15 WOODSIDE ST - BUILDING INSPECTION (3) y The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'h editionT
F SALEM
ia�ed Junuury
Building Permit Application To Construct, Repair, Renovate Or Demolisl• =00F
One-or Tivo-Fo!pA Dwelling
This Secti For Iticial Use Only,-'
Building Permit Number/ to Applic,i
Signature:
Building Commissioner/Inspectorof Bu ldings Date
SECTI . SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
i5 woods;cle S`i- Syl�
I.1 a 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 e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow er'of Record:
Chad C-7gML,�n12 /5 wovclsir)e St. 54�e Nc, 0rJ76
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
In e �I Qe
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S �/oZ00 I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S i
❑Total Project Cost (Item 6)x multiplier x \�
3. Plumbing S 2. Other Fees: S vn/ nV
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
0o Check No._Check Amount: Cash Amount:
6.Total Project Cost: .S w pD ❑Paid in Full 0 Outstanding Balance Due:
y ,r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ( ac�.� q ( C /-/ a O
t on CJk an tQW(te- I.icensc Number Expiration Date
Name of CSI: I lulder
3 3 Noi-fh St- M eI ven/ M� List CSL Type(see below)
T- Description
Add U t InrestricteJ(up to 35,000 Cu.Ft.
Restricted 1&2 Family Dwelling
S' mature M %lasonry Only
fS S 7 q C-�--9-1c-a- RC Residemial Rooting Covering
Telephone WS Residential Window and Siding
SF Residcmial Solid Fuel Burning Appliance installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address
Expiration Date ,
Signature 'relephone
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 t 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
1, doOC,NCr_ Q-Jtii` V ,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.
J 0 00 4 k S LnJk t t �
Print Nay
Signatbfc of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 fund under M.G.L.C. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and i IO.RS, 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.) Ifabitable room count
Number of fireplaces Q Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system (9 r,S Number of decks/porches
Type of cooling system - Enclosed Open
3. "Total Project Square Footage" may he substituted for"Total Project Cost'
!a CITY OF SM LN1, NLkSSACHUSF—TTS
BL'IIDL`G DEP1RTNLONT - -
� '7 120 WASHINGTON STREET, 3w FLOOR
\ a'� TEL (978) 745-9595
F.iLc(978) 740-9846
KI>fBFRI.HY DRISCOLL T*lIOMAS ST.PtERRB
MAYOR pIRECTOR OF PUBLIC PROPER TY/BUI DMG CO\LNIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elect ricians/PIumbers
4 licant Intnrmation Please Print Legibly
Natilc IBusil)y&organiratiomindividual): S(AJ 'P-lc`*r C D^+1Zr4t i al0 l c7f 17 C7� 4/ ICE
Address: 45 NetJ Oe eat, t:tv
J7
City/Statc/Zip:Str.4r�pSr�J_ AC, 0,C Phone #: 75;1 03 a373
Are you an employer?Cheek the appropriate box: Type of project(required):
4. ❑ I am a general contractor and 1 6. ❑New construction
1.0Q 1 am a employer with
employees(full and/or part-time).* have hired the subcontractors listed on the attached Sheet.' 7• ❑ Remodeling
2.❑ 1 ship
a sole have
no proprietor o partner-
shipand love no employees Theo subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. q. ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.) officers have exercised their -
ri ght of exemption r MGL I I.❑ Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work b P a
myself.[\o worker!camp. C.
152,§1(4),and we have no 12.❑ Roof repairs
employees. N'o workers'
t [ Other I3.
insurance reyuired.J ❑
comp. insurance required.]
.information.
tI a lia:un slur checks box el mast andiallout the amoiblowvork and thew warts! compensation policy
♦ Y Pp vir indiralin t am Doing all worlr and rhea bite outside camnetan moat submit a new a1PJavi1 indicting such
Ionjnocwpth who submit this mW g dry
=Gmtmeton that chat this box mint coached an mWitiorctl ahret mhawina the!mine of the subcamracton and their waken'mmy.pohry information.
