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NEW, SINGLE FAMILY HOME The Commonwealth of Massachusetts Y OF Board of Building Regulations and Standards SIALEM Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only -� Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 0 8 KkQ_TkW LA t4F- 1 y 014q L la Is this an accepted street?yes k no Map Number Parcel Number 1 1.3 Zoning Information: 1.4 Property Dimensions: R..l 111, $50 IUD, '3r Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) J 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard I Required Provided Required Provided Required Provided oC kIs J 1�,' Ib' y5' 3b' 1 70' 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 19 On site disposal system ❑ Check if yesff SECTION 2: PROPERTY OWNERSHIP' i 0' 2.1 Owner'of Record: �- mctiwe[A S'ENntAArl 41 R yll.l.AbE Sr. , KA Q•6LCkAeA1D4Ac 01145- Name(Print) City,State,ZIP 4"1 t7- �1l.l.Dct�fC ST. �18��31- 3'1SI No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction IZ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition [3 Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work : cot-6tno(,Ttonl of k NEW SInJUIE Fk"11.' KovSE SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 15,61000 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ S6 b00 ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 01000 2. Other Fees: $ 4.Mechanical (HVAC) $ SD,000 List: 5.Mechanical (Fire Suppression) $ NIA Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 300 , 006 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C5 - 0(#1324 0 2oZo KENNEtH C., License Number Expiration Date Name of CSL Holder List CSL Type(see below) U R V7 Vi"oAhE ST No.and Street ,I Type Description MhQ4l EY��PtO M� p q�[ U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances ;-K( I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP Telephone 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 I,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. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' 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' s a b tion is true and accurate to the best of my knowledge and understanding. lof 3� ZotB Ckmr'U or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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 can be found at www.mmL og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss 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.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" The Commonwealth of Massachusetts = Department of Industrial Accidents x I Congress Street,Suite 100 Boston,MA 02114-2017 r www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 5 A Or T LE If 4- M A r) Co. t tj(.• Address: (a 1 Ct \I t Lt,h(a tr ST• City/State/Zip: IAMLO ,E VICAOI Mk DLJLtS Phone#: (119 (03 l ' 9-75. 1 Are you an employer."Check the appropriate box: Type of project(required): 1.®I am a employer with _employees(full and/or part-time).* 7. ®New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3. t am a homeowner doing all work myself.[No workers'comp.insurance required.)' 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.) *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors 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 sub-contractors have employees,they must provide their workers'comp.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: Travelers Insurance Company Policy#or Self-ins.Lic.#: UB-2L574850-18-42 Expiration Date: 08/27/2019 Job Site Address: S M0r�-'Cl� LN , ShLEM r t4k City/State/Zip: 5AL(,EMI We ()Iq Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereb�cer urt th ins ar at the information provided above is true and correct. Si n re: Date: Phone#• Z a k a J dal— LAPS tO Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A ® DATE(MMIDDMIYY) CERTIFICATE OF LIABILITY INSURANCE IC 11/01/2018 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 policy(ies)must have ADDITIONAL INSURED provisions or 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 NAME: Greg Bates Farquhar&Black Insurance Agency HCNN Ext: (781)599-2200 AX Na: (781)581-3940 85 Exchange Street-Suite 101 E-MAIL greg@FandBlnsurance.com ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# Lynn MA 01901-1475 INSURER A: Travelers indemnity ofAmerica 25666 INSURED INSURER B: Travelers Insurance Co 39357 Bartlett&Steadman Co.,Inc. INSURER C 67 R Village St. INSURER 0 INSURER E: Marblehead MA 01945 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1811112007 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTR TYPE OF INSURANCE INSO LI WVD POCY NUMBER MM/D E F MMIDO/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 L)AMAUE U.)RENT 17 CLAIMS-MADE 7X OCCUR PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 5,000 A 680-2L52590A-18-42 08/27/2018 08/27/2019 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY ❑PRO- ❑ 2,000,000 JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: CNTBL $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED BA-2L704986-18-SEL 08/27/2018 08/27/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident Uninsured motorist BI $ 20.000 _"' UMBRELLA LIAB OCCUR EACH�OCCURRENCE $ RXCESS LIAB HCLAIMS-MADE AGGREGATE $ ED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ERH YIN 500,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE -1 N/A UB-2L574850-18-42 08/27/2018 08/27/2019 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached ff more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Salem Salem City Hall ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington St. AUTHORIZED REPRESENTATIVE Salem MA 01970 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CITY OF SALEK MASSAaiLJSEM BLMDING DEPARTMENT 120 WASHINGTON STREET,P FLOOR ItL. (978)745-9595 KMERLEY DRISODLL FAX(978)740-9846 MAYOR THomAs STYiERRE DIRECTOR OF PUBLICPROPERTY/BunDING ODIMSSIONER Construction Debris Disposal Affidavit (required for all demolition & renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, S54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licenses waste deposit facility as defined by MGL c 111, S150A. The debris will be transported by: V (name of hauler) The debris will be disposed of in: (name of facility) (address o acility) Signature of applicant (today's date) The Commonwealth of Massachusetts FOR Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code,780 CMR USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers a K&%'rtri 1-rj ly LoT 1V4 1.1 a Is this an accepted street?yes no Map N muMap� Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Ar(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 5' ( log I b I qS1 3bt1 -10 ` 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 C9 On site disposal system ❑ Check if yesIN SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) City,State,ZIP (o"I Ci ViLLMA0 ST. 08t (.3t- 3-1P No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction d Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work2: S t O(a LE f+AM l Lq t4ortie SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I.Building $ 1 15,01 000 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee S 019 00 ❑Total Project Costs(Item 6)x multiplier x 3.Plumbing $ 5-01 ODD 2. Other Fees: $ 4.Mechanical (HVAC) $ C-pl 000 List: 5.Mechanical (Fire $ Su ression Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 3 p 0t 00D 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or MC Registrant Name No.and Street Email address City/Town,City/Town, State,ZIP Telephone 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 ..........G4 No...........0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' 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 a lication is true and accurate to the best of my knowledge and understanding. ,, ...,.J l I S I i Y P t 's or uthorized Agent's Name(Electronic Signature) —� Date NOTES: 1. 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 can be found at www.mass.¢ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) 3 r tX>o (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) 2 t %4 W Habitable room count Number of fireplaces t Number of bedrooms 4 Number of bathrooms 3 Number of half/baths t Type of heating system Number of decks/porches r Type of cooling system Enclosed Open r 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" CITY OF SALEA MASSACHUSEM j BuIIDING DEPARTAENT 120 WASIENGION STREET,37fD Raw TEL (978)745-9595 KIMBERLEYDRISODLL FAX(978)740-9846 MAYOR Tklows STYmRRE DIRECTOR OF PUBucPROPERTY/BunDING OO& IISSIOMR Construction Debris Disposal Affidavit (required for all demolition & renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris, and the provisions of MGL c40, S54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licenses waste deposit facility as defined by MGL c 111,S150A. The debris will be transported by: D pC j STP(n D l SP05 1. (name of hauler) The debris will be disposed of in: Repyt c Seayif'e& pE � TC�a�st-a:a- STrri toa (name of facility) add F iWr ST. , PIA960yl Mik Ola�o (address of facility) S na re of applicant (today' date) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ` Please Print Legibly Name(Business/Organization/Individual): J we s S%No PAP, Address: l�( N 0 0-11\ S r. V N 1 T l 0-k City/State/Zip: SDr LEM t Mpc 0111tb Phone#: ?8 38 Are you an employer?Check the appropriate boa: general contractor and I Type of project(required): 1.El4.I am a employer with ❑ I am a g employees(full and/or part-time).* have hired the sub-contractors 6. [�New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp. insurance comp.insurance.# 9• Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all worts and then hire outside contractors must submit a new affidavit indicating such. tContraetors 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 sub-contractors have employees,they must provide their workers'comp.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: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 certify under the pain nd penalties of perjury that the information provided above is true and correct. Signature: VT& Date: Phone#: '! l 3 8i -5-04 57- Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone##: CITY OF SALEM, MASSACHUSEM BUILDING DEPARTmENI 120 WASHNGTON STREET,3"11 FLOOR TEL. (978)745-9595 FAX(978)740-9846 KIMBERLEY DRISCOLL MAYOR Tf IoMAS ST11ERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: 0140 Is T� JOB LOCATION $ iKNe-yt l L,.j . SPLL-Ernl Mlay- 61q':�O HOME OWNER ADDRESS: «[ Uopto, SfPtif-t uNtr (o-�- I ! L614, lk PRESENT MAILING ADDRESS: � fS I N otI4K S'CW T- UNIT- MA" The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two(2)units or less and to allow such homeowners to engage an individual for hire that does not possess a license,provided that the owner acts as supervisor. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official,on a form acceptable to the Building Official,that he/she be responsible for all such work performed under the Building Permit. The undersigned"homeowner"assumes the responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned"homeowner"certifies that he/she understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPECTOR