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352 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusctts Board of Building Regulations and Standards Town of ki Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Famt11LDAtw1,hng Mona This Stion For Official se Only _ Building Permit Number: /�/ Da[ Ap ied: Signature: ✓" 51-j q///"Q ) O,� Building Commissioner/Ins for o Buil rags JJX Date SECT k INFORMATION 1.1 Property Addr ss: 1.2 Assessors Map& Parcel Numbers 313 aL,��s�� Aa�� ]Aa Is this an accepted street?yes_ no_, Map Number Parcel Number i 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(11) 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 Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check ifyes❑ P P y SECTION 2: PROPERTY OWNERSHIP' 2.1 Qwlter orI}R d: H� o'L �� 2SeYLi A✓-� Name(Pri ) Address for Service: SignatuhU Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': rP f P t SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 061 I. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ rSu ression p Check No. _Check Amount: Cash Amount:_ 6. Total Project Cost: $ 6;A0, 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES d � 5.1 Licensed Construction Supervisor(CSL) _ 0600-1.17 C�Ra� I License Number Expiration Date N4me of CSL-Helder List CSL Type(see below)--0- Address T Description UUResi"10dential ricted u to 35,000 Cu. Ft.) Rted I&2 Famil Dwellin Sign t re MRCntial RofiTelephone WSnSFntialSolid Fuel Bumin A liance Installation D Demolition 5.2 Ijggjgter ome provement Contractor(HIC) af'/s /o X737 HI Company vme or IC Reg stran a e Registration Number Address ,` Expiration Date Signa Telephone 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.........� ........... ❑ 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 1, Alf L> / ,as Owner or Authorized Agent hereby declare that the statements and information a foregoing application are true and accurate,to the best of my knowledge and behalf. fit, Print N me Signature ner or Authorized Agent Date (Signed under the pains and penalties ofperjury) 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 not 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 I I O.RS, 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 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" , CITY OF SALEM PUBLIC PROPRERTY a+; DEPARTMENT ,X1.1 K'11 AIM,-II \II m I!: WA\i11V:H1N Sl.(LL I' • Sdt 1']t, bL\\\.N IIt I 11,,�I77C fici. 'P8.713-9i'13 • 1:,x 97a-74" 1346 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers lapolicant Infnnn'rlion /� Please Print Leeihly Name 10uvluat)r;tanttui,nv l nJl,,dual l: 0/J�c4egk2 1ddress: 70 ley /1 Cily,Seata7ip l 13,4, Thune •/ fSJr /7 L li .\rc lou a yer:' Check the appropriate boa: I*)PC of project(required): P yer with a. I ;un a general contractorf, and 1 . new construction , on a cmlu englloyccs(lull antb'ur part-time).• have hired the suh-contracture ?. E3 ,un a sole prnprieux or partner- listed on the attached sheet. C] Remodeling .hip and have no employees These sub-contractors have 8. 0 Demolition ,corking for me in any capacity, workers' comp. Insurance. q. 0 Budding addition I No workers' comp. insurance 5. 0 We area corporation and its I required.) otficers have exercised their 10.0 Electrical repairs or additions 3. 0 I ;ml a homeowner doing all work right of exemption per NIGL I I.0 Plumbing repairs or additions myself (Ko workers' comp. c. 152, g 1(4),and we have no 12.0 Ruof repuirs insurance required.) r employees. (Ko workers' 13.0 Oliver comp. insurance required.) •,uo .,pphcwd null cheeps box nl must alw lilt o,n the wcben heluw.huwina their wuAws'cumpunutiun Iwlicy m1wimiliun, ' I loma,woen aha wbmir this affidavit indicating They ate dolna all v.rk a.W then hire out>Id<cawxmn muss.uhmil a new alGaarll ,uch. 4..mrxu,n that ah,ck this box mtal aaxhod.tn add.liunal.),cel,h,,wiog ate nam,:of IM sub-conlrxmn and their %uhen'comp.ptd,cy mfwmamm lam un employer that is pro vidigg workers'c'umpenvatiml insurance for may employees. Below is the policy kind job a/te information. Ir..urancc Company Name: �;AWI tZ' q f70W? - -- _ _----.---- I'ulicv it kir Sclf-ins. Lie.^n: AG '��7//0 Eapirallun Date: ��,�j•� Job Site -\ddress: '73)- T�/q/ -fy►-!_. City:SlatuZlp: Sed( ,41 .\ttach a copy of the workers' cumpcnxatlon policy declaration page(showing the policy number and expiration date). haduic to wcurc cucemge as required uudcr Section 25A ul'\IGL c. 152 can lead to the imposition of criminal penalties o(3 rine op r.).S].500.00 and/ur une-year imprisonincnt• as ocll as ci>it penalties in the farm of a STOP WORK ORDER and a fine .If till (l) S250 Goa day agalml lilt Violator. Ile advL+ccir at a copy u1 Illl>malclncrlf may be lamarded to the Olflce of In,;.0 t:a num uf,he UTA :br insw.uxc anear�c Ihcabun. l Ila herr Ay c:r/ifv under der patine m!d p nohiev u/perjury rhur the infurmatlon provided above it true and correct. Ph,.i. . :r /Td C Failuse Indy. Dd not write is this area, lu he cmupletrd by l ity kir rmvn,r//u m/. 1 City kir I'min: _... _ Pulvnitit.iccrne 0 Issuing %whurily (circle one): I. Du.Ird of IIc,dUI Z. IluJdin:: 141mr(lnrut 1. Cil).