I um un employer that is provldinR workers'compensation insurance for my employees. Below is the policy and Job rite
information. 1 T
Insurance Company Name: vC^I •1- N S U f Cn AI C P C (3n"7 b�lz_
Policy 4 or Self-iim Lie. N: wC I 31 S — 3 S ISS 1-C6_)6 Expiration Date: z_t ) I
Job Site Address: 15 LJOOd66ie -, 4 City/State/Zip: /v19. Oi57J
,knack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
of MGL c. 152 can lead to the imposition of criminal penalties of a
Failure to sccuro coverage as required under Section 25A P
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 aline
statement ma be forwarded to the Office of
�• against the violator. He advised that a copy of thisy
a atnst
of up to S_�0.00 a Jay b
•nsurance coverage verification.
DIA for n
' utiutts al'the b
investigations
l do hereby certify a tiler the Ins arrd penal!!s ujperjury tlrat the infurmadon provided above is rrae and correct
OQiaial use only. Do not write in Jhie urea,to be completed by city or town njjlr/ul
City or Town: .--
Issuing Aulhorily(circle one):
1. Board of Health 2. Building;Department 3.City/Town Clerk J. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: . __. ... Phone 4:
J
Information and Instructions
Massrchuscus General Laws chapter 152 requires all employers to provide workers' compensation tilt their employees.
Pursuant to this statute, in emplufee is defined as"...every poison in the service of another under any contract of hire,
Cypress or Implied. oral or written."
An employer rs delined as"an individual,partnership,association,corporation or other legal entity,or any two or inure
a the li,reeoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of .m individual,parmership,assoemtioa 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 shaU 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 eumpliance with the Insurance coverage required."
Additionally, i%,IGL chapter 152. 4, 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 connpliance.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-contractors)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 confirmation of insurance coverage. Also be sure to sigh and date the affidavit. The alfd4vit should
he relumed 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. Sclf-insurcd companies should enter their
self-insurance license number on the neeropriatc line.
City or Town Officlals
Please he titre that the affidavit is complete and printed legibly. 'fhe 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.
Phase be sure to fill in the permitflicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pcnnit'licetse applications in any given year,need only submit 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 permirs or licenses. Anew 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.it dog license or permit to bum leaves cte.)said person is NOT required to complete this affidavit.
I he 00ice of Itnvelrigatlons would like to diank you in advance fur your cooperation and Should you have;my quest Wtls,
please du nut hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of fnvesdundons
600 Washington Street
Boston, MA 02111
Tel, q 617-727-4900 ext 406 or 1-877-MASSAFE
it:.bCd -�ti-us Fax 0 617-727-7749
www.mass.gov/dia
.,_ >lussachusctu - Department of Public S:d'cq
1 Board nt Building Rr ulations and titanrl;trJs,
Construction Supervisor License
License: CS 105348
JONATHAN WHITE
33 NORTH ST
METHUEN, MA 01844
Expiration: 9n/2013
o:L it Trrr: 105348
12/01/2010 17:03 FAX 781 314 3286 Waltham Building Dent.
z ool
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.nutss.gov/dta
9)Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Leeibly
Avillicant Information 11 LL /'
Name(Business/Organization/Individual):S W_
` (Sue Ttt)C l arpor 2Ato Vh
Address: I4 S NPtx Sfi
city/State/Zip: S Wa.wt 5 CoVk Akik OtgOl Phone#: S - a333
- Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I 6 New constroction
1 Al am a employer with have hired the sub-coutractors
employees(full and/or part-time).* listed on the attached sheet 7. ❑Remodeling
2.❑.I am a sole proprietor or partner- These sub-contractors have g. Demoliflon
ship and have no employees employees and have workers' . y Building addition
working for me in any capacity. comp.insurance?
[No workers'comp.insurance 5 We are a corporation and its 10.❑Electrical repairs or additions
required.) officers have exercised their l l.❑Plumbing repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 12.0 Roof repairs
myself.LNo workers' comp. c. 152,§1(4),and we have no
insurance required.]t 13-I]Other
employees.(No workers'
comp.insurance required.]
' +Any applicant that checks box#1 must also fill Out the section below showing their Workers'wmpcnactors policyinformation.
1, t Homcewners who submit this attdwit indicating they are doing all wodc and then hire outside wntroctots mast submit anew affidavit indicating each.'
4Contraotom that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'cenip.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: h.t y Ml1•Gf. � I 'Roll
I
policy#or Self ins.Lic.#: C 1_T
31�, 3 s i S51 0�o Expiration Date:
City/State/Zip:
Job Site Address:
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 ceritfy a der the sins and penaties if r�ury that the information provirterl above is true and correcr
ate: N—l3 -gel
lure:
Phone#•
official use only. Do not write in dtis area,to be completed by elty or town offtclaL
!i Perinit/License#
City or Town: -
Issuing Authority(circle one):
3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
1.Board of Health 2.Building Department
6.Other
Phone#:
' Contact Person:
i
i
i
A� CERTIFICATE OF LIABILITY INSURANCE °A onz2011
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 pollcy(les)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 endorsement(s).
PRODUCER CONTACT
Thomas St Jean Insurance NAME:
P O Box 3543 ac N Eli: (978)531-8053 AI[ No):
106 Lynn Street Suite 301 q�egg,
Peabody,MA 01961 IMURI!i AFFORDING COVERAGE NAIC F
INSURSFt A: COLONY INSURANCE COMPANY 39993
INSURSO Sweet Contracting Corp dba Billy Sweet Chimney Sweep INSURER a: PHOENIX INSURANCE COMPANY 25623
P O Box 287 INsuRERc: LIBERTY MUTUAL INSURANCE CO 23043
Swampscott,MA 01907
INsuRExo: TUDOR INSURANCE COMPANY 37982
N9URE2 E:
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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LM TYPE OF INSURANCE POLICY NUMBER MMIOM'Yri) flMM=i LIMITS
GENERAL LIABILITY tbd 04/082011 04/082012 EA0IOCCURRENCE $ 1000000
COMMERCIAL GENERAL LIABI CITY PREMISES TER.
ocmrrence $ 50000
CLAIMS-MADE OOCCUR MED EXP(Any one parson) $ 5000
PERSONAL&ADV INJURY $ 1000000
GENERAL AGGREGATE $ 2000000
GEN'L AGGREGATE U MIT APPLIES PER. PRODUCTS-COMPIOP AGG $ 2000000
POLICY R6 LOC $
B AUTOMOBILE LIABILITY BA7167M153 11/302010 11/302011
eeCdoent
ANY AUTO BODILY INJURY(Per person) $ 250000
ALL OWNED SCHEDULED 40C�PREN�
RY(Per accident) $ 500000
AUTOS AlfTOR
HIRED AUTOS NON-OWNED DAMAGE g 100000
ql OS
4
UMBRELLA UAB OCCUR RRENCE $
Mass UAB CLAIMS-MADE DIED RETENTION$C WORKERS COMPENSATION wc1-31s-351551-020 05/072010 OSN72011ATU- 0T.ANDEMPLOYERS LIABILITY YIN
ANY PROPRIETOR/PARTNERIE CUTIVE ❑ CCICENT $ 100000
OFFICERIMEMEER EXCLUDED'+ NIA
(Mantlxloryln" EL DSEASE-EA EMPLOYEE S .100000
f yyes descrioewder 500000
DAG RIPTON OF OPERATIONS holow El DSEASE-POLICY LIMIT $
D Professional Liability EOP0034231 08/312010 08/312011 100000
DESCRIPTION OF OPERATIONS)LOCATIONS VEHICLES(Attach ACORD 101,AEEalonal RemarMv Schedule,Hne.apace Iv on,ane d)
CERTIFICATE HOLDER CANCELLATION
Chad Gambone
15 Woodside Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Salem,MA 01970 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Ov 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD