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50 WINTER ISLAND RD - BUILDING INSPECTION (3)
The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 730 CNIR SALEM Revised aLlar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a I One-or Two-Family Divelling / Chas SicttonForOEilcial Use Building Permit Number;. Date Appl f t.� Building Official(Print Name) $ignaturg� i Date SECTION I:SITE INFOOLATIO. f Ll r1.3Zoning tA-,�ess sjoro I{M L2 As•essors tV[ 3o Parcel Numbers accepted street?yes_ no l Map umber Parcel Number nformation: L4 Pr erty Dimensions: Proposed Use Lot Area(sq ft) Frontage(ft) etbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L o.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTIONZc; PAOPERT$'OWNERSHIPt777 2.1 wnert of Record- wP 0+IC' 't5 70 Name(Print) City,State,ZIP (cnd�s�flPrl,C M No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WOW(cbeck all that apply) New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition Cl Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Cl Specify; Brief DescriPtien of Proposed Mork . s b S Glr FS (A� tnfPf' YS h - SECTION 4: ESTUN ATED CONSTRUCTION COSTS- Estimated Costs: Item OfBela[Use Only..., Labor and Materials I. Building $ 1. Building Permit Fee:S' Indicate how fee is determined: 2. Plectrical g ❑Standaid.Cil tt6tvnApplicationFee ❑Total Project Cost(Item 6)x multiplier e 3. Plumbing S ?, Other Fees: $ 1. Mechanical (IIVAC) S List: i. Mechanical (Fira $ inp re„ion) _ l'otal All Fees: .S_ Check No, Check Amount: __Cash Amount. 6 1,0:11 Project CusC 5 5 Qua 0 f 0 Paid in Pull 0 Outstanding Ilnlance I)ne: SECTION 5: CO:VsrRUCrION SERVICES 5.I Coatstrttction Supervisor Liccnse(CSL) License Number —Expiration Data Name of CSL I lolder List CSL Type(see below) M Description No.and Street Unrestricted Buildin s u to 33,000 cu. tt. icted 1&2 F;unil Dwellin City/Town,State,ZIP nn Coverinow andSidin, Fuel Burning Appliances tionTole hone Email address lition 5.2 Registered Home Improvement Contractor(FIIC) FIIC Registration Number Expiration Date I IIC Company Name or HIC Registrant Nave No.and Street Email address City/Town,State ZIP role hone 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 ..........O No...........❑ SECTION 7a: OWNER AUTHORIZATION TO DE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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. Print Otwter's Name(Electronic Signature) Date SECTION 7h: OWNEW OR AUTHORIZED'AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the informntion contained in his.pplication i true and accurate to the best of my knowledge and understanding. Print Owner's or Authorind Agent's Name(Electronic Signaturo) 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 find under M.G.L. e. 142A. Other important information on the FIIC Program can be round at www m;tss.euv%ocu Information on the Construction Supervisor License can be Found at eww.ncts . nyv_I{_s 2. IVhen substantial work is planned,provide the information below: Total floor area(sy. !t.) --___ _(including garage, finished bascmentlatties,decks or porch) tiros; living area(sq. ft.l -- f Iabitable room conic _ Numberoftirapluces_,—_------ Number ofbcdnnnns Vumbcrofbathrnoms Number ofhal6baths _—""--- I'ype of healing system .. _ .—"-- ._-- Number of decks/porches 1)tie ofcooling svaem - -- fiuclowd —_. _ )pen ----------- "I' u,il I'ngart Squ.ue I:oorl,e" w.ry he sobstinn:d t,a Grt.d 1'11iiaa Mist" y,w,.iF a n+ .n vwa.s a- .: �.o m x � -J.- r. .....w ...w{{- e.�....A..Tmwn+s+aes.sn.• ravhnwr�'o-� —�..r. ... wwa.. w.�'w.'^1•»,`p +. v i � �f CITY OF S.U.E.�tl,ALkSSACHUSETTS './ BtiILD4NG DEPAR'I�tE.y"C • l ] 130 WASHINGTON STREET,3"°FLOOR _ cadKi—' TEL (978)745=9595. F.ix(978) 740-9846 .,fBERLEY DRISCO1-L T HOMAS STNPIERRB ,)MAYOR . DIRECTOR OF PUBLIC PROPE1tTY/BUII-DING COMMISSIONER Workers' Compensation insurance Affidavit:DuilderslContractors/Electricians!Plumbers AnDlicanf Intormatlon Please PrintLeeibly M yr. Name(BusiiwssiOrS,tnizatiordlndividual):�! ' "tom ` �� Address: - City/State/zip:Ste' a Phone#: F317 -4 2 A�re `ou an employer?Check the appropriate box: Type of project(required): 1.19 1 am a employer with 4. ❑ I am a general contractor and 1 6. 0,Ncw construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ f am a sole proprietor or partner-, listed on the attached sheet:t ?• [:],Remodeling ship.and have no employees These sub-contractors have 8.,❑Demolition working,for me in any capacity. workers'comp insurance. 9 [:] Building addition [No workers comp.insurance 5. ❑ We are a corporation and its. I officers have exercised their 10.❑Electrical repairs or additions ' required.). _ 3.❑ 1 am a homeowner doing all work right of exemption per MGL I l EI Plumbing rcpnirs or additions myself.