2A LINDEN ST - BUILDING INSPECTION (003) y
P �1
The Commonwealth of Massachusetts
'} Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling '
's Section For Official Use Only
Building Permit Nu Date Applied: 15' D
Signature: uC-�
Buildt mi 'o n pector of Buildings Date
SECTION l: SITE INFORMATION
1.1 Property Address:�,A Lnn L, S1— 1.2 Assessors Map& Parcel Numbers
L l a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided ReqProvided Required Provided
uired
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public 11 Private❑ — Municipal❑ On site disposal system 13Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow ri of Record:
Name(Print) Address for Service:
`7> //t� SOT —.5 a7
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': -rdSko.il_ 1310...-, Ce lltil oz-�
j Sa- Fluor Q..�icr.o r tJa.tL5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees:$
Supression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ a Q is 00 paid in Full 0 Outstanding Balance Due:
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7—)
License Number Expiration Date
Name.f 3-i Idle" List CSL Type(see below) 00
ZDResidential
Descri tion
Address restricted(u to 35,000 Cu.Ft.)
stricted 1&2 Famil Dwellin
Signature 'y $s9`/3 ason Onl
y sidential Roofing Covering
Telephone sidential Window and Siding
sidential Solid Fuel Burning Appliance Installation
Demolition
5.2 Registered tt' me Imp1 n r,rovement Contractor(HIC) /L/ O
A �
HIC Company Name or HIC Registrant Name Registration Number
Gc t 2 cTcl�^t..s,M iv t SR/v-�i :31 /O
Address
��Js� g7¢ ,yy_�,Y� ExptrattonDate
Signature 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 o M e building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I -I;L s elo,,..k� , as Owner of the subject property hereby
authorize c a( 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 ,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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjurX2
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 I O.R6 and I IO.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"
Mar 23 2009 7: 31 HP LRSERJET FRXCSG 5083899905 page 1
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CERTIFICATE.OF LIABILITY INSURANCE 0MY)
3/19/ZO0zoD9
PRODuCER (900)333-7234 - FAX 508) -88S3 THIS CERTIFICATEISISSUEDASA MATTER OFINFORMATION
EASTERN INSURANCE GRDUP LLL ONLY AND CONFERS NO RIGHTS UPON.THE CERTIFICATE
233 WEST CENTRAL STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
NATILK, MA 01760 ALTER THE COVERAGE AFFORDED THE POLICIES BELOW.
INSURERSAFFORDING COVERAGE NAIC e
'ALIBIED Atlanitic Weat1wrizationELC NWRERA Arbella Nutual Insurance Co. —176W-
61 Rear 7efferson Avenue INSURER B:
Salem, RA 01970 INSURER C:
NSURER D:
NlURER P.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHEINSURED NAIAEDA13OVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENTWITH RESPECT TO WIMICHTHS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBIECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POUCIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED-BY PAID CLAIMS.
I OD TYPECP DI9{.RANCE - POLICY NUMBEN UCV iPKC v6 P UCY EKPIRATION LIMITS
CENERM.UABILDY TBA24397 03/20/2008 03/20/2009 EACH OCCURRENCE s 10j00
% CONNEROIAL GENERA.LIABILITY OAM ET s
ATMAIMSMADE QOCCUR MEO E](P(Atry enM RVEonJ S
::: — PERSONA-AAOVINIURY i
GENERA.AOOREGATE i GENL AGGREOATE LqINpITAPRIES PER: PR COUCTS•COM P/OP AGO S POLICY % jam} LOC
AVTOMOBRE UASILRY TRAZ4197 03/20/2009 03/20/2010 COMOrNED,NGLELNITANYAUTO IEsmdw.Q
ALL OWNED AVT OS
BODILY INJURY E
A % BCHEOULEO AUTOS (Per Rrsenl
K HIRED AUTOS BODILY INJURY
% NDN-0WNm AUTOB (Pr saURnt) i
PROPERTY DAMAGE f
(Pr saM,N)
OARACELJABILITY AUTO ONLY.EAACCIDENT i
ANY AUTO
OTHER THAN BA ACC i
AUTC ONLY: AGG E
EXCPd3NMBRELIAUABILRY EACH OCCURRENCE i
OCCUR DCLAPASMADE AGGREGATE E
i
DEDUCnA!
$
RETENTION i
i
HORKERR COMPBRBAnON AND TOA24397 03/20/2009 03/20/2010 %
EMPLOYER,LABILITY
A ANY PRCPRIETOR/PARTNER/EXECVTNB E.L.EACH ACCroE E 500
OFFICERN4ABER EXCLUDED,
EL DIlEASE•EA BdPLOYfi f 500
RYEE,d VROFdsr
SPBCML PRDVINONE S,NN I EL.DISEABk P0.ICY LIMB 8 500
OTHER
OESOMPTON OP OPERATIONS/LOCATONSI CLEB I EXCUGONS ADDED BY ENDONNNSW [I SPECIAL PROWMONS
ONSERVATION SERVICES GBnU INC. 15.NAMED AS AODMMML INSURED. -
HOLDERCERTIFICATE
SHOULD ANYOP THEABOVE DESCRIBED PMIC103 BE CANCELLSO BEFORE THE
EXPIRATION DATE THEREOF,THE M8UN0 INSURBR WILL ENDEAVOR TO MAL
CONSERVATION SERVICES GRDUP, INC. DAYS WRITTEN NOMCETOTHE CERTIFICATE HOLDER NAMED TO THE LiIf,
ATTNE KEVLJ BUT PAH.URE TO MAIL SUCH NOTICESHALL IMPOEB NO OBL,CATION OR LN1EIUW
40 WASHINGTDN STREET OF ANYOND/PON THE INSURER,ITB AOErns OR REPREBSNTATVM
%WTBOROUGH, MA 01581 AUTHORIZED REPRESENTATIVE
Rosemaryulbwwvm
ACORD25(2001108) FAX: (508)389-9905 cACORD CORPORATION 1983
a CITY OF SALEM
PUBLIC PROPRERTY
' DEPARTMENT
SSD
tl A` Nt 12: SI:NLLT • 5nt1'tt. kill.%%!i%1111 :1 1 I\3197--
7t-715-43'15 • f vx 9711-74C'1346
Workers' Cumpensation Insurance :lls1'Gdatit: BuilderVContractors/Electricians/Plumbers
%moicant Information ,1 11 Please Print Legibly
Nainetnp,aKaLorgan lrattola,Indouluct0: AJA — 4-; �r^ ZwY wv LL C_
ldt fa,.: cot 2 -Tc��S i9✓
Cily,Slarc.%ip: :519/rte-, OW-9 mune •!: `1`79--2qy —WY3
.\n•you -lnployer7 Check the appropriate box. '1'y pe of project(required):
4 I ;tun a general contractor and 1
I, :un a employer with� � ❑ 6. C] New construction
englloyces(lull Jn1L'ur part-time).• have hired the sub-contractors
2. ❑ 1 ant a sole proprietor or partner- listed on the :atachcd sheet. �• C] Remodeling
ship and have no employees These sub-contractors have 6. Cl Demolition
working liar Inc in any capacity. workers' comp. Insurance. q. ❑ pudding addition
Kn workers'cum . insurance 5. ❑ We area corporation and its
I P I
required.) 10. Electrical repairs or additions uircti fficers have exercised their ❑ P
I J o
3. F1 I am a homeowner doingall work right of exemption per MOL 11.0 I lurching repair or additions
myself INo workers' cutup. C. 152, j 1(4),and we have no 12.❑ Ruuf repairs
insurance J re4 uired. t employees..Lisa workers'
❑
comp. inwranec required.] 13. Other
•
%,.% Ihwt checks bot It must.dao lilt dm the wcWu.Iwluw>huwing thea wurkui cunlpenautiwt iwhcy ml4'rm:,60n.
'
It who o0mul this 2171dav it indica.ing Iles)ate doing.11 work and Ihcn hire""side""undone must.ut mita new sIrdaviI indi"mg%itch.
- {',•ntcwhnn that thc,k this box motor artachcl.m add.tiunal shoo t.hawing 16e name of this subiontrxlon and their wurkera'comp.p.dwy Infixsnadan
f ant use employer that is pruvidiug workers'cutnpenanion insrtrance or etry employees. Befory is the puficy stied job.,iter
ltrjurnrathae. ^ o /
Inmiraucc Company Name.Hh r/ G( --- _ - -- - -------,--
1'olicv a or Sclf-inn. Lic. d:'T d /�- aYJQ'_7. . .. ._ Ewpirauon Date: 3 / 20
Job Site -lddress: a "9- L clly:5tata Zip:
Attach it copy of the workers' curnpenution policy declaralion pulse(showing the policy nunber and expiration date).
I;Jllurc to secure cuserage as required under SCL(iun 25:\ ul'>IGL c. 152 can lead to the imposition of criminal penalties of a
tin: op to iI.5001M Jndrur one.)car intprisamnent. Js well Js cis it penult lit in the Putin of a STOP WORK ORDER and a fine
of op ut 5'_50.00 it Jay against die vitAnor. He adwsed that a copy of this mdtcmenl may be lures arded to the Oil ice of
Im;al Ra none at :he UI.\ :or imut.Ircc c. cr.I�;c Icrit iaal:on.
/do her,by t:rtify udder t/r paint mrdpeperwhiec of perjetry that the iu/ormulian provided above is true olid correct.
Dieu 4
1)f/i,tial use wily. Do not twrite in this area. tube ruurprcar/by city'or ra Nn u1j%t toot I
( ity mr loon: ... Permit/Liccme q
Issuing; .%oil ilr (circle noe):
I. II.,ard of IIc.Illll !. IBuldimq Ilcparuncul 1. ('i1y,-fowu Clerk J. Electrical lm;pector 5. Plumbing Inspector
6. Other _
Clinic❑ 1'cnun: .. _. Phone it:
i
Information and Instructions
N f.us.,,ltusetts Gencral Laws chapter 152 1vquire>all ernplo)ers to provide workers' compensation tier their employees.
l'u ou.tnt to :I is +t it use, in empluree Is defined as- .e%ery pe,son in the service of another tinder any contract of hire,
c%press or imphcd. oral or written."
\n employer is defined as"in individual, partnership, .szociauou, corporation or other legal entity, or any two or snore
.,r the h,ret!jIrg engaged m a loin[ enterprise, and including the legal representatives of a deceased cmplu)cr, or the
rccaver or tiu>tee of.un ❑,dtvlduai, partnership, association or usher legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
,Iwcllmg house of another who employs persons w do maintenance,construction orrepaur work on such dwelling house
or ,al rhe grounds or building appurtenant thereto shall not because of such employment be deemed to be in employer."
\IGL chapter 152, i25C(6)also states that "every state or local licensing agency Shan withhold the issuance or
renrsval of a license or permit to operate a business or to construct buildings in the communwealtb for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Addiuunally. MGL chapter 152, a25C(7)sines"Neither the commonwealth nor any of its political subdivisions shall
iter into any contract for the performance ufpublic work unit] acceptable a>ndencc of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s) nume(s), address(es)and phone number(s) along with their cerfiftcate(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 contimration of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he rcnuned to rhe city or town that the application for the permit or license is being requested, not the Department of
1 ndustriai 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 be sure that the affidavit is complete and printed legibly. The Department has provided•a space at the bottom
of the affidavit fur you to fill nut in the event the Office of Investigations has to contact you regarding the applicant.
]'Ease be sure to fill in the pcnnililicense number which will be used is a reference number. In addition,an applicant
that must submit multiple permit,licase applications in any given year,need only submit one affidavit indicating curent
policy int'ormatfon(if necessary) and under"Job Site Address"the applicant should write":dl locations in (city or
townl." A copy of file affidavit that has been officially stamped or narked by the city of town may be provided to the
applicant as proof drat a valid affidavit is on file for future penmits or licenses. A new affidavit must 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 i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I liJ t)t Ilio of \vould hie IJ drank )ou in adv:ulcc fur your cooperation and should you Ila%c sly que>tjoni,
please do nut hesitate to give us a call.
the D.panmcnt's address, telephone and fax number-
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TCI. !1617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
a r a PUBLIC PROPRERTY
DEPAR
I II. '1'8 '4i-7;')i ♦ 1 \X. ';_N '4:'O84i,
Construction Debris Disposal Affidavit
(required fior all demolition and renovation work)
In accordance w illi the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
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 lacility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
No L 5,1,,— C "o✓ ;
(name of hauler)
I he debris will be disposed olin
/J (name of facility)
(address of racitily)
.ignaturc of parmit applicant
Male