IT) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40.§54) 11.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone'.' Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if�cs❑ po SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: d )�` Rohe 1`�6 .1'r,-=. � 0 ss a' a k.., . c 1 9 0 Name(Print) 5 City.State.ZIP _ 35 la:, SVie- 978- 716 7310 i ft,6, 1iilll s d �Comcr4klae No.and Street Teleplunar Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction O Existing Building❑ 1 Owner-Occupied SKI Repairs(s1 ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ t Number of Units I Other ❑ Specit.: Brief Description of Proposed Work-: �baik orn 4e STAl1 7E CC/&I t t5l',J SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ '/.;(Jj 1. Building Permit Fee: S indicate how fee is determined: 2. Electrical $ Rw 0 Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ p 2. Other Fees: $ 4.Mechanical (HVAC) S List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: S /0. ppp. 0 Paid in F I ❑Outstanding Balance Due: 5.1 Construction Supervisor License(CSL) G c7 1,2 , MC License Number Expiration Date Name of CSL Holder u List CSL Type(see below) So` No.and St3kt Type. Description U Unrestricted(Buildings up to 35,000 cu.ft. e5 4j y R Restricted 1&2 FamilyDwelling Cityfrown,StaWZlP M Masonry RC Roofs Covering WS Window and Siding C, 1 SF Solid Fuel Burning Appliances I Insulation Tel hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /3 !y HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name S-5 ee-��`i,9 sfi Gees�I�ascvnstR. �Fd �'AI,a,.Gj �a No. Strcet Email address _f ha �, (f �G� 7 7�� 3 17d3, City/Town. Stalk.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 1,as Owner of the subject property,hereby authorize comas CA Ae r S - to act on my behalf, in all mauers relative to work authorized by this building permit application. ,ZV010gF 47" &t ) sS/�'Ji'1O 7 Print er's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,) hereby attest under the pains and penalties of perjury that all of the information contained ' is =7rd to the best of my knowledge and understanding. Authorizeic 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 Horne improvement Contractor(HIC)Program),will!ice 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 www.mass-eov/oca Information on the Construction Supervisor License ran be found at Mvww.mass.aov%dos 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basementlartics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of ha[Mths Type of heating system Number of decks/porches Type of cooling system Enclosed Open The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . 600 Washington Street Boston,MA 02111 U11 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Indivi'dual_):/ Address: City/State/Zip: hs U Phone.#: (fr 2� � 3 U SAS Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet. modeling ship and have no employees These subcontractors have g, ❑ Demolition working for me in any capacity. employees and have workers' y ❑Building addition [No workers' comp.insurance comp.insurance.t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs - insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I must!also fill out the section below showing their workers'compensation policy informatics. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'corm.policy number. - - I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. 2Lic.#: Expiration Date: Job Site Address: 3 / r � ��' City/State/Zip: 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi er t bs and penalties o er' ry that the information provided above is true and correct Sim Date: -� t � Phone# official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License#- Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: / ' ® ` • DATE(MM/DD/YYVY) ACORO CERTIFICATE OF LIABILITY INSURANCE 7/19/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING-INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If 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 confer rights to the certificate holder in lieu of such endoreement(s). -CONTACT — PRODUCER NAME. A.J. George Insurance Agency Inc. n/CDNoEa: (978) 531-2179 FAX (97e) 531-5142 16 Foster Street E-MAIL ac,Ne. ADDRESS:aj ginsurance@yahoo.com Peabody, MA 01960 INSURERIS) AFFORDING COVERAGE N.C. INSURER A NORTHLAND INSURANCE COMPANY INSURED GOMES BROTHERS CONSTRUCTION INSURER B: INSURER C' 57 CENTRAL STREET INSURER D: PEABODY, MA 01960 INSURER E: INSURER F' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO fERTIFY 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 Tills 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. a15R TYPE OF INSURANCE ADD( sueR P LI V EFF P LI V E%P LIMITS LTR Ixsa MD POLICY NUMBER MM/DDP/YYY MMIDDIVIYV GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 50,000 CLAIMS-MADE CI OCCUR MED EXP(Any one person) $ EXCLUDED A 422000002 03/16/13 03/16/14 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PEO LOG $ AUTOMOBILE LIABILITY Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/FARTNERIEXEOUTIVE NIA EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? u (Mandatory In NH) E.L. DISEASE-EA EMPLOYE $ If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION City of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 93 Washington Street ACCORDANCE WITH THE P ISIONS. Salem, MA 01970 AUT ED REPRESE ATIVE ©1988-2010 ACORD CO . All rights reserved. ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD I �, I g18 4_,,, l i 121„ . 1 36,,,. 1!5_,,. - ,�- ,� 21 2 r n ( 4�0 L j„ D•VDB30x15x34.5 TOILET-1 ----_-VB271834-------- OD N '------------- --- _ I n� 09 I �