[No workers'comp. c.)52,¢1(4);and we have no 12.❑�oof re ' insurance requiied.]t employees.[No workera'. 13.1]d Other Preo+ comp:insurance required.) I 'Any applic tit that cheolts box ri must ais„fill oui the section below showina thou wotkm'c0rnpenimton policy information. t I Innteowtten who submit this affidavit indicating they am doing all work and then hit*outiida contractors must suhmu anew affidavit indicating,such :(,ontmctors that shack this box most attached,an additional shot showing the name of the sub-contractors and their worker'romp.put icy information: I am on employer that Is providing ivorkers'compensarlon htsurance for my employem Below/s the policy and Job site information. Insurance Company Name: over . Lt rW Policy#or Self-ins.Lic.#: ` 1 OL" V )` 5 0 ` Ettpiration Date: 7 ' ' Job Site Address:. . [ r ` "� City/State/zip: 5 c(1f - a 9?0 Attach a eopyof the workers'compenzation,'polley declaration page(showing the policy number a . expiration date)., Failure io secure coverage as required under'Section 25A of MGL c. 152.carclead to the imposition of criminal penalties of it fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against theviolator. Be advised that a copy of this statement'may be forwarded to the Office of Investigations-ol'the DMA for insurance coverage verification! I do hereby e�fy�the p,Jos au p rattles of perjary'Mat the Injormatlon provided above is rue and correcL . Si Dare• '///D l o #' 32,7 Official use only.. Do not write In this area,to be completed by city or town off clal City or Town: Peimit/Licenye# Issuing,%tohority(circle one): 1. Board of kiealth 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.O Other. __.._._ Contact Person: -..-__ — Phone#: Client#: 5821 MCCUECORPO ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE 6125/2IDDIYYYY) /25/2013 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(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.H 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 endomement(s). PRODUCER CONTACT NAME: HUB International New England Pa"c°"N ,Ea,:978657-5100 AC,Na: 978-988-0038 299 Ballardvale St EMAIL ADDRESS: Wilmington,MA 01887 INSURER(S)AFFORDING COVERAGE NAICtt 978 657-5100 INSURER A:Hanover Insurance Company INSURED INSURERS:Liberty Mutual Insurance Co McCue Corporation INSURER C Hartford Fire Insurance Co Peter Whittemore,Assistant Controller INSURER D 35 Congress Street INSURER E Salem,MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. LTRR TYPE OF INSURANCE INNSIR WVD POLICY NUMBER MWDDYIYYYY MWDDYYYP LIMITS A GENERAL LIABILITY ZHN917872501 7/01/2013 07/01/2014 EACH OCCURRENCE $1000000 X COMMERCIAL GENERPI LIABILITY PREMISES Ea occurrence $500000 CLAIMS-MADE 5�OCCUR MED EXP(Any one person) $1 O 000 PERSONAL B ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY PRO- $ JECT LOG A POMOBILEUABIUTY AWN919839801 7/01/2013 07/01/201 OMBINEDSINGLELIMIT $1,000,000 ANY AUTOBODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIREDAUTOS X NON-OWNED PROPERTVDAMAGE S AUTOS Per acdtlenl S B UMBRELLA LIAB X OCCUR TH7611260716012 7/01/2013 07/01/201 EACH OCCURRENCE $15 000 000 EXCESS UAB .0C'C' -MADE AGGREGATE s15,000,000 OED I X RETENTION$10000 S C WORKERS COMPENSATION 08WELB9057 10/10/2012 10/10/201 X WC STAryU- OTH- AND EMPLOYERS'LIABILITY YIN ER ANY PROPRIETOILPARTNEWEXECUTIVE — E.L.EACH ACCIDENT $1,000000 OFFICERIMEMBER EXCLUDED? ® N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000000 If yes,descdhe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks Schedule,If more space is raquirad) CERTIFICATE HOLDER CANCELLATION Salem Parks and Recreation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEED_REPRESENTATIVE RI ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S947916/M947910 MWO01 wlf"Ilvifrf t 4 Cerfif icate of iflame AC515tance Grsre REGISTERED ISSUED BY Date Fabric No. Co. L & A TENT AND AWNING manufactured 1 10 RIVER HGA0 -)N MANE W40 This is to certify that the materials described on the reverse side hereof have been name• retardant treated (or are inherently rjonf)ammob4e} FOR--Neil Olson ADDRESS CITY— STATE.-.-- Certification is hereby made that: (Check "a" of "b") ❑ tia he arficfe�,r.�,scribec cr ft-1- I(_j S.d 1 r T S e.f 11 f 1-.are have teena Pame-retarulant ;,f,)r!% a a;,,! -Lite -r! Regula!tons of 'Vas rif •-a the Siaie Fire Minis ,al Name of che(--1Fral us"_ Cre:r Reg. No .. Method 61'applica! (-n .6) The aritclesdescribe.oter ne reveise siap_ hereof are made fion,a fiame rpsistani tabric or materiat registered and approved by the Slate rare Marshal for such use Trade name of flame-resistant fabric Weatherspan No. 1310 The Flame Retardant Process Used 41:1 not.t_ .. .Be Removed By Washing (.11 w%V net] Snyder Mfg. G Nome TO@ u1 Appfit-tw a, Superintendent ARM, 1> G) 71