18 WINTER ST - BUILDING INSPECTION (2) (ol — 4000
�s
n "Pile Commonwealth of Massachusetts
� Board of Building Regulations and Standards CITY OF
BIL� Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised,tlur 2011
One-or Two-Family Dwelling
This Section For Official Use Only ;
Building Permit Number: Date Applied:
I
nDuilJing Ot}icial(Pont N;une) p2 �q
Signature I W VD e
SECTION 1:'SITE INFORNIAT10N
1.1 Pro erty A dress`•
( � ) 1 nT�� � � 1.2 Assessors map&Parcel Numbers
I.1a Is this an accepted street? es
Y no_ Map Nwnber Parcel Number
1.37.oaing Information: IA Property Dimensions:
Zoning District ProposedProposed Us�—
Lot Area(sy tt) Frontage(R)
I.5 Building Setbacks(ft)
Front Yard Provided
Yards
Provided Re
Require) Provide) Rear Yard Required wired
y Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
1 O?ynert of Record:
amt.(I not) N CitY,St ue,LIP �7 �
0 andd resg
QlO�y/,p�p ,lr�
Telep ane —� Email Jd
SECTION 3: DESCRIPT[O OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building ner-Occupied ied ❑
P us(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units
Brief Description of Proposed Work Other ❑ Specify:
Ps
SECTION�: ESTIb1ATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
3. Plumbing $ ❑Total Project Costa(Item 6)x multiplier x
2. Other Fees:
d. Mechanical (FIVAC) $ List:
5. Mechanical (fire vV
Su )ression) S Total All Fees:$
6. "Total Project Cost $ Check No.—Check Amount:
Cash rlmotmt:_
❑Paid in Full ❑Outstanding Balance Due:
Y " 6 r`a
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date s
List CSL'fype(see below) '
Name of CSL Flo der ..
vT & wv-� �e-ter ------ Type _ r- Description
No.and Street Unrestricted Buildin s u to 35,W0 cu. ItJ
O(CcC72 Restricted I&2 Famil Dwellin
� M Mason
Cityff iwn,State,"LIP RC Rootin Coverin
WS Window and Sidin
'r1 SF Solid Fuel Burning Appliances
l Insulation
� D Demolition
Tele hone &nail address C!,
5.2 Rcgisteredtlamelmpr�emCntCont tret�o�(HIC) HICRegistratioonNumber ` ration Date
e CJDA)' c �1
J C trant Name �Q�V
HIC mp:uy NanK;rur i-I�IC 12eKts`
Car- Email aJJress
No and tSt 02._ l�
Tele hone '.
Ci /T wn,State,ZIP
R$'.COhIPENSAT[ON INSURANCE AFFIDAVIT(M.G,L.c. 152.§ 25C(�
SECTION 6:WORKE
ith this application. Failure to provide
Workers Compensation Insurance affidavit must be completed and submitted w
this affidavit will result in the denial of the Issuance of 'building permit.
Signed Affidavit Attached? Yes ..........
No...........0
SECTION 7a:OWNER AUTHORIZATION IE BE COMPLETED W HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT`
1,as Owner of the subject property,hereby authorize this building P rmit application.
t4 act on my behalf,in all matters relative to work auto e y
�y a) le � �{�/� 0 — Date
Print Owner's Name(Electmnw Signature)
SECTION 7b:OWEW OR AUTHORIZED AGENT DECLARATION
N
6y entering my name below,I hereby,attest u r the pains and penalties of perjury that all of the information
contained in this applica io ue an urn t t the best of m nowledge and understandin/.
