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25 LYNDE ST - BUILDING INSPECTION The Commonwealth of Massachusetts cs Board of Building Regulations and Standards ��LEM Massachusetts State Building Code, 780 CMR l kdd�sld;t/or 2g(l Building Permit Application To Construct, Repair, Renovate Or Demolish a S One-or Tivo-Family Divelling --------------- This Section For OfficialLIV only Building Permit Number: Date.Ap lied: ! Building Official(Print Name). Signattae. - Date (� SECTION 1:SITE INEORNIATIOW CJ� 1.1 Property Addr ss: L2 Assessors blap&Parcel Number- 5 �<< Map Number Parcel Number - I.[a Is t is an accepted street?y _� 1.3 'Zoning Information: 1.4 Property Dimensions: "Zoning District Proposed Use Lot Arca(sq 11) Frontage(It) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required ProReq vide) uired Provided Required Provided 1.6 Nater Supply:(M.G.L c.40,§54) Ll Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal E3 On site disposal system ❑ Public(3 Private❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP!' 2.1, OWnef Rceerd: 'ne rin) . W"--1•� City,SlatZIP No.and Succt Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Constriction❑ Existing Building py Owner-Occupied ❑ Repairs(s) 1 ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.E3 Number of Units__U Other ❑ Specify: Brief Description of Proposed Work=: er"t) rr OAJ a (7q iov.r /"OV07 A/ew �A�eniePts an/n K /i.rurr r SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Itcm Labor and Materials) I. Building S �a 000 I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S v ❑Total Project Costs(Item 6)x multiplier x }, Plumbing S ?j 2. Other Fees: S . yt 4.XIechmtical (FIVAC) S C)UO List: Al� l] (J 5.i\lechanicaI (Fire S Total All Fees:S suppression) Check No._Check Amount;_Cash Amount: 6.Total Project Cost: S Cl/(j 0 Paid in Full Cl Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5/.1�Construction Supervisor License(CSL) r �o0 ��ke� G�fe\� License Number Expiration Date Name of/C�SL Holder List CSL'rype(see below) -Type • Description No.:md Street t _ U Unrestricted.Buildin u to 35,000 cu. It. ?_ea t. lm �(� R Restricted )Z Family Dwelling city/Town,Stat IP M 'Masonry RC Roofing Covering WS Window and Siding [,� � /��to SF Solid Fuel Burning Appliances / �C0� I/K I Insulation Tcie hang Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ek Gf�� H C Registration Number Expiration Date I IIC Comp;mName or Hf gislrant Name �. Qt nlv\ or "!> Np,and qtreet\� �a a\ CM'-3J60'�Gf� Email address Ci rrown Stat ZIP 'r 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 nffrdavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... V No...........❑ SECTION 72:OWNERAUTHORIZATION TO BE.COMPLETED WHEN:, OWNER'S AGENTOR CONTRACI'ORAPPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize A�t�� l' L"� / t m' f i 4 d t9 ct or my beh f,in all matte relative to work authorized by this builds g permit application. o — fd V4 'Print Owner's Nam Electronic Signature) Data SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 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 knowled a and understanding. CUIhi) Re 'Print Owner' Au or thorize Agent's Name(Electr me Signature) Date NOTES: I. A n 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 can be found at \aww mass cov'oca Information on the Construction Supervisor License can be found at ww�:'Jns 2. When substantial work is planned,provide the information below: Total fluor area(sq. R.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths rype of heating system Number of decks/porches Type of cooling system Enclosed Open 3. Total Project Square Footage"may be substituted fur`"rotas Project Cost" QTYOFSALFJK MAssAa*w DMEMODEranaAW �w�+araYcrwSa�r,31°lloaa 8aaaffiPtB2'la�L Fi1Y A�P 7i498I6 �� 7hOwsST.P�1aa DMKxvcFRAMWjMaMTAwffzwca3mw9m Construction Debris Disposes/Affidavit (required forall demolition andrrenova'don work) In aoeordmae with the sbM edWan of the Stage&Wdbg Code, 7W CF^Secdw 111.5 aeM and the provtstag of MGL 000,S M4;SIB Perms Is Issued with the c»nditlon tlnrcthe debris rewltbwg from thts workshe6 be dkposed of in a property ikensed " wase depok Chas defined by MGL c 111,S 15K The debris wf0 be transported by: (name of hauler) The debris will be disposed of in: (name offedifty) (address of fadiity) Sig at re 9f applicant Date The Commonwealth of Massachusetts Department of Industrial Accidents a I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly t Business/Orm Business/Organization A in yJ/) /IW)lot P�(J Address: 0 1 Cq-(\er eA• '/ 9177-3&6-1q60�r City/State/Zip: �� m @hone#: / 77-3&6-'1760 Are you an employer?Check the appropriate box: Business Type(required): I.M I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. LNo workers' comp. insurance required] 8. Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers'comp. insurance required]* 11.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp. insurance req.] 12-0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that isproviding workers'compensation insurancefor my employees. Below is the policy information. Insurance Company Name: r�y 0- A*E J k� Insurer's Address: 01 A07 67, 196 3WJC City/State/Zip: SAN A)V iAleO A)e -f 7F,; o 5-- Policy#or Self-ins.Lic.# 764A/ea G- 7G 15' Expiration Date: 4(,V/46 //7 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 7 do hereby c fy, mrd the pains and penalties of perjury that the information provided above is true and correct. Si nature: D Date: Phone#: Oficial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer 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 or other 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 dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the 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 permit to operate a business or to construct buildings in 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 until acceptable evidence 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 your insurance company's name,address and phone number along with a certificate 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 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 submit multiple permit/license applications in any given year, need only submit one affidavit indicating current - policy information(if necessary). 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 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 dog license or permit to burn 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 Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Fonn Revised 02-23-15 (77�feizair�iairu_/ecrtf c{n%�a.�Jtrtulelr`l Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 178864 Type: Corporation Expiration: 5/28/2018 Tr# 289263 CABINETRY UNLIMITED ENTERPRISES IN PETER BAGARELLA 21 CALLER ST SUTE 2 – - -- – --- PEABODY, MA 01960 --------- ----_-- — --- __---__-- Update Address and return card. Mark reason for change. '— Address — Renewal — Employment —' Lost Card 20M-05'1: -- r Mr\SSACHUSETTS DRIVER'S Massachusetts -Department of Public Safety LICENSE Board of Building Regulations and Standards 'w .1 +`''. Cnnurudiar Suncn ia-,r �_�:. °i cxo °^H0h®rA License. CS-087554 - ,042288.2014, NONE S96855668' 428-26904-28-1965 PETER BAGAREgAA s cussu.*n"Ru ,s sex M 14 HOT 8:00 21 CALLER ST iNONE STE.2 ��yy^^�� i BAGARELLA PEABODY MA 01*60 ` z PETER >� VVVVVV 1` s 28 MARLBOROUGH RD - 1. 1. SALEM,MA 01970.1814 t;21 �fJje�( „ �1 X51 Expiration s ooaan.mu ne.m.lsmss Commissioner 04/28/2017 1 .._..... .-. - - --CERTIF.. . BELQW. THIS.. ICATE 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 pollcy(les) 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 endorsements). NTACT CO]DIDBLCla1 Lines PRODUCER N Harris-Murtagh Insurance Agencyrinc. PHONE (978)532-2844 F�, 30 Central Street Exna IRE$& INSURERS AFFORDING COVERAGE NAICP Peabody MA 01960 INSURERA:Utica First Insurance 15326 INSURED INSURER B: CABINETRY UNLIMITED ENTERPRISES, INC. INSURERC: 21 CALLER ST #2 INSURER D: INSURER E: PEABODY MA 01960 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1652523038 REVISION NUMBER: THIS IS TO CERTIFY THA--HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTW971-S�ANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRAC-OR OTHER DOCUMENT WITH RESPECT TO VJFIICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDI-IONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ILTR TYPE OF INSURANCE POLICYNUMBER MIDDY EFF MMIDOPOLICY UP LIMRS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 300,000 D N 50,000 A CLAIMS MADE X❑OCCUR PREMISES FA n.r. ,, $ ART50e396400 4/5/2016 4/5/2017 MED EXP(My one Penin) S 5,000 PERSONAL&ADViNJURY S 300,000 OF.N'LAGGREGAILUMIT APPLESPE.R GENERAL AGGREGATE S 600,000 X POLICY❑JECT LOC PRODUCTS COMPADP AGG S 600,000 OTHER AUTOMOBILE LIABILITY MBodenllINED SINGLE LIMIT $ BODILY INJURY[Per P. un) $ ANY AU'0 ALL ONMED SCHEDULED BODILY INJURY(P.a. -It) $ AUTOS AUTOS NON-O MED PROPERTY DAMAGE $ 7 HIREDAUTOS AUTOS $ I U MBRELLA LIAB OCCUR EACH OCCUR REND $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTION$ H. $ IYgRKER9 COMPENSATION T T T R AND EMPLOYERS'LIABILIW Yyry ANY PROPMETOP/PARTNEFUEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ O-FICERJMEX EMBER CLUDED (MduGetory In NH) EL DISEASE-EA EMPLOYE $ Ii ns.aewioe unear E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS,VEHICLES (ACORD 101,AUOihOndl RBnldrk6$CM1BEUIe,Tdy CB dM1eCME if rude eplCd Id requi241 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FOR EVIDENCE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORE)name and logo are registered marks of ACORD INS026(20AGI) ti t e r �f BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this _ certificate does not confer ri hts to the certi{icate holder in lieu of such eonldomement s . PRODUCER NAME: rva J INCPHONE . :INC( 888) 443-6112 PAYCHEX IN_.DB_TT-_N'CE AGENCY _ L Ad.No,EsIr _ E-MAIL 210"702 OP: F E SS6 �. =43-6112 ADDRESS: PO BOX 33013 INSURERI$)AFFORDING COVERAGE NAICe V 29459 SAN ANTONIOTX X52 6-� INSURER A: Twin Cicy eine Ins Co INSURED INSURER 8: INSURER C: CABINETRY `---N:='_'EP. ENTERPRISES INC INSURER 21 CALLER J+ 2 INSURER E: PEABODY MA C- 960 INSURER`, COVERAGES - CERTIFICATE NUMBER: 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. NOTNATHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR VAY 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. fNyF TYPE npfYCpYA.CC( ADOL 5'I!dF PULICY.NI%VIER 7WI ),/M1T5 v'• t"BU OCCURRENCE 5COMMERCIAL GENERAL LIABILITYCLAI?f5-:`APE i0C^wR E TORENTED S'IISES(Ee one person)%P(Any one parson) $NAL B ADV INJURY $RAL AGGREGATEGENL AGGREGA`E iVIT P�LIES PER: UCTS-COMPIOP AGG 5 PeucvCl -__-=1 -OC 1 $ •OTHER. ( COMBINED SINGLE LIMIT $ AUTOMOBILE LIAElLITY � IED accident) ANY AUTO BODILY INJURY(Per person) $ OVMED 1 _l$OH-RULED BODILY INJURY(Peraccident) $ AUTOS ONLY N-O PROPERTY DAMAGE HIRED -- .0MOtaMED $ AUTOSONLY' �RJTOS ON!Y ' (Peracadenq �-I UMBRELLAL!A9 OCCUR I EACH OCCURRENCE 5 EXCESS LIPS I i CLA!MS-%IADE I � AGGREGATE $ T 5 UcJ ncT�'L i PER OT& N'lIFEERS'ClIA/PEATd TIlsV ' Ii i Y' STATUTE ER AND PROPR PTORI ANY PROPRIETORIRAR-tiR1EXEWiIVE YIN I E.L.EACH ACCIDENT S100/ OOO OFECERIMEMBER Ex-------r � 'iI N/A ;-- 06/O6/2076 06/06/2017 E.L.DISEASE.EA EMPLOYEE I10OT 000 A (Mandatory in 11 '_; 76 WEG KZ7215 If yes.describe urns' E.L.DISEASE-POLICY LIMIT $500/ 000 DESCRIPTION O=CFER=TIONS below �I DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHOLES(ACORD 101.Additional Remarks Schedule.may be attached if more space Is required) Those usual co Rhe Insured' s Operations. CERTIFICATE HOLDER CANCELLATION SHOULD ANY GF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Town