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7 HORTON ST - BUILDING INSPECTION y 11/17/2008 11:18 9787489846 CITYOF SALEM PAGE 01102 V - z The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of tiOMassachusetts State Building Code, 780 CMR, 7" edition Building Building Permit Application To Construct. Repair. Renovate Or Demolish a One-or 7tto-Family Dwelling ilk. This Section For Official Use Onl Building Permit Number- Datc Applied: Signature: Building Cornmissioncrt Inspe0of of Buildings Date SECTION 1: SITE INFORMATION r 1.2 Assessors Map & Parcel Numbers T1 at Is this an accepted/street?yes no Map Number Parcel Number 1.3 Zoning Information: IA Property Dimensions. Zoning District Proposed Use Lot Area(sq fl) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards (tear 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: Publik Private Q Zone! _ Outside Flom Zonc? Municipal Q On site disposal system ❑ Chcck if yeso SECTION 2. PROPERTY OWNERS lip, 2.1 nW .74 t f Re d: F.'q rin Address for Service: Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Usting Building Q 1 Owner-Occupied ❑ 1 Repairs(s) Cl Alteration(s) 0 Addition Q Demolition ❑ Accessory Bldg. 0 Numbcr of Units I.Other Q Specify; Brief Description o Proposed Work=: l,�t SECTION A:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $a(, 1, Building Permit Fee: $ indicate how fee is determined: 2. Electrical $ - Q Standard City/Town Application Fee ❑Total Project Costs(Item 6)x multiplier x 3. Plumbing $ "' 2. Other Fees; $ r� 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Su ression $ Total All Fees:$ dt�� Check No._Check Amount: Cash Amount: 6. Total Project Cost: $ 0 paid in Full 0 Outstanding Balance Due; 1111712008 11:18 9787409846 CITYOF SALEM —_PAGE 82102 SECTION 5. CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 3�5t C> f, b _ ' .-, '{"t-e License Number Expo tion Date m "SL•H91dcr �5List CSL.Type(see below) Type I Description U I Unrestricted(upijo 35.000 Cu.Ft. Signal a VL R Restricted 1&2 Family Dwelling M Mmnry Only tt RC I Residential Roofing Covering Telephone WS Residential Window and Siding SP Resident al 5and Fuc! B7ming Apolianu Installation D 1 Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or Pic Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.1$2.§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 79:OWNER AUTHORIZATION TO RE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, P ,5� as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work 6Aorized by this building permit application. <.e--� I� a � Si natureofowner I Date —T SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the stailementg and information on the foregoing application are true and accurate,to the best of my knowledge and behalf.�� pnNam '1± Signature of owner or Authorir d Ajentt Date J Si ned under the painsnd penalties oC ei u NOTES: 1. An Owner who obtains a building permit to do hWher own work,or an owner who hires an unregistered contractor (not registered in the Home improvement Contractor(HIC)Program),will ro 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 I IO.R6 and t I0,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.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of haiftbaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage-maybe substituted for-Tolal Project Cost' .1 I Y -1 -21-WARWOMMUMMM ONE A ✓{(B TODOKOJ)fI00IpJB000L O�l/�OdO?�(lEd� .. l� �\ Board of Building Regulatloni and Standards ..License or registration valid for Individul use only HOME II PRbvEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Re�istYllbfl - 5375 One Ashburton Place Rm 1301 �a Y, /2009 Tr# 126164 Boston,Ma.02108 to Corporation ROGER A.TREI�JI TORS,INC. - p _ROGER TREMBL*, 10COLONIAL Ri7 - SALEM,MA 01970 Administrator Not valid witho t sl nature CITY OF SALEM ,q ,,,91 PUBLIC PROPRERTY � DEPARTMENT .11II'.. n 11 1NIIA "I I 12. W,1,1n\t:I,^51:tl.la Is 5,\11']1,kQ,\\r.