17 COLLINS STREET - BUILDING JACKET 10q I Z8'
The Commonwealth of Massachusetts I PErT SERVICES
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR pt{ �L� 20�
Building Permit Application To Construct, Repair, Renovate Or Demolish a 23
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
IO
Building Otticial(Print N°one). Sigpature, D e
SECTION 1:SITE INFOR°NIATION`
I.I Property Ad ress: 1.2 Assessors blap&Parcel Numbers
1-1 e. t'r.S Sala....
1.1 a Is this an accepted street7 yes fno Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
L5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Require) 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Checkif es❑
SECTION2: PROPERTY OWNERSHIP!
2 1 Owner°of Record:
. IAA�40_ 5 Llnc k
NN me(Print) City,State,ZIP
iSo, anJ Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED\VORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units - I Other ❑ Specify:
Brie:'Description of Proposed\Nark=:
�t6 L2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcin Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost}(Item 6)x multiplier x
3. Plumbing S P 9ther Fees: S
t.Mechanical (Flv;\C) S List:
5.i\Wclianical (Fire S Total All Fees:.S
Su ressiun)
Check No._Check Amount: Cash Amount:_
G.Total Project Cost: S �W ❑Paid in Full Cl Outstanding Balance Due:
—�aM
SECTION 5: CONSTRUCTION SERVICES
5.1 Coustructioti Supervisor License(CSL) CS pro 1-451 1,5—X--/6o
License Number Expiration Date
4 Name of CSrHoldcr List CSL'rype(see below)
PcGY—e rfu -� G �j< rype Description
No. and Street
U Unrestricted(Buildings up to 35,000 cu. 11.
5�.>el:�. LA r 'S e 1 �t 3E Restricted 1&2 FamilyDwelling
City/Ibtm,State,ZIP Ni Nfasonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
TT<le hone Entail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 7 9� '3,3Y-t dd
EA�,,,AxsL .�,5 HIC Registration Number Expiration Date
IIIC Conip;my Ntune or IIIC Registrant N:une
-A t l lA. AA ieAdR✓ F�:G�u��Sc7Uefi?�vi .N3L�
No. and Street+
Email address
3 A. 3c4,`-l`J SS. 97L,��-
Ci ITot— vn,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.C.c. 152.g 25C(6)),.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this nftidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........)!!;.— No........... ❑
SECTION 7a:OWNER AUTHO.RIZATION,TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT`
I,as Owner of the subject property,hereby authorize
\\�f •t9 act on my be ,in all rapitters relative to work authorized by this building permit application.
x rf r s Name(Electronic Signature) Date
/ SECTION 7b:OWNER'ORAUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
r��yy contained in this application is true and accurate to the best of my knowledge and understanding.
✓ Print Owner's or Authorized Agent's Name(Electronic Signature) 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 fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
wwvv.niass. vl_ �Information on the Construction Supervisor License can be found at www.nia;s.gov�!dns
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
Type orcooling system Enclosed Open_
3. "ifolal Project Square Footage"may be substituted for"rut:d Project Cost"
The Commonwealth of Massachusetts
Board u(Building Regulations and Standards CITY
!J Massachusetts State Building Code, 780 C'MR, 7*edition OF SALEM
"'www Rr�•ierd Jmnuvr
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For O.II)cial Use Onl
Building Permit Num Dale Applied: n 'O
Signature: fo' �I D
Building Commissioner/Inspector of Buildings Date
SECTION I: SITE INFORMATION
Property Address: Z /'//� � 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accented streeO yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq 11) Frontage(11)
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❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPER -OWNERSHIP'
qr
IfQ qr f rAY
d.
N /(P Add for Service:
>�- 7 7
Si ore Telephone
SECTION 3: DESCRIPTI N OF PROPOSED ORKs(check 11 that apply)
New Construction❑ Existing Building Owner-Occupied dr I Repairs(s) 6 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.IT NIpberofUnits Other ❑ Specify:
Brief Description of Propo d Work':
8 N q .c RC nFI
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCISI Use Only
Labor and Materials
I. Building is 1. Building Permit Fee: S Indicate how lee is determined:
❑Standard City/Town Application Fee
?. Electrical S ❑Total Project Coslr(hem 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (fIVAC) S List:
S. Mechanical (Fire S
Su ression Total All Fees:S
O Check No. _Check Amount: Cash Amount:
6. Total Project Cost: 11 ,S 0 Paid in Full 0 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
rul'(:SL
uction Supervisor(CSL)
License Number li.rpintiun Date
List CSL Type(see below)
r Descri ion
U l Inresiricted u to JS,000 Cu.Ft.
