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48 HOWARD ST - BUILDING INSPECTION -t 13 -7 crAsfrl Blit 3336 The Commonwealth of Masi UlfDepartment of Public Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than.1"(ar fI3vo*nWY2'2we1lmg y� (This Section For Official Use Only) J ' Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) L12 Hmward -5-1 Salem 0 )9'7b No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2•PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building 0a Repair Ill I Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify, Are6uilding plans and/or construction documents being supplied as part of this permit application? Yes ❑ No W Is an Independent Structural Engineering Peer Review required? Yes ❑ No 14 Brief Description of Proposed Work: rs ; 0;P9 pe. flc-- o (6044Ca t�V M No I os 1- � o _P SECTION 3:COMPLETE THIS SECTION IF EXISTIN BUILDI G UNDERG 1NG RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A5❑ B: Business ❑ E. Educational ❑ F, Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4* S: Storage S1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IHA ❑ HIB ❑ 1 IV ❑ 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 Permit- Debris Removal: Public Check if outside Flood Zone❑ Indicate municipal m A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required trench or specify: i ❑s enclosed❑ Railroad right-of-way: Hazards to Air Navigation ti'.1 I_i<,onc omn�i;110mIjr�_l'x_r,Ix_L, Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: Gra �L Foy �.v . Ct /z ( CWA-j5), LD,w (J a jzz DlQC) plu MAIt�rj SECTIO 9: PROPERTY OWNER tUTHORIZATION Name and Address of PropertyP��ner '1tiCCt t456 �w�� SAIC) Name(Print) No.and Street City/Town Zip Property Owner Contact Information: �A&le�� yzr -- (tet-4-a61 - s00 'fun® oc bvz�g tAmk Title Telephone No.(business) Telephone No. (cell) e-mail address •co r'[, If applicable,the property owner hereby authorizes ;lose A ur�A C �i3 NAzell uocd 5"1 ----X gLDs AZ ---A 0>1YS Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building rmit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft of enclosed space and or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Oum rl - .�•�Jr�aS�� Yahx�=cc�;� Name(Registrant) Telephone No. a-mail address Registration Number _3 NAZ.'96,nt5D S—( LI)GAl ate_ 9- 17-/7 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor i � Con,S;+r[. Ck bn Company Name Tese A UrizAS Name of Person Responsible for Construction License No. and Type if Applicable -5 Fla7elwors-f 5-1- . --AL061V '"A o Street Address City/Town State Zip h b06-Telephone No.(business) Telephone No. cell a-mail address SECTION 11:WORKERS"COh1PEN5ATION_IM URANCE A_I+IDAVT M.G.L.c.152.§ 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 the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No 13 SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to L ) 20 6 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. oSe A Ur-i/.e A U/r f) C' n2S+i(!<}ipn .tu9en.,sa� lrl7 19H� 179614 Please print and sign name Title Telephone No. Date ;1$ FlaTeua bod !n-- / Vg11)F✓✓ D:),14A Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name 6ate I J. 48 Howard Street Extension Salem MA 01970 Scope of Work and Work Contract 48 Howard Street, LLC and Jose Urias-JJ Construction Contract Terms and Conditions NOTE:all permits must be signed off by the Building dept./punch list items must be corrected prior to final payment. Insurance Contractor Agrees to carry necessary liability, property and workers compensation insurance.Contractor requires subcontractors to carry necessary liability and workers compensation Insurance. Insurance must be coverage in the amount of$1,000,000 liability Insurance and $500,000 workers compensation Insurance. Hold Harmless The Independent contractor hereby covenants and agrees to defend, Indemnify and hold harmless the owner,Its agents, officers,directors and employees of and from all liability, claims, actions, causes of action, lawsuits and demands including attorneys fees and costs,fines and/or penalties for personal Injury, bodily injury, death(including personal injury, bodily injury or death of the independent contractor's own employees)and/or property damage arising out of or in any way related to the independent contractor's work or operations for or on behalf of the owner on, about or away from the owner's premises or associated with the breach of the construction agreement or the construction specifications. Contractor to accept all deliveries, i.e. cabinets, appliances, etc. Contractor must be available to correct any necessary defects originated by cityltown inspector, 48 Howard Street LLC Inspector or Buyers Inspector Scope of Work Install vinyl siding on 3 sides of building ACCEPTANCE By signing below,Jose Urias-JJ Construction and 48 Howard Street, LLC agree that the above work will be completed for the agreed upon price noted below and in the agreed upon time frame noted below.48 Howard Street, LLC will allow a 5 day grace period above and beyond the agreed upon date below to complete the work.48 Howard Street, LLC agrees to pay for the work in 2 payments. 