\t IIt It ] Is li'.1. )78.715.9i')5 • 1'\x 97$-741 Js+6 Wurkers' Cumpensation Insurunce \fftduxit: Builders/Contractors/Electricians/Plumbers %policant Information /ice Please Print Leeihly Viunc IOu.um,s t)rgamnuinNlndnlduall: I + 7 ,Address: 10 CjbACNr &),A, g Cily,State,Zip 5,, MAZ)��t1� Phone il:l i`1b3)7L/s 2066 .%rc y uu an employer:'Check the appropriate but: Type ur project(required): I :un a employer with 4 1 .un a general contractor and l 6. New construction I. ❑ - enqlloyces(lull anlL'ur part-tine).• Mare hired the sub-cuntracturs i. C] 1 .1111 a sole proprietor or partner- listed oil the ariachcd sheet. 7 11F Remodeling ship and have no employees These sub•contractom have S. E] Demolition working tier Inc in any capacity. workers' comp. Insurance. 9. O Budding addition I No workers' comp. insurance 5. [1We are a corporation and its ' I required.) officers have exercised their 10.0 Electrical repairs or additions ri hr of c.xem tion P cr MGL I LQ Plumbing repairs or additions 3. ❑ I am a hamcuwner doing all work g P myself. LNo workers' comp. C. 152, q 1(3),and we have no 12.❑ Ruul•repairs IR,urance required.) 1 cmpluyees. INo workers' U.❑ Other comp. in,urance rcquircJ.1 •\ray .... h, .a That t.vcks box 01 must also ii it uut the wco an iniuw showing Iholr wurkui cumpenvuiwt lwlwy udiurtgtitnl ' Ilom vlwlxn who.,to mit this affidavit indicating They ne Join$all wudt mat then him oohlde cularaetors must.uhmil a new aifdavil indiub k;o,,h. ('..ntnsa.n that shack this box mtal anachcd.In uddaiunal ntrer.hawing Itw nanlo of Ih sub ontran.Crs and their uurkun'nrnp.ptdlcy mfutm:aian lam an employer Thur is pro vidhag workers'c•uxrpcn Cation insurance jar ary employers. Below is rhe policy and job.vie infer„Curium. ` ^ in,urancc Company Name: / (S'I5 Policv is or Sclf-ins. Lie. 0: (n e)_ (�/ u '1 ,, rr l� Expiration Date: 1tiU lite -\dJress:� , f P-rh � ' Se1._o},, )' vim, City;StataZlp: 61S�J .\ttacb a copy of me workers'cumpcnsatiun policy declaration page(showing the policy number and expiration date). hallule to secure cu\erage as required uudcr SCLllarl 25:\ ul'.\IGL c. 152 can lead to the imposition oferiminal penalties o(3 fin: up m 51.5110.X1 and/ur tine-year imps isunmcnt, is well is cn d penalties in the furan of a STOP WORK ORDER and a fine of up aC 5250.00 a Jay .Igainst the vioiator. Iie ad%i.scd that a copy of this matcmcnt may be tures arded lis the Oil ice tit Im.,Il,au,nb ui;he UTA :Of Inwlanee errs er.c�c \erilieal:un. film hereby a crsifv aadef rhe paunitvntd penahiev of perjory Char the information provided above is true and correct. [1%%uingAu1huriIv l toe only. Dd nnC mrile iu this urru, !a hr ruwp/rlyd by Ivry ur rotvn .,/�iciu/. I r fawn: Per mitA.iec rise tl(circle nue):rJ of Ilcallh !. ISuddinq Mparuucut I. (JI).Towu Clerk J, Electrical lospccror i, Plumbing lo,peetor ert Teresa: .. _. Phone 4: ;� sees Information and Instructions Lus.tdtuwtts Gcncral Laws chapler 152 requires all etnplo)ers to prnvidC workers' cumpenxahon tinr their cmployces. ('ur,,u.utt to mis ,nature,in emphoe-e is dctined as" _es cry poison in the service of another under any contract of hire, e.press or unphod. oral or written." \n employer is defined as"an individual, partnership. associanou, corporation or other legal entity,or any two or more ,t the 1,4010,111; engaged in a joint enterprise, and including the Icgal r:pre5eiitatnves JI a deceased empluNcr, or rhe receiver or trustee of an uidrviduai,parmcrship,association or other legal enrty,crnploying emplo)ees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the ,swelling huuse of another who employs persons to do maintenance,construction or repair work on such dwelling house ,w ,nn the grounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer." `IGL chapter 152, i25C(6)also states that "every state or local licensing agency shall withhold the issuance or renewal lifts license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of eumplfance with the insurance coverage required." kddiiiunally. `IIGL chapter 152, §25C(71 states"Neither the commonwealth nor any of is political subdivisions shall enter into any contract for the performance ol'p thlie work.until acceptable cvidence of cumpiiance 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-contructor(s)narne(s), address(es)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 date the affidavit. The affidavit should be 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-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 u space at the bottom ,if file affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. I'f,:ase be Sure to fill in the pcnnit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pennitllicense applications in any given year,need only submit one affidavit indicating currant policy intbrmation(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 must be tilled out each year. Where it hume owner or citizen is obtaining a license or permit not related to any business or commercial venture i i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I ll,: i)r3icc of lovesfigatiuns would h;.e to think you in adt•:utcc fur your cooperation and should you lease:sty questions, please du not hesitate to give us a call. fhc Wilarunent's address, telephone and fax number: The Commonwealth of Massachusetts Depamnent of Industrial Accidents Otnce of Invesdgadons 600 Washington Street Boston, MA 02111 Tel. k 617-7274900 ext 406 or 1-817-MASSAFE a,tn:d -'-'q.ii5 Fax M 617-727-7749 www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE 08/07/2008 PRODUCER 7/200 " PRODUCER (800)333-7234 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION EASTERN INSURANCE GROUP LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 WEST CENTRAL STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NATICK, MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURED Roger A Tremblay Contractors Inc INSURERA: Selective Insurance Group 10 Colonial Road INSURERB: Insurance Co of State of PA Suite 4 INSURER C: Salem, MA 01970 INSURER D: NSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN ANY REOUIREMENT,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 ADWI TTF(MMMDfYYI YPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POCIO EXPIRATION LIMITS GENERAL LIABILITY S 1842342 04/15/2008 04/IS/2009 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADE ' I OCCUR MED EXP(Anyone person) $ 5,000 A - PERSONAL d ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 POLICY FX PRO- .LOC JECT AUTOMOBILE LIABILITY A 9091417 04/15/2008 04/15/2009 ,COMBINED SINGLE LIMIT ANY AUTO {Eeeccldenl) $ 1,.000,000 ALLOWNEDAUTOS BODILY INJURY $ A X SCHEOULEDAUTOS (Per person) X HIREDAUTOS - BODILY INJURY $ X NON-OWNED AUTOS (Por sodden/) X $SOD' DEDUCTIBLE PROPERTY DAMAGE COMP./COLL. (Per accident) $ GARAGE LIABILITY ' ..? AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN EA ACC $ AUTO ONLY: AGG $ EXCESSNMBRELLA LIABILITY S 1842342 04/15/2008 04/14/2OQ9.� EACH OCCURRENCE $ 2,000,000 11 OCCUR FICLAIMS MADE AGGREGATE..... $ 2,000,00 DEDUCTIBLE $ RETENTION $ C $ WORKERS COMPENSATION AND 6874659 07/01/2007 07/01/2009 X WC STATU- ER EMPCOYERS'LIABILITY - - E.L.EACH ACCIDENT $ 100,000 B ANY PROPRIETOR(PARTNERJEXECUTNE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 100,000 1/ e,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 OTHER DESCRIPTIONF OPERATIONS I LOCATIONS 1 VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I 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 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Rosemary Fulham PMA 1aA11 Y•^ "— ACORD 25(2001108) ©ACORD CORPORATION 1988 •`''" CITY OF SALEM y 5 I A PUBLIC PROPRERTY DEPAR'T'MENT Construction Debris Disposal Affidavit (required Ii)r all demolition and rcnovation work) In accordance .c ith the sixth edition of the Slate Building Code, 780 C NIR section 1 1 1.5 Debris, and the provisions of.vIGL c 40, S 54; Building Permit N is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I 11, S 150A. The debris will be transported by: 1 name of huller) I lie debris will be disposed of in { � �—(namr ul IScilrty) 56 lD" Apc> C) 7.°7-IQ luddres<nf lacililVl ,igualwr of prnn«appl uu Q J lair