R Restricted Id2 Famil Dwelling
Signature M M (Ant
RC Residential Routing Covering
relcph ne IW S I Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
p Residential Demolition
FRegisttred Improvement Conerector(HIC)ICRegistrantName Registration Number
Expiration Date
Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. S MOD
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 ..........C3 No...........O
SECTION 7o:OWNER AUTHORIZATION TO BE COMPLETED 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.
Sianature of Owner Date
SECTION 71s:OWNER'OR AUTHORIZ KPft DECLA TION
1 t i3YD aNG� rf. ,as caner or Authorized Agent hereby declare
that the statements anq information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf. /v/�G4Fr� (JO} iq/OvsV R/
riot Name
Signature of(honer or Authorized Agent Date V
(Simited under the Vains and penalties of 'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will ad 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 1 IO.R6 and I IO.RS, respectively.
'_ 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
). "Total Project Square Footage" maybe substituted for"Total Project Cost"
-117 5,7
f
'7
COf01{� e
BU!LDINC DEPT
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SEP I 1 10 42 AM °90 ..
CITY OF SALEM HEALTH DEPARTMENT RECEIVED
BOARD OF HEALTH CITY OF SALEM,MASS.
9 North Street
ROBERT E. BLENKHORN Salem, Massachusetts 01970
HEALTH AGENT -
508-761-1800
September 7, 1990
Mr. Michael W. Sosnowski
17 Collins Street
Salem-,MA-0-1970
Dear Mr. Sosnowski:
The Salem Health Department has received complaints that a trailer has been parked
in front of your house for two (2) months plugged into an electrical outlet on the
house, creating a trip hazard for neighborhood residents.
A site inspection conducted by Sharon A. Cameron, R.S. of the Salem Health Department
on August 29, 1990 noted the following:
-An "Allegro" trailer, Florida License plate DEK 73D, was parked in front of
N�Z17 Coffins street'�An extension core ran from an outlet on the exterior of
the-house-;-across-the`` to the trailer.
Please be advised that this set-up violaees 105 CMR 410.256 of the State Sanitary
Code Chapter II, which states: "No temporary wiring shall be used or made available
for use by any owner or occupant, provided, that extension cords which connect
portable electric appliances or fixtures to convenience outlets shall not be cgnsid-
ered temporary wiring."
You are hereby ordered to remove this temporary wiring within 24 hours of receipt
of this order.
Failure on your part to comply within the specified time will result in a complaint
being sought against you in Salem District Court.
Should you be aggrieved by this Order, you have the right to request a hearing before
the Board of Health. A request for said hearing must be received in writing in the
office of the Board of Health within seven (7) days of receipt of this Order. At
said hearing, you will be given an opportunity to be heard and to present witness
and documentary evidence at to why this Order should be modified or withdrawn.
l
iM
i� .• n
SALEM HEALTH DEPARTMENT
c 9 North Street
Salem,.MA 01970
SOSNOWSKI
SEPTEMBER 7, 1990.
PAGE 2 ,
You maybe represented by an attorney. Please also be informed that you have the right
to inspect and obtain copies of all relevant inspection or investigation reports, orders
and othqr documentary information`-in the possession of this Board, and that any adverse
party has the right to be present at the hearing.
Feel free to contact this office at (508) 741-1800 with any questions.
Very truly yours,
FOR THE BOARDOF HEALTH REPLY TO
Robert E. Blenkhorn, C.H.O. Sharon A. Cameron, R.S.
Health Agent Registered Sanitarian
REB/BAS
cc: Electrical Inspector
Zoning Officer
Certified Mail P 070 312 219
J
c
G M I�vl VV
Cunningham Lindsey U.S.,Inc. [07A
P.O.Box 703689 Cunnin ham A
Dallas,TX 75370-3689 Lindsey
Telephone(888)738-8714 Facsimile(214)488-6766
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS Ch. 139, Sec 3B
Building Commissioner or
Inspector of Buildings
120 Washington St., 3rd Floor
Salem, MA 01970
Claim Number: A033597144
Policy Number: 40521400000
Company Name: ARBELLA INSURANCE GROUP
Date of Loss: 02/09/2015
Insured: MICHAEL SOSNOWSKI
Property Location: 17 COLLINS ST, SALEM, MA 01970
Claim has been made involving loss, damage, or destruction of the above captioned property,
which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6,
to be applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please
direct it to the attention of the writer. Kindly include a reference to the captioned insured,
location, date of loss and claim number.
Cunningham Lindsey
Catastrophe Department
cicat@cl-na.com
800-867-3885