o' .'7sw-cn AUTHORIZED REPRESENTATIVE 25 GREEN S' 7,1 IPSWIC--, MA ,: 939 ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD © N TCo mohwealth of Massachusetts 9 City of Salem Inspectional Services 'lug RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595x5641 Application For Building Permit (For Buildings other than a One- or Two-Family Dwelling) (This Section for Official Use Only) PIN: TB-16-1152 Date Applied: 10/6/2016 :Building Official(Print name): SECTION 1: SITE LOCATION (Please indicate Block#and Lot#for locations for which a street address is not available) 25-U1 LYNDE STREET , Salem, MA SECTION 2: PROPOSED WORK Are Building plans and/or construction documents being supplied as part of this permit application?: No Is an Independent Structural Engineering Peer Review Required? Yes[-] No❑ Brief Description of Proposed work: IN UNIT 1: REMODELING ONE (1) BATHROOM, MOVING FOUR(4)WALLS, NEW KITCHEN CABINETS, AND IN UNIT 2: NEW FLOORS SECTION 3: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION, OR CHANGE IN USE OR OCCUPANCY(Check Here_if an Existing Building Evaluation is enclosed(see 780 CMR 34)) Existing Use Group: Proposed Use Group: SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No. of Floors/Stories(Include basement levels) &Area Per Floor(sq.ft.) 0 0.00 0 0.00 Total Area (sq. ft.)and Total Height(ft.) 0.00 0.00 0.00 0.00 SECTION 5: USE GROUP SECTION 6: CONSTRUCTION TYPE 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 inside Flood ZoneF-1Municipal will not required ❑ Licensed Disposal Site E]or or Identify Zone: Is enclosed or specify: Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Report Process: Nota applicable ❑ a ? Yes Is their review completed? pp Is Structure within airport p approach area. or Ccnstent to Build Enclosed ❑ Yes ❑ No ❑ ❑ ❑ SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor Does the building contain a sprinkler system?:#Error Special Stipulations: THIS IS NOT A PERMIT ' �DNDIT, Commonwealth of Massachusetts 6 City of Salem Inspectional Services RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641 SECTION 9: PROPERTY OWNER AUTHORIZATION 25R LYNDE STREET REALTY TRUST ATLANTIC 22 HAWTHORNE BLVD SALEM MA 01970 COAST HOMES,LLC TR (978) 360-1900 If applicable,the property owner hereby authorizes PETER BAGARELLA 21 Caller Street Suite#2 PEABODY MA 01960 To act on the property owner's behalf,in all matters relative to the work authorized by this building permit application. SECTION 10: CONSTRUCTION CONTROL(Please fill out Appendix 2) (If building is less than 35,000 cu.ft.of enclosed space andlor not under Construction Control then skip Secbon 10.1) 10.1 Registered Professional Responsible for Construction Control Name Phone Email Registration Number Address Discipline Expiration Date 10.2 General Contractor CABINETRY UNLIMITED ENTERPRISES, INC Company Name CS-087554 CONSTRUCTION SUPERVISOR PETER BAGARELLA License no. and License Type if Applicable Name of Person Responsible for Construction Address: 21 Caller Street Suite#2 PEABODY MA 01960 Phone (978) 375-2969 Email Address peterbagarella@comcast.net SECTION 11:WORKER'S COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152§25C(6)) A Worker's 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?False SECTION 12: CONSTRUCTION COST AND PERMIT FEE Total Estimated Costs(Labor and Materials): $18500.00 Building Permit Fee: $126.00 Enclose check payable to the City of Salem, Ck# 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. (978) 375-2969 Please print and sign name Title Telephone Address: 21 Caller Street Suite#2 PEABODY MA 01960 Date: 10/612016 THIS IS NOT A PERMIT Commonwealth of Massachusetts a City of Salem Inspectional Services 4 RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641 Municipal Inspector to fill out this section upon application approval: 10/6/2016 Name Date THIS IS NOT A_PERMIT {