112 of the work Is to be paid on the project start date and 112 upon completion of approved work. Project Start Date: August 26,2016 1 Price: $12,000 Payment Schedule: $6,000 Due upon full execution of the contract $6,000 Due upon 100%completion Amount Of Days To Complete Project: 30 days Additional days of work due to approved overages: Contractor Name: Jose Urias - JJ Construction Print Sign Date 48 Howard Street, LLC 3 Print Sign Date 1:1 gu� SIT I IV AY�q I, lips UP me v Ap Mma A" its 010. AN a AIM P Q, ovt il RIP m.I " �Iijw wm.1 4 d, Mb As FW mw CP Af f.iffif 1044 oil VANWO Jl,i Q,46- p E� oiskar �kq " 1 64, yY lt� ,611"I'll WIN v ti I- A• s 09" Pau 'it1 im L 1, 1 u 14A IPA T Pill IVt 41 V lot- IP`, -It", ai� '7511 pit t 3 i){ I"�F} f�, (�,`i•�F � . r d,. iYi i�� � � t��� 1 i�a �F4r`�� �#i' tii t ty� � t il z 14>✓ ., I I W L`a # t I «��A YT I I i t , ",�F .� � .+ t' i ! t .w. i1u ` � ki, '�'�� s a R i i i t i• m . �` � I f� � �b ssr¢ .#.; ,` +� #„ i � r �ilt e ' 4 s k. : � np i�w �I€i��',i� ' t. •� i f i �.ry� e N h siH p w d ,it+r`itlx J. 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'A <# tp t� �wuS�spp pX. 6 + 1 will : y •-z, fi' Ri Y lit �t FGXy� i 3 o N Iz F t owl I 3,i i'i fi �, tud a :: . zt #,ia sx• v Y7vi+ir +su,,q v # n ' '4f' ., `, Y j N ik j,ix,. I p.w ti %. x ", ,aY,O - " v#!.W 1 � sI rrt i ..,- DATE eco CERTIFICATE OF LIABILITY INSURANCE 05/02/'°DI201166 �' Os/02/ 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 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(ies) 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). .. _. - _ .. .. CONTACT PRODUCER NAME. ALEXANDER FLORES LIGHTHOUSE INS AGENCY INC/PHS AHC No Ext: (857)237-6602 FAX No: 617 507-5686 EMAIL 470 West Broadway ADDRESS: ABAIRES100WAOL.COM :;Guth Boston, MA 02127 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: MOUNT VERNON FIRE INSURANCE CO. �, 040851 INSURED JILT CONSTRUCTION INSURER B: 23 H.AZELWOOD ST INSURER C: A.I.M. MUTUAL INSURANCE COMPANIES �',. OSS3591A INSURER D: MAL,DEN, NIA 02148 INSURER E: INSURER F' COVERAGES CERTIFICATE NUMBER: 027376107441401 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IrvSR - - ADDLSUBRI POLICY EFF POLICY EXP LTR " TYPE OF INSURANCE POLICY NUMBER MMIDUYYYY MWDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S I, 000, 000.00 DAMAGE TO RENTED 1,000,000.00 X COMMERCIAL GENERAL LIABILITY S PPREVISES(Ee omurranoe CLAIMSMADEOCCUR MED EXP(Any one person) S 10,000.00 CL-2676528-1 4/23/16 04/23/17 1,000,000.00 PERSONAL B ADV INJURY '! $ _ - _ - GENERAL AGGREGATE 8 2, 000, 000.00 L.-^JL�3t dE :TL MI 'AF ESPER J_PRODUCTS COMPIOPAGG S2. 000, 000. 00 POLICY I TRO LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accden0 is 1 ANY AUTO BODILY INJURY(Perp on) Ii S B ALL OWNED SCHEDAUTO'ULED BODILY INJURY(Per widen) $ AUTOS NON OWNED ! PROPERTY DAMAGE HIRED AUTOS AUTOS W Per accident _ IS UMBRELLA LIAB OCCUR JII EACH OCCURRENCE S -- EXCESS LIAB CLAIMS-MADE AGGREGATE I$ DED i RETENTION$ 5 WORKERS COMPENSATION O YLATIM TSI OER AND EMPLOYERS'LIABILITY �L YIN .Y PROPRI'TORIPARTNERIEXEOUTIVP EL EACH ACCIDENT S 100,000.00 O-rl ERIME IBEE EXcwoeD^ NIA! WCC-50050-195922015-1 09/23/16 04/23/17 --- IM'ndtory NP) EL DISEASEEAEMPLOYEES 100, 000 00 l D-S C ler CRIPI PJII GP OPERATIONS below ' E.L.DISEASEPOLICYLIMIT ', S 500,000.00 DESCRIP'NON,OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,d more space is required) CERTIFICATE HOLDER CANCELLATION L'`-I CONSTRUCTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 23 HAZELWOOD ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MALDEN, MA 02148 AUTHORIZED REPRESENTATIVE ALEXANDER FLORES I - - - ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD The CommonweAM ojM4ssachuseus Dep&hneirt ojlWUWrW.4cvdents I CongressS&M4 Shite fee B.oston,M4 02II4-2017 wwnsmascgov/did Workers,Compensation hwurmwe Affidavit Builders/Contiradora/Elechiclam/Plambes. TO BE Fff"WITH THE PERMITTING Aifl$ORM ApnHcant Lfermation t please plot I ealb)v Name(Business/ - . ioolnmvrduaw .), 1 "C-0 "r1;)!n Address: -�2:4 N AZA- uj 0 or7. S City/State/zip: Phone:#: 2.o., 9 Are yea w employwT Cb%k the.apprepr(ate Dor: - - Typeof pro)«t Cr�r�: ,.W w;m ( . � - employer ). 