-f unit Clerk J. Electrical Inspeclor 5. Plumbing Inlpeeror 6. Other Clliacl l'cnun: _- Phone rl: f Information and Instructions a , N I.us.icI,u>ctts General Laws chapter I i2 requires all employers to provide workers' winpens.uion for their rnlployces. I>urou.ut to mis stature,an empluree is dctined as" esery prison in the service of another undcr.tny contract of hire, c.pre>s or unphed, oral or svntten.'. \n empluprr is dctined as "an individual, partnership,.ssociatwu,corporation or other legal entity,or any two or more I rhe loregoo,g engaged in a Joint enterprise, and including the legal representatives of a deceased cmpluycr, or the receiver or trustee of.m individual,partner>hlp, association or other legal enmty,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the .Iso:llulg house of another who employs persons to do maimcnunce,construction or repair work on such dwelling house or all the grounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer." ,�IGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renesvul of a license or permit to operate a business or to construct buildings in the cummunwcullh for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Acidiuonully. MGL chapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract tot the perfomnance ul-Public work until acceptable evidence ufcuntpliance 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)narnels), address(es)and phone nunlber(s) along with their certificale(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the memhers 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 .%ccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The aff idavit should Lie reumled 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 a space ul the bottom of the affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant. I'L:ase be sure to till in the pcnnit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pernitiliceise applications in any given year,need only submit one affidavit indicating current policy infolnwtion(if necessary)and under"nob Site Address" the applicant should write"alt locations in (city or town)." % copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof(flat a valid affidavit is on file for future pernits or licenses. A new affidavit must be tilled 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 Jug license or permit to burn leaves cte.)said person is NOT required to complete this affidavit. I he t),lice ,I labevtt--ation> %wuld line to dlank y,)u n)advance fur your cooperation and should foil Ila%e any quebtiolls, please du nut hesirate to give us a call fhc Dcparunent's address, telephone and fax number' The Commonwealth of Massachusetts Department of Industrial Accidents Offlee of Investigations 600 Washington Street Briton, MA 02111 Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE Fax 0 617-727-7749 www.mass.gov/dia CITY OF SALEM Y � � =l ' PUBLIC PROPRERTY �,K1•� DEPAR"['MENT I \:.;I I T . 1.\II \I. \t.\.,U Construction Debris Disposal Affidavit (required lilr all demolition and renovation work) In accordance %%ith 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 # is issued with the condition that the dcbris resulting front this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c I 11, S 150A. The debris will be transported by: 1 name oC hauler) The debris will be disposed of in (name of facility)_ � . 517- (it lacdilVl ,1L JIW I' 11t l ci-1111t allpllcint i dale ACORQ CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDNYYY) 04/07/2009 PRODUCER 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 R orence Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Malden, MA 02148 INSURERS AFFORDING COVERAGE NAIC# INSURED A B Carnes,Inc. INSURERA: Essex Insurance Co. 30 Arrowhead Farm Rd. INSURERS: Granite State Insurance Company Boxford, MA 01921 NSURERC INSURER D: INSURER E: COVERAGES THE POLICIES OF)NSURANCE 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' ry➢E OF 1N$URANCE POLICY NUMBER PRICY EFFECTIVE POLICY EXVSNTNIN - LIMITS LTR GATE NIM/0 DATE GENERAL LABILITY 3CZ1798 03/18/2009 03/18/2010 EACHOCCURRENCE $ 1,000,00 X COMMERCIALGENERALLMBILITY PREMISES Ea occurrence) $ 50,00 CLAIMS MADE OCCUR MED EXP(Any one person) $ 5,00 A PERSONAL A ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,OO GEN`_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S 1,000,000 PCY JECT OLILOC EC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per aced.rd) GARAGE LABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR ❑CLAIMSMADE AGGREGATE S $ DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION SIC 742-62-18 03/31/2009 03/31/2010 AND EMPLOYERS'LABILITY TORY LIMITS ER IN B ANY OFFICEW EIMBER EXCLUDED?ETORIPARTNERIEXECUTWEr-1E.L EACH ACCIDENT $ 1,000,00 (MaMetory in Hill E.L.DISEASE-EA EMPLOYEE S 1,000,00 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1 DDO,DD OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS 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 TH EREOF,THE ISSUING INSURER WILL EN DEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR "PROOF OF INSURANCE COVERAGE ONLY" REPRESENTATIVES. SPECIMEN COPY ONLY AUTHORIZED REPRESENTATIVE / William Kell /]DA ACORD 25(2009101) ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD