3 GOODELL ST - BUILDING INSPECTION �vl
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T"edition Building Dept
Building Permit Application To Construct, Rrpair, Renovate Or Demolish a
(y y Odoom
ne- or Ttca-Fumiis Duelling
This Section For Official Use Only
Building Permit Number Date Applied:
Signature:
Bus lding Co im ner Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 rope Add f 57 1.2 Assessors Map dt Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area(sq it) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public O Private❑ Check if es❑ P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 is1 and 3 �&VG/ l S %
s�Osdh/
Name(Print) Address for Service:
Signature - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed
Wyoork':
d/ri 7
- PrIK60
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Of lcial Use Only
Labor and Materials
I. Building f 2 s 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical E ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing E 2. Other Fees: f
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ress ion
Check No. _Check Amount: Cash Amount:
h. Total Project Cost: S 7 y7 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Ol��l 3 � f -!Y Kolb
" •��,� �-�� L¢cnsc Numbcr Expiration Date
N.;Ime of CSL- i 1 er List CSL Type(we below)
�o crJ�� 27
Address T Description
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signatu` M Masonry Only
RC Residential Roofin m Cover
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered H me Improvement Contractor(HIC) 1007.3 3
HIC Company Name or I),IC Regi tr ame eqo� _ Registration Number
Addresa 66 6-PL,
Expiration Date
Signa Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 .......... (;I-- —No........... O
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 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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. i
Print Name 44
Signature of ner orized Agent Date
qui, un 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 ff41 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 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/anics, 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"
AGUMLL VCR/ lrIVMI Cyr Lf/1t00tL.t I! t 04/07/2009
PROIXICER 781-324-1809 FAX 781-397-9270 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
New England Heritage Insurance Agency Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
110 Florence Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Malden, MA 02148
INSURERS AFFORDING COVERAGE MAIC 9
vis A B Carlres,Inc. INs)RERA. Essex Insurance Co.
30 Arrowhead Farm Rd. wsURERa Granite State insurance Company
Boxford, MA 01921 INSURER -- —
D
iN�)RER 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
POLICES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE POLCYNUNBER "�F-aloT#iECRVE P�O�IA.9'EXWRATtWI --- LIMITS
GENERAL LMBILnY 3CZ1799 03/18/ZO09 03/19/ZOID EACLIocanvaNCE F.O
X COMMERCIAL c€��AL LIABILITY � FREe�s°ANA
CWMS MADE OX OCCUR MIM EXP(ABY ens TgNm)
A PalsonwLBAOVnuunY
C 34ERAL AGGREGATE PRODUCTS-COMProP AGG AUTOYOB"LUINUTY ` SINGLE UNIT
S
ANY AUTO _
ALL OWNED AUTOS BODILY INJURY --
SCHEDULEDAUTOS (Pa Persrn) $
HIRED AUTOS BOOLY INJURY
NNXYOWNLD AlTT03
(PmemdeN) S
PROPERTY DAMAGE s
(Pw aadde+S)
GARAGE LIABILITY AUTO ONLY-FAACCIOENT S
ANYAUM OTHER THAN EAACC t
AUTO ONLY, AGG $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE S
71 OCCUR EICLAIMS MADE- AGGREGATE f
S
DEDUCTIBLE $
RETERIION S t
WORKERSwrvENSATION HC 742-62-18 03/31/2009 03/31/2010
AND EMPIDYERS'LIABILITY TORY ACCIDENT
Ht
ANY PROPWETORX+ YIN E1_EAGIACGIOEINT s 1.000 00
B OFF(K-dMAKY In Wo N. AILRSi>!Ht ExalWED? �I� EL DI -EA EMPL s 1 000.00(
SPECNL° PROVISIONS bel w EL DISEASE-POLICY LIMIT S 1:000,00
OTHER
DESCRIPIKINOFOPERATIONSILOCATIONSI VEIBCLWIEXCLUSIONS ADDED BY 60DIS91Ba/SPEWL
ontractor Subject to terms, conditions, endorsements and exclusions on the Policy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THHK#,THE ISSUING INSURER BILL ENDEAVOR TO MAIL 10 DAYS VNRITTEN
NOTEE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 80 SHALL
rIWOSE 40 OBLIGATION OR LIABRM OFAIP/NMIO UPON THE INSURE,ITS AGENTS OR
"PROOF OF INSURANCE COVERAGE ONLY" RE3 SENTAIRIM
SPECIMEN COPY ONLY AUHDRfffDaEPRESFNrAT1VE
William (Cell IDA
ACORD 25(2009!01) 019> ACORD CORPORATION. All rights reserved.