7. pNewccuFbu0w xplam..,avepro rib?rw; a ' .namveaomooygn.wAcieg tormcro S. DRemoaelmB . lhio:iakar iamy loasasrs ] 3.plamahome dobgskwmkmyaelt:[Nowwkm'cmipmnm .ra�d..lt 9: ODemeliti . topBuildmg'aik! 6n. w 4.plma6onrtDwdwigbehftftmumctmamconAWel watmmypaopmty. twat - eameiliatall wnmeaaeidewhaw mimm'compeamtionh arzrcwle 11.0 Electrical/epausoradditions peap[se?ora wrthao930.qes. 12.o oradtlrtions Phmlbmg'tepane s.Q iamagmerat wiaoedraoallwekbcd the eebxmuaemeL'seie oa the ar/ir3edshept: 13. Roof .. . . TDeaewn-comaaaoommvamplayeeeam/uve.vonlTm•aomp•m :- 4J: .. : ,/eP8II8 6.pwe are14.pOther . IS],I](4),end weliatieno emylnYas-pJo wmliva'tvmF ��1 ' " •Anyapplkatctfat checks boxf)must abofiOaatkesa'dbobobvallbwfofihef imrl(ej6 ampmaodaml cY .. .. . t Homeownem who sitbmvth3 afbda'vitiu gtheydie&h*allnew a&devitindiumg'nsA tConaaemre ton check this box nmoramched aoaMdonal abeetakowiog ffie met.oface x&ccMrtieto.eand ante whedwarza ftw emma have emPloyeez..utb ,cnbcpnp■ aheve employees,Posy madpeoride wottaele'comp.pobry ctiea. lamanexgpfoyerthat$ riding>Porkers'conip�[a9eeinryrmrcejormyemPl04ie 8elowisebepoliryon4ja4tite- tnjoimalloa. InsmancecompanyName: L,r ATH 111.1 S e )AI s Aa Gn/('Y 1 N c Policy#or Self-ins.Lic.#: Expiration Datc: il'a3 Job site Addiess: �� ).0114ty- / .ST 'SAIPP-) city/biwaip: 0111 Attach a copy of the workers'compensation poney declaration page(showing the policy member and expiration date). Faflwc to suave coveaage as mpinA ander MGI:'a 152,§25A is a ai®al vioh�punishable by s fni up to f1,500.00 and/or one-year Impriscnm®t,as well as civil penalties m the furor of a STOP WORK ORDER add a tine of ap to$250.00 a day against the violator.,A copy ofthis�tatement maybe fotwa lla to*a Offioc ofkvwdp icmi ofthe DIA fair inswunce coverage verification. I do herebyeerYify(�wiAwfae/pn/� w an/d ppema&iet ojpojm7 that the Fnjormabon prmvided aboom m ome and correct QIOAAfinM• OJ�` / 1 I/` 0 / /.1. Date: 47-)Z- no Phone M 4 t)AZda/ase only. Do not write is"area,to be completed by airy or town offleial City or Tom: PerialbUcense# Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.Cetyfrown Clark 4.Electrical Inspector S.Plumbing Inspector 6.Other CoMacl Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all errtploym to provide workers'convensation for their employees. Pursuant to this statute,an employee is defined as"...every person in The service of another under any conbad of him, express or implied,oral or writtep" An easployer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association ar other legal entity,®ployieig employees. However the owner of a dwelling house having not more then throe apartments and wbo resides therem,or the occupant of the dwelling house of another wbo employs persons to do maintenance,construction or repair work on such dwelling house or on Bre grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or peranit to operate a business or to construct buildings to the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required:' Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for The performance of public work=90 acceptable evidence of compliance with the minumice requirements of this chapter have been presented to the contradmg authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to yon situation and,if necessary,supply sub-cautractor(s)namne(s),address(es)and phone numbers)along with their certificate(a)of insurance. Limited liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'comnpensation 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 sore to sip 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 ender their self-insurance license number on the apptopmiOle]me. 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 Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must subrnt multiple permit/license 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 ofthe 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 mast 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 dqg license or permit to bun leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrie]Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MA_SSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia