Loading...
30 1/2 DEARBON ST - BUILDING INSPECTION the Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 730 CMR, Tu edition OF SALEM I/ fl Building Permit Application To Construct, Repair, Renovate Or Demolish 1. 2008 One-or Tu•o-Family tcel/ing This Section F Oltic•al Use Only Building Permit Numb/.. Date A plied: Signature: Building Commissioner/Ins for of Buildings Dale SECTION 1:SITqV4FORMATION 1.1 Property Ad ress: 4, .2 Assessors Map& Parcel Numbers 1. 1.la 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 Il) 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 13 Private❑ Check ifyes❑ Municipal❑ On site disposal system 13 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owners /o/f Record: l J aV sTA i� Ly G /` 30`/2 V{b.-r bOW S 'T Nome(Prin� / Address for Service: 97'5- 7yy-3o 13 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other 'Specify: Brief Description of Proposed Work': 1;n s.- , i _ AXooy 4.1X— 20 w /� W cr- / ,2rt.i CX ,�,�- `J ,// r c -/ X -/7 L+ I t`� CC/Cu ee .A< <IEGc/ rtel//�f"Pr SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials I. Building S (9 0 8 S 7 I• Building Permit Fee:S Indicate how fee is determined: 2. Electrical S ❑Standard City(Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IiVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees: S J < Check No._Check Amount: Cash Amount: 6.Total Project Cost: S (91 Ci0 J 0 paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5,1 Licensed Construction Supervisor(CSL) / 90 9D Z111112-11 _ r f k &✓ License Number Expiration Date N:unc of CSL-I[older ,� 7>? & //a Z1,7 /e A Gxoi�/ lr�U/r/60 I.isl CSL pe[seekeluwl Address It' Description Il l!nrestrictcd a 1u 35,000 Cu.R•1 R Restricted 1&2 Family Dwellin Slgaature M Mson Only 7;1- RC Residential Rooting Covering I clephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation U Residential Demolition S,Z�Jtfgistered Fl�r�e Improveme,Pt�optractor(HIC) !� r dr vitt aI CGrG< Sa ,f din S/ L L_C 1(,04892 1 11 Company Name or Ii IC Regi stmnt Na ne Registration Number Z9 A P" -1,6 �� ti o C)/ Addre �r/�a f� o�f s W1,_ tf7f Z 0 - Gxpimtion 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 .........,,So No...........0 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 77b:OWNEW OR AUTHORIZED AGENT DECLARATION 1, x c �/'�o-.mac J ,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. / n Print Name ZZ Signature of Owner or-Authorieel hale(Signed under the pains and penalties of perjury) 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 110.116 and I IO.R5,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.) Ilabitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halt/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" CITY OF SALEM ;eg ,, PUBLIC PROPRERTY ' ! DEPARTMENT , I2C.WMltl\G ION S faELT •Sml;M,Mass.w:nt si,ru at97.^ l'r.c:978-745-9595 • Psx. 978.730.9446 Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 3 tlicaut Information Please Print Le ihly Naintlc- l0ucrncvslQ,rpanivatinry lndindu/all): .U�/J �d✓t.S. LZ- C Address: 2 "Q114LSH r 177211 /1-✓_12 City,Starci%ip: ,7 -c' ' / Phone i!: 7o l — �,��LG�i F� Are vnu an employer'Check the appropriate box: 'i'ype orproject(required): F1ats a employer with 4. ❑ 1 :un a general contractor and 1 6. (] New construction // ent pluyces(full antVur put-time).• have hired the sub-contractors _.❑ I am a talc proprietor or partner- listed on rhe attached sheet. �• E] Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working lin me in any capacity. workers'comp. insurance. 9, ❑ Building addition No workers'comp. insurance 5. ❑ We are it corporation and its 10.[]Electrical repairs or additions required.) oBiecrs have exercised their 3.❑ 1 an a homeowner doing all work right of exemption per NICL I I.❑ plumbing repairs or additions myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.) r anployccs. (No workers' 13.❑Other comp. insurance required.) •any a,pbcaW owe chocks box ill muss also Jill out the section Wow showing their w'orkui cumpunsmiou policy infurmmiun 'l tamauwmrs who submil this affidavit indicating nwy are doing all work and then him outside cwnrxton must.uhmu a new afrdavil indicating.wch. -C,mmwmrs that check this box trials attached an additimal sheet.hawing the name of the subrcmlractors and their workun'comp.policy infix marion. I ant an employer that is proridirtg workers'c-o tipenvadots insurance jar my employees. Below is the policy and job site iojorinution. Insurance Company Name:__._.. .... .-.....__.....-._—_-- Policy 4 or Self-ins. Lic.8: -_... .. .._ Expiration Date: Job Sito Address: _ City/State/Zip: Attach it copy of the workers'compensation policy declaration page(showing;the policy number and expiration date). Failure to secure coverage as required under Section 25A ui':vIGL c. 152 can lead to the imposition of criminal penalties of a tine up to i 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 1250.00 it day against the violator. He advised that a copy of this statement may be forwarded to the 011ice of In\esrtgauons ul'thc UTA for insucu:cc arvcragc ,criticatiun. 1110 hereby certify under thee�p ins rnt enultiev ujp rjury that the information provided above is trite and correct. tiw:t:ottre� ��L'`'_rn 1 Date: Fh,tt:e;i: 79 ( q7Q 2 0 LL Ojficfel use artly. Do not avite in this area, to be coutpleted by city ar tmvn official. i City or fawn: _._ _ Permit/Liccnte d_. Issuing.\udutrily(circle nuc): I. lioard of llcalth 2. Building Department .l.City/fora Clerk 4. Electrical Inspector 5, Plumbing; Impector 6. Other .__. Conlacl I'cnulr. Information and Instructions ,Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of)tire, cypress or implied, ural or written." . An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the fbrogoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the ICLCiver or trustee ul ;ur Individual,parmership,assoeiaroa 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." .%IGL chapter 152,Q35C(6)also states that"every state or local licensing agency shall 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 compliance with the insurance coverage required." Additiunally, N[GL chapter 153, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall _ anter into any contract for the performance ufpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),addresses)and phone nuniber(s)along with their certificate(s)of insurance. Limiter!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 au LLC or LLP docs have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should he returned 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. Self-insurcd companies should enter their self-insurance license number on the appropriate line. City or"town Officials Please be sure that the affidavit is complete and printed legibly. The 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. Plcasc be sure to fill in the pcimit/license number which will be used as a reference number. in addition,an applicant that must submit multiple pennit'lice»se 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 tnay be provided to the applicant as proof that a valid affidavit is on file for future permits 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 t i.e. a dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. I he office act investigations would like to thank you in advance fur your cooperation and should you have any questions, Please do not hesitate to give us a call The Ucparnncnt's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents O[Hce of Investigatlons 600 Washington Street Boston, MA 02111 Tel. Il 617-727-4900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 itceiacd ?-31i-(15 www.mass.gov/dia CITY OF SM EM, NL-kss kcHusETTS • BLIMLNG DEPARI-M&NT ' 130 WASHLNGTON STREET, 3io FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KI.NfBERLEY DRISCOLL MAYOR 'IHouAs ST.PtF�as DincrcR OF PCBLIC PROPERTY/at:=NG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.5 Debris, and the provisions of MGL c 40, S 54• Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c 111, S 150A. The debris//will be transported by: � GI�H -dlF-lQryc'f (name of hauler) The debris will be disposed of in ' S r 4r .L' r r _ L' (name of facility) B 7 ✓G h � (,L- S (address of facility) signature of permit applicant _L2 /3-// c7 Jam Jcbnvlf Jx ' Massachusetts- Department of Public SafetN Board of Building Regulations and Standards Construction Supervisor License License: CS 90902 RICHARD BORGES ^ `e 28 HAMILTON ROAD _. q PEABODY, MA01199c60 t Expiration: 11/1/2012 (' mmissiinrr Tr#: 5481 ✓k Ldm7narr�iiealli� o�.//�voo¢yrr�dtt"l1 Once of Congo ARaira&gvsioess Regnlatioin4:. '+ HOINEIMPR,OVEMENT CONTRACTOR 164893 r Expiretlon. li/302011. - Tn! 291C KY3 Mf ' on ADVANCED ENIE49n bT. NS LLC. � *; RICHARD BORGES �* ' 28 HAMILTON RDS " PEASOnY MA Mecn I I / .' 12/13/2010 MON 8: 46 FAX 6174231789 2002/002 �`� CERTIFICATE OF LIABILITY INSURANCE DATE /13Y""' 12 13 30 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS t CERTIFICATE DOES NOT.AFFIR NATIVELY 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(es) 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). r PRODUCER NAME:TACT Paul T Mu h Paul T. Murphy Insurance Agenc PHONE E. 781 321-9700 s,X No: (781) 324-4253 16 Lebanon St !=Ess:S$: aul@ tmineuranee.com Malden, MA 02148 PRODUCER 7064 rusmNEo _— INS %RSIAFFORDING COVERAGE NAICr INSURED INSURERA:Scottsdale Ins Advanced Energy Solutions LLC INSURERB:Peerless Ins 75 Greenwood Ave INSURERC:AIG Wakefield, MA 01880 INSURER D: INSURER E: I 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 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 OFSU01 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. /NSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OFINSUR/WCE --_ -----'�' POLICY NUMBER MIODIY WIIDD'VYYY UMTS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A X COMMERCIALGENERALLIABILITY CPS1014919 5/7/10 5/7/11 DAMAGETORENTED $ 100,000 CLAIMS-MADE aOCCUR MED EXP(A ore esm) S 5,000 PERSONAL a ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2 000 000 GEN'LAGGREGATE LPAITAPPUES PER PRODUCTS-00MP/OP AGO $ 210001,000 POLICY TRO- T LOC $ AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT ANYAUM (EaacoiWri) $ 1,000,000 B ALL OWNED AUTOS 8633314 3/19/10 3/19/11 BODILY INJURY(Per person) $ BODILY INJURY(Per wc�den0 $ X SCHEDULED AUTOS X HIRED AUTOS PROPERTYDMMGE $ } (PeraaideM) fat X NON-OWNED AUTOS $ C s UMBRELLA LIAR OCCUR EACH OCCURRENCE $ IX ISS LIAR CLAIMS-MADE AG REGATE DEDUCTIBLE RETENTION S $ WORKANDEMPSCERS-LIAI1.1 006789459 5/14/10 5/14/3.1 WCSTATU- OTH- ANO K ERS CORS'LIABILITY / C ANYPROPRIETORWARTNERJEXECUTNE YIN OFFCERMEMBER EXCLUDED? NIA E.L.EACH AC CJDEM $ 500,000 (mareatefrS6d-ryin NH) E.L.DISEASE-EA EMPLOYEE S 50Q 000 Ilpes,tlescrDe wtler DE SCRIPTION OF OPERATIONSbelow E.L,DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ALIMh ACORD IGI,Addiaenal Rom Hce BOMUM.it m m space b regtired) ' Insulation- Coverage is subiectto policy terms conditions and exclusions. Disclaimer attached. .� CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem, Ma THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Joyce I fax 978-740-9846, AUTHORRED REPRESENTATIVE I t " ©19882009 ACOJRb CORPORATION. All rights reserved. !� ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD I 12/13/2010 HON 9: 07 FAX 6174231789 2002/002 i. ACOORV CERTIFICATE OF LIABILITY INSURANCE DALE(MM DDYYYY) 12/13/10 r 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 B2COW.' TkS 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(es) 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 NOWPaul T Murnhv Paul T. Murphy Insurance Agene PNDNE ci. 'JB1 321-9700 ACX No: (781) 324-4253 16 Lebanon St no k—,E aul@ tminsurance.com Malden, MA 02148 PROD CER 7064. __ INSURE% AFFORDINGCOVERAGE INSURED INSURERA:Scottsdale Ins Advanced Energy Solutions LLC INSURER B!Peerless Ins 75 Greenwood Ave INsuRERc:AIG Wakefield, MA 01860 INSURER D: INSURERE: I NSUREA F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSLRED 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 AFFOFOED BY TIE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES.LWIFTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPEOFINSURACE AWL SUER OLO — - 1---"_----- -_. POUCY NUMBER MOYE MMIDD'YYYY . LIMITS GENERAL LIABRITV MGENERMALAGGREGATE RRENCEt $ 1,000,000 A X COMMERCIAL GENEPALLWBILITY CPS1014919 5/7/10 5/7/11RENTE $ 100,000 CIAIM$MADE OCCUR ow $ Ej000 ADV IN $ 2 000 000 GREGA $ 2 OOO 000 GEN'L AGGREGATE LIMIT APPLIES PER (OMP1 $ 2,000,000 POLICY PRO- LOC $ 3 AUTOMOBILELIAMUTY INGLE LMR ANYAUTO (Eaawidan) $ 1.000,000 BODILY INJURY(Per Person) $ B ALLOWNEDAUTOS 8633314 3/19/10 3/19/11 BODILY INJURY(Per scidenl) $ X SCHEDULED AUTOS X HIREDAUTOS PROPEAGE perewident) S deMl EI X NON-0WNEDAUTOS $ p $ F9S UMBRELLA UAB OCCUR II IE7 EXCESSLIAB AGGREGATE CLAIM$-NMDE AGGREGATE DEDUCTIBLE I RETENTION S - S WORKERS COMPENSATION 006789459 5/14/10 5/14/11 WCSTATU- 0TH- g ANDEMPLOYER$'UABILITY fP (�` � RIMEMBRREXCLUD OXECUTNE Y� MIA E.L.EACH ACOOEM $ 500,000 JMandaeyes,describe ander E.L.DISEASE-EA EMPLOYE $ 500,000 Iyes,dlzuyin H) DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIAR $ 5001D00 4 DESCRIPTION OF OPERATIONS ILOCATIONS IVEHICLES (ANach AOOR0101,Addidonal Remda Schedulo,IfmmspamismgUrod) Insulation- ((( Coverage is subjectto policy terms conditions and exclusions. Disclaimer attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit of Salem Ma THE EXPIRATION DATE THEREOF, .NOTICE WILL BE DELIVERED N I' Y ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Joyce fax 978-740-9846, AUTHORIZED REPWSENTATNE ©1988-2009 ACORb CORPORATION. All rights reserved. ACORD 25(2009109) The AC ORD name and logo are registered marks of ACORD I L