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10 HARTFORD ST - BUILDING INSPECTION The Commonwealth or Massachusetts Board of OF Building Regulations and Standards ,CITY SALE Massachusetts State Building Code, 780 CMR, 7"edition M fY1n R':ai� Hrvisrd Junu��rt Building Permit Application To Construct,Repair, Renovate Or Demolish a /. 'iION )I JI One-or Tu -Family Dwelling This S •tion For Oficial Use Only Building Permit Num er. Date Applied: Signature: Build g nunissibn r,Insrkctor of Buildings Date t SECTION 1:SITE INFORMATION 1.1 Property Adgros': 1.2 Assessors Map& Parcel Numbers l0 flaif�✓l�' S�` Ma I.la Is this an accepted street'r. yes_ no_ P Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq Il) Frontage(Il) 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 Zones? Municipal❑ On site disposal stem ❑ Public❑ Private❑ Check iryes❑ P P y SECTION 2: PROPERTY OWNERSHIP' 2.1 Own/e:t of Record: Name(Print) Address for Service: 'Signature 'felephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ 1 Existing Building❑ 1 Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work-: CO/YPFT� jzEM00&2. hF FaV--,T ftlYRoOM. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building S I. Building Permit Fee:S Indicate how ice is determined: ❑Standard City/Town Application Fee 2. Electrical S t ❑Total Project Cost (Item 6)x multiplierx 3. Plumbing S 2. Other Fees: S Z �� 4. Mechanical (MVAC) S List: 5. Mechanical (Fire S Su ression Total All Fees:S n� 01 Check No' Check Amount: Cash Amount: �� 6.Total Project Cost: 5 W�, 0 Paid in Full 0 Outstanding Balance Due: t SECTION 5: CONSTRUCTION SERVICES 5,1 Licensed Construction Supervisor(CSL) :Rth:T y U 609"SS License Nmnlx:r lispi alio )ate Name tit CSI.-II lulder ee-NNY D tP2 . i,��l ►u List /3lU :\ddr19 Q V I` Description JJ� (/ Ilnreslri[tcJ uCu.to 35,000 CFt.) v It I Restricted 1&2 Familv Dwdlin Si Wture r Nt Mason Only b " 677/ RC Residential Roofing Covering l'ekpho a WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation U Residential Demolition 5.2 Re tstered Home Improvem nt Contractor(HIC) I_IIC Cu WmIC Re-ivsZtra_nt Name Registration Nuptber AJdres -2-11L 'ZO �— „ M (L72 4W-6 Vxpiratio Date Sign 're cp wnl f e 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 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 it tc,V/G�- ,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. z � /� rint Name Signature of vn uthorized Agent (late (Signed under the pains and penalties ofperjury) NOTES: I. An Owner who obtains a building permit to Jo 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. 1.12A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11O.116 and I IO.RS, 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.) flabitabie 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 he substituted for"Total Project Cost" CITY OF S'Uym. INLUSACHUSETI'S BLILDIING DEPARTMENT ' 130 WASHNGTON STREET, 3i0 FLOOR TEL (978)745-9595 FAX(978) 7449846 KI\(BERLEY DRISCOLL ;4fAYOR THosus ST.Pmm DIRECTOR OF PUBLIC PROPERTY/BvUMLYG 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 I l.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 defined by MGL c 1 11, S 150A. The debris will be transported by: _To Ifs ( . c-C)ILT25 (name of hauler) The debris will be disposed of in fiL Ii SFS SI T2Z77-3-- (name of facility) (address of facility) e of permit applicant slate •Icbnaalf.�k 2330 -5 1 / N � LO i LO o ~ � I A r LO O i j. `YI' 1 W 51-411 2268 Mike Lori Fray ler 10 Hartford St. Salem Ma . 2330 v5'-5 1 /2(1 CD -; in ti C� c%') ' 111 -v - 5'-4" 2268 Mike Lori Frayler 10 Hartford St. Salem Ma . 11/30/2010 20:23 FAX 6174567815 ABI Office 2 (L7.J0002/0003 ACORD DATE(MWDD/YYYY) - Im CERTIFICATE OF LIABILITY INSURANCE 12/01/2010 PF006$CR b Phone: (617)456-781 Fe.: (617)456-7615 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ASSOCIATION BENEFITS INSURANCE AGENCY,INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE LYNNFIELD WOODS OFFICE PARK HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 210 BROADWAY,SUITE 201 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. LYNNFIELD MA 01940 INSURERS AFFORDING COVERAGE NAIC# Agency LkN:1782907 INSURED INSURER A: Selective Insurance Company of South Carolina 19259 JOHN H CURTIS INSURER B: 13 KENNEDY DRINSURER C: BEVERLY MA 01915-3919 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. NSR ADD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTME POUCYEXPIRATION LTR INERT DATE MMM M DATE MWDOMRGENERAL LIMITS GENERAL LIABILITY S 1899321 09/27/10 09/27/11 RRENCE $ 1,000,0 X COMMERCIAL GENERAL LIABILITY ENTEO q 100,000 PREMISES nrn,rence) CLAIMS MADE OCCUR ny One person) S 10,000 A B ADV INJURY S 1,000,000 GGREGATE S 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: -COMPIOPAGG. $ 3,000,000 PRO- POLICY LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea acadent) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accdenl) PROPERTY DAMAGE (Per amident) S GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY AGG $ E%CE SS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR OCLAIMS MADL AGGREGATE S S DEDUCTIBLE S RETENTION$ $ WORKERS COMPENSATION AND WCSTATU CTHER EMPLOYERS'LIABILITY IORv uwis ANY PgOPR1ETORrygRTNEILEMECUTIV E E.L.EACH ACCIDENT S OFFICERMIEIABER EXCLUDED? E.L.DISEASEEAEMPLOYEE $ R ye:, s unxr SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT Is OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS JOB:IO HARTFORD STREET-FRAYTLER RESIDENCE,BATHROOM REMODEL CERTIFICATE HOLDER CANCELLATION SALEM BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOM MC.,GRATH EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 120 WASHINGTON STREET 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS SALEM,MA 01970 AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: Frank M.Venuto ACORD 25(20(11108) Certificate# 3276 ©ACORD CORPORATION 1988 11/30/2010 20:23 FAX 6174567815 ABI Office 2 Ia0003/0003 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S(2007/08) Certificate#3276 11/30/2010 20:23 FAX 6174567815 ABI Office 2 Ia0001/0003 Facsimile • a December 1,2010 Total Number of Pages:3 JOHN H CURTIS Fax:(978)740-9846 Attached is the requested certificate of insurance for the above referenced insured. Please let us know if you require any additional information. Sincerely, Jennifer McNeil CSR Association Benefits Insurance Agency, Inc. Lynnfield Woods Office Park • 210 Broadway, Suite 201 • Lynnfield, MA.01940 T 617-456-7800 • F 617.456.7815 • www.abiagency.net