35 FLINT ST NUMBER 202 - BP 11-520 1'
�. The Commonwealth of Massachusetts
N
Department of Public Safety
O/ �",r'„/ \las.echuvtl?tate UudMing Code l.-8UC\IR)5rcrnlh Edition !
r City of Salem
Building Permit Application for any Building other than a 1• or 2-Family Dwelling
j�
(rhe,Scc'uun Fur Official lRr Only)
Building Permrl..Number: - Date Applied: Budding Inspector:
s SECTION L• LOCATION IPeease indicate Block s and Lot a for locations for which a street address is not avLlable)
35 FI,`A+ S+ #202 Salem nRR 01970
X., and Street Cin' /Town Lip Code .Name of Bu riding ldappbcoble)
SECTION 2:PROPOSED WORK
If New Cumtructiun check herr Our check all that apply in the two rows below
Existing Budding❑ Repair❑ Alteration ❑ I Addition(3 1 Demolition ❑ (Please fill caul and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Oihrr @. Specify: I\SPw K,4r.l7a,,. Ca Y1)htl' r
Are budding plans andlur construction documents being supplied as part of this permit application? Yrs a No ❑
Ls an Independent Structural Enginrrring P}er Review required? Yrs O No )R
- Brief Description of Pruprovd Wurk:
RPrnedel rex eh
Re nnn +e cc lk"',et-c ci vdri Covn+�J' P q,nl>I i�S (f /Iew ca6f)+el- t rOuvt�-vr �
.p l u , i r I eft-t( ,� r'�l,e v i-a coat c
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): P
Existing Hazed Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(X). ft.)and Total Height(ft)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A•I ❑ A-2r ❑ A-2nc Cl A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational O
F: Facto F-1 ❑ F2 O H: Hi Hazard H-1 ❑ H•2❑ H-3 O H-4❑ H-5❑
1: Institutional I-I ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage SI ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Sproat L'se:
SECTION 6:CONSTRUCTION TYPE(Check as.applicable)
IAO 10 CI IIA ❑ 1180 IIIA C3 1118 1 IV C3 I VA ❑ VB ❑
SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench remit: Debris Removal:
I'ul+Iii O. 0heil d uubnle Pin,-.I Lnnr❑ Indicilr mumcil•.d❑
\ trench will not be Licrmrd Cl
rcquired ❑or trench ,,r
I'ncalc❑ nr u,Jcnln% Line:_ nr nn Cdr•corm O
liailroad nghlol-way: Hazards to Air Navigatioin \I-\ Ih�bn, i . nnu„, „iL ,., I'.., •:
\,,I \pphda(dc❑ LVru.I,nc„,[I... Ir,I• i
14nld cn,J, cd ❑ I lr•❑ -r\,i❑ \..❑ O 1
SEC rlO.N 8:CON TENT OF CE RTIFICA I OF OCCL'PA NCY
I .hlnn .•I l- •Jy L-yl�n juin-1 _ r, a,,i ni,li, n l kcul,.ui l lit.id i•cr lL
Ir.„.ihr buil,Lnq, •nidin.ui Alvin Alcr" .icm` `Prcial�ul¢ilatiun.
SECTION 9: PROPERTY OWNER AUTHORIZA TION
ne anal .\.LIt of I'ruperle l)..net
KGi- FI ,,,,+ Sl #2oZ S�,Iev7A M/� _ �i�17o
\.ime tPnnt) \'u..indmrvet lih; r.nvn rap
PnryvrthlAnwr Conl..it Inturm.ulun:
rale relephone No. (busmr>e) reiephone No. (cell) email d.f.trr..
If:uF+phcablr, the prupert%is,ner herrbv.tuulhuntrs
\arae - Slrcel Addre s City/T...vn dale Zip
In act on the ro aer1% .n,ner.beh,df, m all matters rulame hu work.ndhonrvd by this buddln• +ernut o + +Itcat ion.
SECTION 10:CONSTRUCTION CONTROL IPlease fill out Appendix 2)
III t•ud.hn•Is I.ea than li,lkti it.ul 1.11 11xd.+ace.md/11r-1111 under Gmaruc hon Gnoml Ihen check here❑and k+,5.•Jn... Ill I I
10.1 Registered Professional Responsible for Construction Control
Mys+c.0,):lc(er/j0kn Rsszr X81 .933 . ZSoy
Name(Registrant) Telephone No. e-mailaddress Registration Number
I K VjAr^;, Cf �lJobirun /_•4 0)�0 7 /7 - IT'Z
Street Address City/Town State Zip Discipline Expiration Date
10.2/General Contractor
1 �llf<�I`G Q(J IlG�er�
Company Name:
�a�� m R(sser CS -T�1 syy
Name of Person Resprmsible for Cunstructiun License No. and Type if Applicable
1 R VL,rAti Q4- wr,bvr L erdcl
Street Address City/Town tate Zi
Z&I .Y�_ 2,7py 791 .953 60 oKA P
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L.e.152.IS 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in th:ee
of the issuance of the building permit.