TINS ACORD name and kqp Bre registered marks of ACORD
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
III /'N Vi.9iVj , 1 \' •i'3-V_ '6 L•
Construction Debris Disposal Atiidavit
(rcyuired I'or all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 C NIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
0-4Kfto�
(name of hauler) -
I he debris will be disposed of in
Jress(vlarllityl �^4 U/
e
n,Iwe of pitnut ally
' lalr
CITY OF SALEM
J
r• 4 PUBLIC PROPRERTY
te . 1
DEPAR"I'MENT
I I 'I'8 -44 )YA • I \1C '; N-`J:
Construction Debris Disposal Affidavit
(wquired litr all demolition and renovation work)
In accordance %%ith the sixth edition of the State building Code, 780 CMR section I 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
I 11, S I50A.
The dchris will be transported by:
I name ut 110L1ltr)
I he debris will be disposed of in
(nwne of I-johty)
ladtlres. u(lacililVl
agnulwc of Immit applicant
Jai.'
CITY OF S.0 EN1, 1L1SSACHI;SETTS
• BU DING DEPARTMENT
• p
120 WASHINGTON STREET, 3'FLOOR
'Il- (978) 745-9595
FAX(978) 740-9846
KJ-,IBFRi RY DRISCOLL
,ViAYOR 'IldO!•fAS ST.PffItRs
DIRECTOR OF PLBLIC PROPERTY/BUILDING CO>DRSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name (BusimOrgAni:atiorolndividual): //'/ f �qex"
Address: 30 {2 w
City/State/Zip: - /-?%-e Phone J?l G
Are you a foyer*Check the appropriate box:
Type of project(required):
1. am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7• ❑Remodeling
ship and have no employees These sub-contractors have g. ❑ Mmolition
working for mein any capacity. workers'comp,insurance. 9. ❑ Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its 10 Electrical repairs required.] officers have exercised their ❑ pairs or additions
3.❑ I am a homeowner doing ail work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' 13 ❑Other
comp. insurance required.)
'Any applicant that checks boa sl must atm NI Wt the sectio,below Showing their workas'compensation policy information,
'1 f.sneowran who submit This affidavit indicating they are doing ail work ant then hire outside contractors most suhmit a new affidavit indicating such.
:Comrad.Yon that cheek this box mug attached an 3dditiwd sheat showing the name of the ssdf comnacbrs and their wwkera'comp.policy info n atiw.
I um on employer that Is providing workers'compensation Insurance for my employers Below is rhe Polley andm site
information s
Insurance Company Name: 610Prn c Te 5'7*0r-c
Policy N or Self•ins. Lic.H: /40 74c,2-(e'1-1 b Expiration Date: 3--3/-- d�
f V
Job Site Address: 3' 6etive (z City/State/Zip: Sff-je/1 `_-
,%ttach 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5230.00 a day against the violator. Ile a . 'd that a copy of this statement may be forwarded to the Office of
I do esttgationx ol'the DIA for insurance env• gat verification.
I do hereby certify under the patina ars penaldes of perjury that the information provided above is true and correct
�h•tr t ire / - Dutc: �i ' �{''
Phone>l: S -�Slf �Lb
Oficial use only. Do not write in rho area, to be cumpleted by city or townofficial
i
City or Tuwn: _. __ Pcrmitn.lccnse q
bsuing Authority (circle one):
I. Board of Ileallh 2. Building Department 3. C'ityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
I
Cunfact Person: __ _ _ __. _.. Phone N: