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14 WINTER ST - BUILDING INSPECTION (6) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY y Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM Revised Januury aBuilding Permit Application To Construct, Repair, Renovate Or Demolish a /. 2008 IOne-or Tivo-Fumil_v Dwelling This Section For icial Use Only Building Permit Number: ,-/ I hat Applied: Signature: // Building Commissioner/Inspector of Bdildings % to SECTION 1:S1J"$F4bRMATION 1.1 P oQerty,Address: p� I. Assessors Map& Parcel Numbers Aeot I.la 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 11) Frontage Ill) 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) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public O Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: /YI9Ry�NA/ *ANA//Nq /I/ /.[//A/TL'R 5744,67' - WaA4 �Y4 Name(Print) ' Address for Service: 9 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply) New Construction❑ Existing Building II( Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.Cl Number of Units I Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building S p pd�- I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost"(Item 6)x multiplier 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due: do Ood6CAv�. SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) S'S' Q a aoia License Number Expiration Uate Nat fCSL-I holder Ust CSL Type(see below) L'^J_ -r Description Address ✓� O Y, U unrestricted u to 35,O00 Cu. Ft. ft"� io � R Restricted I&.2 FamilyDwelling Signature �"I ... M Mason Only Q7k— �yy N RC Residential Roofing Covering 1 lephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 R istere4 Hotpe lmprovemeot Contractor(HIC) ( ••' G 9 Re HIC of any`M a I IC Registr ame " Registration Number + n7�ao _ Address dL// Ol Q Expiration Date Signutu SECTION 6: WORKERS'C MPENSATIONINSURANCE 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 ..........01" No...........0 . SECTION 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I , as Owner of the subject property hereby - authorize �� - .a_?tit to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date ` (Signed under the 2ains and penalties of perjury) 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 rra have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.115, respectively. 2 When substantial work is planned,provide the information below: Total floors 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 SALEM a, , PUBLIC PROPRERTY 'yo DEPARTMENT IJfnt.`R:.tiv DRISCOLL N ntR 120 WASHINGIONS'I REL•T SALEM.MASSACIa sf:ilSG1970 'fta.:978-.145-9595 tr I=Ax:978-740-9a46 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A I filicant Information Please Print Le ibly Name (find nesslOrgani ratinNl ndividual): Address: 7 � CityrStarc;%ip: ` 19 -70 Phonefl: Are you an employer?Check the appropriate box: "Type of project(required): I.�1 am a employer with� fi ❑4. .❑ 1 am a general contractor and 1 New construction . employees(full and/or part-tints).' have hired the sub-comractors 7. ❑ Remodeling 2.❑ 1 :un a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp, insurance. 9. ❑ Building addition ho workers'cum insurance 5. ❑ We are a corporation and its I P• 10.0 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 1 I.❑ Plumbing repairs or additions " 3.El I am a homeowner doing all work g P ,�,/ myself. LNo workers' comp. c. 152, §I(4),and we have no 12. sU' Roof repairs insurance required.] t employees. LNo workers' 11 Other comp. insurance required.] -Ally applicant Ihut checks box of must also fill out tire wction below showing nicir work rs compensation policy information. 'I lomauwra:n who submit this affidavir indicting they arc doing all work and[lien him outside conlrncors must suhmil a new afraavii indicating umh. -Contractors tlml check this box must at achW an additional Accl showing the none of[hc sub�contrniom and their workers'eonip.policy information. I arm oil employer that it providing workers'compensation insurance for cry employees. Below is the policy and job site information. �I&Insurance Company Name: , ' Policv 4 or Self-ins. Lie. B: o2af�G`Qa�Q Expiration Date:_//H/LD// Job Site Address; / ,J l u. rh� �lt� City/State/Zip: AG !l Attuch it copy of the workers' compensation policy declaration page (showing the policy t uniber and expiration date). I-'ailure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a tine 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 the violator. Ile advised that a copy of this statement may be forwarded to the Office of - 111vcsti,,aliuns of the DIA for iosuiancc coverage verification. l do hereby certify nader Ilse pains and penalties of perjury that the inforinatfon provifded above is true/)and correct. Siullll Ie � � Date'(/vi 7111 /V Ih c + - 7 yL/ 9-i 7s- Official rise surly. Do not ivrire its this area, to be completed by city or from official. Citv or Town: Permit/License —__..-- Issuing Authority (circle one): I. Board of Ilealih 2. Building Dcparttneat 3.City(fovo Clerk a. Electrical Inspector 5. Plumbing Inspector 6.Other contact l'ersou: _.-._-. .. _. -_-_ 1 hone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an empft ree is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an 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 house 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, 1vIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract far 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 rill 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 number(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 confirmation of'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 not in the event the Office of Investigations has to'contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pennitAicense applications in airy given year,need only sitbrnif one affidavit indicating current _ policy information(if necessary) and under"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 Office of Investigations would like to drank you in advance fur your cooperation and should you have;my questions, please du not hesitate to give us a call The 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-MASSAFE Revised 5-26-05 Fax #617-727-7749 www.mass.gov/dia >. CITY OF SALEM ,r PUBLIC PROPRERTY DEPARTMENT 12C \\ IN!iLM:rr # 5.tIIM. %f%1i\t �111 :11 : _11I . Construction Debris Disposal Affidavit (retluired for all demolition and IUnOWAt1Un Work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 1 11.5 Debris, and the provisions of MGL c 40, S 54; Building Permit tt _ 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. 5 150A. The debris will be transported by: (name of hauler) 'I he debris will be disposed of in (namn�laahty) la; Iress u(iucilily) In signature of�permit picunt ' Mute -- 7/14/2010 12:41 TM FROM: Soucy Ineucance Soucy Insueance TO: +1 (978) 744-2252 PAGE: 001 OF 002 ACt�/7a CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODNYYYI 7/14/2010 07/14/2010 PRODUCER 978. 744.7110 FAX 978.741.2059 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Soucy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P. O. Box 4467 HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 201 Washington St. Salem, MA 01970 INSURERS AFFORDING COVERAGE NAIC# INSURED 7. B. Kidney & Company, Inc. INSURERA. Hanover Insurance Co. 22292 41 Osborne Street INSURER B: Salem, MA 01970 INSURER NSIJRER D. NSURER E' COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L TYPE OF POLICY NUMBER POLICVEFFECTIVE POLICYEXPIRATION LTR INSR DATE MMIDO DATE(MMIDD= LIMITS GENERAL LIABILITY ZHN 0797293 01 07/22/2009 07/22/2010 EACH OCCI IRRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISESOEa occurrenoa $ 100,000 CLAIMS MADE AI OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL a ADO INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBID SINGLE LIMIT $ ANY AUTO IEa ec"ideNETO ALL OWNED AUTOF BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Par accdan) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY ALTO OTHER THAN EA ACC $ AUTO ONLY. AGO $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 71 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ WORKERS COMPENSATION WC S A U- ANOEMPLOVERS'LIABILITY YIN TORV LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDEDY (Mandatory In NHI E.L.DISEASE-EA EMPLOYEE $ It vas descnbe under SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ertificate of Insurance for Workers Compensation policy will be sent under seperate cover. re: 14 Winter Street, Salem, MA 01970 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL City of Salem-Public Properties Dept. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 120 Washington Street REPRESENTATIVES. Salem, MA 01970 AUTHORIZED REPRESENTATIVE Paul Soucy ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD _ 7/14/2010 12:41 PM FROM: Soucy Insurance Soucy Insurance TO: +1 (978) 744-2252 PAGE: 002 OF 002 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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 endorsement(s). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009101)