Da e
Print Owner's or Aulhori d Agent's N: ne(' eclronic Sig ature)
NOTES:
I. An Owner who o ains a bui mg permit to do his/her own worn,or an`oillnertvhave access to ires an the-arbitrationcontractor
(not registered in the lie Improvement Contractor(HIC Program),
program
r vsvannus�n o a Inforlm t on onCtl'ie.Co structioOnler Supervirtant sor Li efo ation on the nse can be toundHt% Program is
found at
2. When substantial work is planned,provide the info lm tion beloamge, finished basement/attics,decks or porch)
ludin
Total floor area(sq. ftJ Habitable room count
Gross living area(sq. Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
Type of heating system -- Enclosed_______—Open
Type of cooling system
3. "Total Project Square Footage" may be substituted for,,Fond Project Cost"
ACORD
CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDryyyy)
PRODUCER (978) 745-6464
Rose Insurance THIS CERTIFICATE IS ISSUED AS A - 01/30/2014
66 Lorin ONLY AND CONFERS NO RIGHTS MATTER.OF INFORMATION
g Avenue _ HOLDER. THIS CERTIFICATE og THE
MEND, EX O
P.O. Box 958 ALTER THE COVERAGE DOES NO TEND R
Salem AFFORDED BY THE POLICIES BELOW.
INSURED MA 01970- INSURERS AFFORDING COVERAGE
Serven Construction Co"panY ITC INSURER A ESSEX INSURANCE CCHPANY NAIC#
14 Griffen Terrace
INSURERS:Hartford Insurance
INSURER C:
I'
MA 01902-
INSURER 0
COVERAGES INSURER E.
THE POLICIES OF INSURif—Ell STED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF AlY 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.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
NSR DD'L
LTR NSRD TYPE OF INSURANCE
A POLICY NUMBER PODGYEFTECTIVE PoLICY EXPIRATION
3DJ7526
GENERAL LIABILITY (MMA)DIYYI DATE(MM/DDryyl
O1/2B/2014 Ol LIMITS
X COMMERCIAL GENERAL LIABILITY /28/2015
EACH OCCURRENCE 9 lOOQQQO
❑
CLAIMS MADE OCCUR DAMAGE TO RENTED
/ / / / PREMISES Ea xnfrrenoe S 10000
MED EXP(Any one Person) 5 5000
GENL AGGREGATE LIMIT APPLIES PER PERSONAL a INJURV S 1000000
GENERALAGGREGATE g
POLICY PRO- 2000000
JECT In PRODUCTS-COMPrOP AGG $ 2000000
AUTOMOBILE LIABILITY / / / / NOHPID
ANY AUTO
COMBINED SINGLE LIMIT
ALL OWNED AUTOS (Ea a=de q 5
SCHEOULEDAUTOS / /
/ / BODILY INJURY
HIRED AUTOS (Pa person) S
NON-OWNEDAUTOS / / / /
BODILY INJURY
(Per MXdem) S
PROPERTY DAMAGE
GARAGE LIABILITY PROPERTY
axideMl S
ANY AUTO
AUTO ONLY-EA ACCIDENT 5
OTHER THAN EA ACC S
EXCESSIUM IRELLA LIABILITY AUTO ONLY:
OCCUR / / AGG e
CLAIMS MADE EACH OCCURRENCE
5
S DEDUCTIBLE AGGREGATE
RETENTION S
B WORKERS COMPENSATION AND S
EMPLOYERS'LIABILITY 636OUB-6B2233 S
ANY PROPRIETORMARTNER/EXECUTIVE 09/13/2013 09/13/2014 X 'fVR STATU- _
OFFICER/MEMBER EXCLUDED?
TORY LIMBS ER
Ifyes,descdWtWer E.L.EACH ACCIDENT $ 100000
SPECIAL PROVISIONS below
OTHER E.L.DISEASE-EA EMPLOYEES 100000
E.L DISEASE-POLICY LIMIT $ 500000
DESCRIPTION OF OPERATIONSfLOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED
POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Jeanne Charniqo 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
18 Winter Street FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
Salem, NA 01970 INSURER,ITS AGENTS OR REPRESENTATIVE$.
AUTHORIZE PRESENTATIVE
4CORD 25(200U08) ,
NS025(ome).ae Lac
mACORD CORPORATION 1988
Peg.1 M 2