Is a signed Affidavit submitted with this application? es❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND FEE
Item Estimated Costs:(Labor
and Materials) Total Constructiofrom Item b)=S
1. Building S I $ 600
Building Permit FeeConstruction Cost x _(Insert here
2. Electrical 5 /ooJ appropriicipal factor)=$
3. Plumbing 5 /p[,Q
J. fvlechanical (HVAC) 5 Note:Minimum fee (contact municipality)
5. Mechanical (Other) 5 Enclose check payable h. Intal Cost p'Y•5 'zp bG0 e check number hereSECTION U:SIGNATURE OF BUILDING PERMITCANT
Hv -niering my name below, I hereby altum under the pains and penalties of pequry Ihat.dl of the In1."matiun nrd in this
..pplic.11wn rs true and accurale to the bent of me kn,nu.r ledgeand under<t.mding.
JohA RisS"`-
I'Ir.n.•print.Ind .ipn n.rmv rrtlr — _--
1 R V d ti roI rh,.n \ , e
rtvob� r p/
�lircf 1,l.lre.. til\; Gnrn :�I.IIv
I \luni:ipal Inspectorto lilt out this section upon application approval:
Massachusetts- Department of Public Safch
SBoard of Building Rc�-,trlations and Shmdards
Construction Supervisor License
License: CS 51844
Restricted to: 00
JOHN M RISSER
3 LAUREL ST
WOBURN, MA 01801
oL _�
Expiration: 5/13f2011
<' mmisioner Tr#: 15535
OT/ee Liomnnoeuaeald� o�../l�aaxrGEudd
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
. RegIstration:,r-I05480 Type:
Expiration_TItT/2012 DBA
MYSTIC BUILDERS'--.
i
John Risser
3 Laurel St.
Wobum; MA 01801 " _-i;-.v."r-� Undersecretary
CITY OF S.1LE.NI, 1L-kSS.AcHUSETTS
13LILDNG DEPARTMENT
' 130 WASHNGTON STRm,3t0 ROOR
TM (978)745-9595
FAX(978) 740-9846
Kj.,%j3E rY DRISCOLL.
MAYOR THO..%Lu ST.PIEItan
DIRECTOR OF FL:BLIC PROPERTY/Bt:RDLNG 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 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit At is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
V /dac( wtis of Qos r
(name of facility)
Eve.r-� Mass
(address of facility)
sigbature of permit applicant
date
mn �ird,k
l
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.inn:;M:FY:1k1Aan 1.
12^.WAtHI.M;I U\5'I S ELT • SAI Ii M,MASs3enr cern 6197-.
1'ra.:978-743-9395 0 1:%x.978-7407944
Workers' Compensation Insurance AfftdaviC Builders/Contractors/Electricians/Plumbers
kimlicant Information Please Print Leeihly
Name u
(BusiouvslQraaairatinNlndivutuull: /� M\/S I +L C� IG1 L'�S
City,S131c;/.ip: wo'6j/ 4- Ml/ -0 01 Phone J: '78(- q33- 2� Oy
Are ypu an employer!Check the appropriate box: 'Type of project(required):
I.®I ant a employer with 1 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).' have hired the sub-cuntracturs
_.❑ i :un a sole proprietor or partner-
listed on the attached sheet. 7• ❑ Remodeling
ship and have no umployces These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. q, ❑ Building addition
IKa workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.) officers have cxcrciscd their
3.❑ i an,a homeowner doing 311 work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. [No workers'comp. c. 152,g 1(4),and we have no 12.❑ Roof repairs
insurance required.) r employees. iKo workers' 13.0 011ier
comp. insurance required.)
'Any:yphwol+hut chucks box ill musl also lilt son the w:eliou b0ow showing their wotkui cumponsaiion policy inhumation.
'I lumcuwnen who w+bmit this affidavit indicating lliq are doing ull work amt then hire outside caurxton must.utmtit a new afflitavil indicaling vetch.
-
C,mirwurcv+hat chuck this box must mtwhcd on additional ehoel.hawing the came of the sub�contrxion and rheic wurkon'romp.policy infurmatiun.
/am mr earyduy¢r that lr pruvidinq rvurkers'c•ourpen.rntinn in.rurnuc¢fur my eurp/oyees. Below is the policy and job site
iujonnurion.
Insurance Company Name:—'A s.- Agem-j
Policy g ur Scif-ins. Lic.ft: /JCC-5dU-(-4 Z ' 101- 2-a rl— _ Expiration Data: 74h j2'tc, Z 0 3-Z
7
Job Site :lrhlrcss: 5 E Ln I1 `�� C'ity;Slate/"Lip: Mtr'� "` M 01576
Attach is copy of file workers'compensation policy declaration page(showing the policy number and expiration date).
Failure ro secure coverage as required under Section 25A ul•>IGL c. 152 can lead to the imposition of criminal penalties of a
lint up to 31,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and 3 fine
ofup m]250.D0 a day against the violator. Ile advised that a copy ofthis,iatcment may be forwarded to the Oil ice of
I I%�,in au+ms u3-the DIA for insurance covera-c sci ilicatiun.
I du hereby certify under dee pains mrd penalties of perjury that the information provided above is true and correct -
/N /L
'7(�i- 933- 2,5_0 `�
FF,t'
se only. Do rat tvrfte in this area, to be completed by city or town a iciuL -
own: Pcnnit/l.icvnse 4._.
horily(circle one):
(Ilealth 2. iluildin:; Dcpartmcnl .1. it)/form Clerk 4. Llectrical Inspector 5, Plumbing Inspector
C duel Teruo: _ ._ Phone H:
Information and Instructions
assachuscits Gcncral Laws chapter 152 requires all employers to provide workers' compensation for their cinl ldytes.
Pursuant to this statute,an employed is defined as"...every person ;n the service of another under any contract of hire,
evpress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
,,t the fbreguing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the ..
receiver or trustee of art individual,partnership,association 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
dweting house of another who employs persons to do maintenance,construction or repair work on such dwelling house n
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
`IGL chapter 152, g15C(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."
Additionally, SIGL chapter 151, §25C(7)states"Neither the commonwealth not any of its political subdivisions shall
anter into any contract for the performance of public work until acceptable evidence of compliance w ith 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),addresses)and phone number(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 sign and dale the affidavit. The affidavit should
be retumed 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-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he 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 not in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference nunhber. In addition,an applicant
that must subunit multiple pennit/liemhse 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 permits or licenses. A new affidavit oust 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.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I the Office ice tit Investigations would like to thank you rn advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OtRee of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax k 617-727-7749
Iftvised 5-'_G-u5 www.mam.gov/dia
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I of 2 10/19/2010 6:55 PM
12/7/2010 11:35 AM FROM: Soucy Insurance Soucy Insurance Agency, Inc. TO: 978-740-9846 PAGE: 001 OF 002
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMD"YM
T" 10/06/2010
PRODUCER,978.744.7110 FAX 978.741.2059 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Soucy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P. 0. Box 4467 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
201 Washington St.
Salem, MA 01970 INSURERS AFFORDING COVERAGE NAIL#
INSURED John M. Risser Dba INSUREPA. Vermont Mutual Insurance Co. 26018
Mystic Builders INSURER B. Hanover Insurance Co. 22292
3 Laurel Street INSURER Associated Employers Ins. Co
Woburn, MA 01801 INSURER D.
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 DD-L rypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICYEXPIRATION
LM NSR DATE MWDD DATE(MMA)DYYM LIMITS
GENERAL LIABILITY BP11019917 01/01/2010 01/01/2011 EACH OCCURRENCE $ 1,000,00
X COMMERCIAL GENERAL LIABILITY PREMISES E.occurrence) $ 50,000
CLAIMS MADE OCCUR MED EYP(My one person) $ 5,00
A PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,00
GENC AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY SEIT IT F LOC
AUTOMOBILE LIABILITY AMN2174811 12/09/2009 12/09/2010 COMBINED SINGLE LIMIT
ANYAUTO (Ea accident) $ 1,000,000
ALL OWNED AUTOS - BODILY INJURY
X SCHEDULED AUTOS (Per person) $
B X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Pere didere)
GA RAGE LIABILITY AUTOONLY-EAACCIDENT $
ANYAUTO EA ACC
$
OTHER TEAM
' AUTO ONLY'. AGO $
EXCESS I UMBRELLA LIASILTY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE
RETENTION $ $
WORKERS COMPENSATION W'CCS006121012010 01/12/2010 2011
/ / TORY LIMITS ER
AND EMPLOYERS'LIABILITY Y/N / Dl 12
C ANY OFFICER/MEMBER EXCUD p PROPRIETORIPARTNEWEXECIRIVE ELEACH ACCIDENT $ 100,006
(Mantlatory in NH) EL DISEASE-EA EMPLOYEE $ 100,000
I yes,describe under
SPECIAL PROVISIONS below EL DISEASE POLICY LIMIT $ 500,00
DITHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
City of Salem NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Public Properties Department IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
120 Washington St. , 3rd Floor REPRESENTATIVES.
Salem, MA 01970 AUTHORIZED REPRESENTATIVE
I Paul Soucy
ACORD 25(2009101) FAX: 978.740.9846 ' OO 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
12/09/2010 18:13 7819332504 MYSTIC BUILDERS PAGE 01/01
Markwood
Management
Incorporated
December 8,2010
To whom it may concern:
Mystic Builders is hereby authorized to do kitchen remodeling in Unit 202 of the Bowditch Place
Condominium Trust at 35 Flint Street, Salem, MA,
Mark W. Livermore
Markwood Management Incorporated
Post Office Box 900 Marblehead, Massachusetts 01945
Telephone(781) 639-4080 Facsimile(781)639-0228
- markwoodmgt@hotmail.com