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202 JEFFERSON AVENUE - B- 202-14 1 • The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 730 CMR SALEM Ravfsed blar 20/1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or 'Two-Family Dwelling This Section For Official Usi Only. Buildi=Offlcial Number- Date,Appliedi, 7 �Buddme) Signature Data SECTION I:SITE INFOILHATION L l Property Address: 1.2 Assessors Map&Parcel Numbers 1.I 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 t1) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Informations 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone?Check it es0 Municipal Q On site disposal system ❑ > SECTION Z; PROPERTId'01.90E1SI07+ t.l Owneri of Record: �OGE(C r1 tt/1�I r r� <SCL CCL"4r 0-ItA 0/170 Name(Print) City,State,ZIP -Je < 97-?-Z35_5_7 0 --,, No.and Street - Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED.WORW'(cbeck all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Aiteration(s) ❑ Addition ❑ Demolition Q Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Descriptio of Proposed Works: e w J✓ t S 3 Fjovn, �( c oButld W . wfuy r or, v� SECTIOtN4: ESTINLATED CONSTRUCTION COSTS COSTS- Estimated Costs: Oft7ckal Use Only... Labor and �•fatzriols Y' . g I. Building PetmitFee:S Indicate how fee is determined: S QStandard.City/futvnApplicationFee, ❑'COtaf Ficlect Cost'(Item.6)s multipl(er x S �- Other Foes .S t. \lechanic.il (IIV\C) S List:_ l i. ,,\lech.wic.d (Pin, .in uc;;on S / 000 1.0ta1 All Pees:S Check No. _Chcc!c,\uwuut: _Gu11 Amount. I'ntal I'rnjcet ( 'uir S f 1] 1'.id in Pull ❑thdst:wdim Itul.utcd I!na: --- I srcrION 5: cONs'rItUCT10N SERVICES 5,1 Constntctibu Supervisor License(CSI.) /� S ^c 9 o� �/ License Number #�, Expir:uiu Date _�UP/tf Nf1 NamcufCS older ListCSLrype(seebelow). -,/ �?9.rzn .�-r! �- Type Description Nu. and Street U Unrestricted Duildin s up to 35 000 Co. III.) Restricted 13c?Fallllly Dwelling City/ruwn, State, ZIP ,VI a rinr RC Ruutin Covering WS Window and Siding /r4/W.rdcTi°y��Ke SF Solid Fuel Burning Applianeos Insulation 1'ele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(IIIC) IIIC Registration Number Expiration Date I I IC Company Name or 111C Registrant Name Email address No.and Street city/Town, State ZIP Tale hone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 9 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'permiL signed Affidavit Attached? Yes ,......... ❑ No•••.••••.••13 SECTION 7a: OWNER AUTHORIZATION TO BE CO(YIPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 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. Date Print Owner's Name(Electronic Signature) 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 information contained in this application is true and accurate to the best of my knowledge and understanding. Q� GE2 /vA(2--T1, I`_ ZZ 73 rint Owner's ur.\utlturimd:\grnt's N.unu(Electronic Signahuo) Mile NOTES: I. An Owner who obmins a building permit to do hisiher own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contractor(HIC) Program), will nn have access to the arbitration program or guaranty fund under M.O.L. c. 142A. Other important information on the HIC Program can be (blind at www nuts±.cuv%uca Information on the Construction Supervisor I.icense Can be Fbund;u www.mnss.,yw_'�Ih'} IVhen substutti;d work is pLmneJ,provide the information below: I'utai flour area(;q. It.) _ —(including g:uage, finished );tsemenVattics,,laks or porch) living:uea(;y. it habitable room onwt _ Inmberu(tiropluec; ---- --- lumber ofbcdrnunts __...----- ..------- --.— NuntherbfbathrOunts - — --- Nuwher b(h.tleb,uhs -- - -- _ -_-----. a , (heatiu,; ,yadrn - __-- umbcri f,kck 'Iv+riltc; ---- _-- Fuelu.;cd p n t .. f•,t.il Pwj� •,:t u,: ACORD 07/22/2013013 CERTIFICATE OF LIABILITY INSURANCE DATE / ) PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Lauranzano Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:American European Peter S. Muenzner . INSURER B: 183 Ocean Avenue West INSURERS: Apt. 3 INSURER D: Salem 0197 0— INSURER 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 ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MWDD/YY) DATE(MM/DD/YV) X GENERAL LIABILITY MAX013902000134 07/22/2013 07/22/2014 EACHOCCURRENCE $ 300,000 X COMMERCIAL GENERAL LIABILITY -PREMISES Ea occurrence) 100,000 PREMISES Ea occurrence $ CLAIMS MADE a OCCUR / / / / MED EXP(Anyone person) $ 5,000 PERSONAL S ADV INJURY $ 300,000 GENERALAGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 300,000 X POLICY JERCOT LOC / / / / AUTOMOBILE LIABILITY - / / / / COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ALL OWNED AUTOS / / / / BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS / / / / BODILY accident) $ (Per accitlent) NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) $ accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / OTHERTHAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ 4 DEDUCTIBLE RETENTION $ WC SLIMIT ER WORKERS COMPENSATION AND / / / / TORV LIMITS ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED'! E.L.0IGEASE-EA EMPLOYEES If yes,describe ontler E.L.DISEASE-POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONSfVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SH06LO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Roger Martin FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 202 Jefferson Avenue INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ., Salem MA 01970- ©ACORD CORPORATION 1988 A{ACORD 25(2001/08) Page I oft q, INS025(oto8p5 ELECTRONIC LASER FORMS,INC.-(800)327-0545 _ CITY O, S.u.Ear, >bLkss kc HL, . SETTS 120 l'1/.13HL4GTOV S-t'ItE$t }1O FLOpZ -ILL (973) 743-9595. :<!S MUZY OCUSCOLL FVC(979) 7-W-9344 ,b L�YO:t -i�t01613$T.Plsatt8 OI.'tECTOtt OF Pt:aUC PRaPERTY/BCtLoC4G COSLAflS5 to. EA Construction Debris Disposal AlfIdavit (rcyuirbd eor all demalition and ronavation work) In accardanca will' tlta sixth edition of the State Building Coda, 730 CUR section t Dcbris, mid the provisions of MOL c 40, S 54; Quilling Pull b 9 this wo is issued with the condition that the debris resulting from l If, S 15I J s0A.hall be disposed at in a properly licensed waste disposal racility as defined by r�,f(;L a Tha dehris will be trnnsportcd by: l7 B ! w g,S 7e 5 r.5,"J ► ,`t� e C�Lei- - M A., (names ut'liaulur) L ((0 39 Y6 6-1a The dubris will bt3 disposed at'in (n;rmu or t'}c�lir�) i 4 y +i•tiwmra olPQr1P nppliamt .I rtc __ t.. '.,ytq� aHYva •..e4:'. yF'. ns.. - "k. '-.--�w °N .r'Cer." i '"q`."' °k,:a` *K°y e.TF-�^ ,1'�+7. r,t ,a74 CITY OF SMY--.M, NNL'oSSACHUSETTS BUILDINIG DEPiRT1tENT, a 120 WASHLNGTON STREET,3M FLOOR TEL (979)745 9595 E4,�t(978) 740-9846 KIMBERI.EY DRISCOLL THOMAS ST.PMM MAYOR. . DIRECTOR OF pt:BUC,PROPERTY/BUILDING COJL%fISSIONER Workers' Compensation insurance Affidavit:Builders/Contractors/Etectricfaris/Piumbers 4Pnlicant information y� Please Print �egibfr Nance(BusinassiorganizatioNlndividual): 9—go—cP �7l�/Y /VNr a Address: 1.���tlir7Par !!P /r } p �liul 2��f Phone#: 9� ate/ - /7 n City/State/Zi ` } Are you an employer?Check the appropriate box. Type of project(required): El am a general contractor and I I. 1 am a employer with ' 4. g - _ 6. ❑New construction em to t:es full and/or part-time):' have hired the sub-contractors P Y ( 7. Erkemodeling 2 1 am a sole proprietor or partner listed on the attached sheet t �ip and have no employees . These sub-contractors have 8.,(] Demolition working';for me in any capac ur ity. workers'comp.insance. 9. ❑Building addition [No workers comp..insurance - S. ❑ We are acorporarion and its 10.❑Electrical repairs or additions required:) officers Have exercised their 3.❑ I am a homeowner doing all work right of exemption per MG[ - I LEI Plumbing repairs or additions myself. [No workers'comp. c:.152,91(4),and we have no 12 0 Roof repairs insurance required.]t employees. [A'o workers' 13.C]Other ,/'eac 4 comp.insurance requircel.) Any applfntm that chmits bar Al must also,roll outthe uclux,below showing their workers'compensation poiisy mfurmation. t I itmeow,etrs wlw7ubmit this affidavit indicating ih4 am doing all work and then hi outside contractors must submit a new affidavit indicating such. Gmtraaos that chuck this box ratter anwhed an additional sheet showing the name of the subeoninAon and their worker'comp.policy infomution:. lam an employer that is providing Ivorken'compensadon insurance jar my employees& Below is the poJhy and Job site information' _. insurance Company Name: Policy a or Self-ins..Lic.k: Expiration Date: - Job Site Address:' City/Staletzip: Attach a copy.of the workers'compensatiou policy declaration page(showing the policy number and expiration date). Failure to xcurc coverage as required under Section 25A of MGL-c.•152 can lead to the imposition of criminal Penalties of fine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwrrded to the Office Of Investigations of tills DMA.for insurance coverage verification _ i do hereby certify under the pains and penaides of peiJury rhat the iitformallon provided above is true and correct ` 5ii,m turc• h/ Date• Phoned• OJJiritd use only. Do not write in thht area,to be completed by city or town ofJlciiart City or'rown; PermidLlcenye# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cily(fown Clerk 3.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: _. Phone#: 1 DBI WASTE SYSTEMS Service Agreement 377 Third St., Everett, MA 02149 Tel: (617) 389-9656 COPY OP n Roll-Off and Compactor Contract Provisions. 1lJ�J V Company or Customer Name MUENZNER , PETER ❑ Monthly Billing K7 COD: ❑ Credit Card ❑ Check Address 183 OCEAN . AVE Effective Date: Initial Term: City,State&Zip 8/2/2 013 SALEM, MA 01970 Credit Card and Debit Card Information Contact Name ET R 978-376-4757 ❑ MasterCard El Visa ElAmEx ❑ Other: Telephone Number Mobile Number Credit Card Number: Service Location ❑ Same as Above - 202 JEFFERSON AVE . Name on Card: City,State&Zip SALEM MA Expiration Date(MM/YY) Security Code(on back): Contact Name Billing Address: Telephone Number Mobile Number City, State&Zip: E'intal ery Date Quantity Size Amt. Per Haul Amt. Per Ton Tonnage Limit Overage Charge Per Ton /1 —1— 0 YD. $425 .00 —3— $85 .00 Charge Delivery Instructions —0— CALL 1ST. Fuel Charge SEE PETER FOR CHECK. —O— I a nee to the coniracf rovision, to acce t the terms and conditions,and to a all char es ass ecified: Authorized Signature Print Name Date AUG . 2 , 2013 Terms and Conditions Loading and Pick-Up: Customer agrees not to load the container over the top rim. No debris may protrude from the container or above the top rim. The container door must be properly closed and the safety chain affixed prior to pick-up. If these conditions are not met when the driver arrives on- site or if the driver is unable to access the container for pick-up when he arrives on-site,customer agrees to pay a trip charge of$50-S150, depending on location. On-call customers agree to schedule pick-ups at least one day in advance. DBI is not responsible for the unauthorized loading of refuse or other materials into the container while at the service location. Relocation and Duration:The charge to move or relocate an empty or partially full container is S50-S150,depending on location. DBI retains the right to remove all containers after thirty days of inactivity. Liability: Customer acknowledges DBI operates heavy equipment and shall not be held liable for damages to property including, but not limited to, driving surfaces,pavement, lawn,wires, landscaping,or any other property at the customer's location.Customer accepts full responsibility for the care,custody and control of the container at the service location and holds DBI harmless from any and all claims for loss or damage to property, or injury to, or death of a person or persons resulting from the customer's use, operation and possession of the container and other equipment furnished under this service agreement. Customer agrees to pay for all damages to container beyond normal wear and tear, including but not limited co damage caused by fire, denting by loading apparatus,or the application of spray paint or graffiti. Hazardous Waste: DBI provides customer with non-hazardous waste collection services.This agreement does not cover radioactive,volatile, flammable,toxic, or any other hazardous waste or any other materials banned or defined as hazardous by the Massachusetts Department of :nvironmental Protection or the U.S. Environmental Protection Agency. Customer agrees to assume all costs associated with the placement of .iazardous or other unacceptable materials in the container.A limited number of tires are acceptable for an additional per unit charge,based on size. Duration and Payment: This service agreement shall be in effect for the initial term set forth, above,and customer agrees to pay all agreed-upon charges and extra charges,as incurred. This service agreement will automatically renew and remains in-force beyond the initial term unless and until it is replaced with a new service agreement or terminated by the parties. Customer will be invoiced monthly for services provided in the prior month and customer agrees to pay all invoices within 30 days.Customer agrees to pay 1 5`I intones 2r month on balances o:r-man-i-ti-,o.e 30 days. Credit card and debit card customers acne mat all chances•::itf Y