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173 MARLBOROUGH ST - BPA 11-566 BASEMENT � r a The Commonwealth ot'Massachusetts Board of Building Regulations and Standards CITY OF SALEM Massachusetts State Building Code, 730 CMR, 7'u edition Revised Anwary Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 200,1 (h rr Too-FumilP Dwelling Tllis Section For OBicial a Only Building Permit Numbe Dat pplieJ: If Signature: Building Commissioner/I r of Buildings Dale SECTION 1:SITE INFORMATION 1.1 Property Addre syy t 1.2 Assessors Map& Parcel Numbers 1'13 .h-cr��8oro I.I a Is this an accepted street'yes t-� no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq Il) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rea Yard Required Provided Require) 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? Public�� Private 13Zone: if yes❑ Municipal 010n site disposal system O SECTION 2: PROPERTY OWNERSHIP' 2.1 Ow ert of Record: Num ) .. Address for Service: c�`) e- 2 -?3 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) al Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ I Number of Units I Other ❑ Specify: Brief Description of Proposed Work': i- 1 _ice '2- 04 04 ry SECTION 4: ESTIMATED CONSTRUCTION COSTS 0 Item Estimated Costs: Official Use Only (Labor and Materials � sy I. Building S �°' i. Building Permit Fee:$ Indicate how tie is Determined: ® 13 Standard City/Town Application Fee 2. Electrical S Q C7 ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: 5 /I 4. Mechanical (IIVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:$ `U' Check No._Check Amount: Ca!AAmount:_ 6. Total Project Cost: $ 1�. 1 ❑Paid in Full ❑Outstanding Balanc cN�1- , t SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) GS G l 531 � I- 1 l lz (Tr _ License Numl+er E.xpimtiun D le Nano W CSL-I Iulder 1 C) p c List C'tiL Type(see below) Address G\-o1f74-owrV0. ` 4� -FMDescription O A l InrestricleJ(tip to 35.000 Cu.Ft.) Restricted 1&2 Family Dwelling Signature M Nlasonry Only RC Residential Roofing Co wring cicphnne4= -1�0'0 WS Residential Window and Siding ear-44 SFResidential Soli)Fuel Burning Appliance Installation U Residential Demolition 5.2 Reg tered Home Im r vera Contractor(HIC) �� ��t5� ��~ Registration Number I I I(,' umpa%Name ur f IIC Ry��i�}nmt Name 6 I�d (7 Address30 ) I R ly'q W- I Expiration Date Signature relephone 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 .......... Nu...........❑ 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:(�OW(NERt OR AUTHORIZED AGENT DECLARATION 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 _ Sig re of caner 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 FIIC Program and Construction Supervisor Licensing(CSL)can be found in 740 CMR Regulations 110.116 and 110.115,respectively. �. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) 0-n Q (including garage, finished basement/attics,decks or porch) Gross living area(Sq. Ft.) habitable room count Number of fireplaces Number of bedrooms N umber ofbathrooms Number ofhalf/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may he substituted for"Total Project Cost" Massachusetts- Department of Public Safeh Board of Buiftlin- Re�-ulations and Snmdards Construction Supervisor License License: CS 81537 }M,. EDWARD J ODELL JR 150 GRATUITY RD GROTON, MA 01450 Expiration: 1211112012 . (' mmi>sionrr Tr#: 7417 07 Is. o/✓ dd[lCRu ,. ... Office of Consumer Again&Business Regulation HOME IMPRgYEMENTCONTRACTOR Registragon`t,�,t29952Tr# 290835 ExplratI&"-- jf30P2011 EDWARDJ.bDELLJ EDWARD ODELC� 150 GRATUITY R�l �� /•' NIA recretary014Unde GROTON, i E• In ODELL Quality Fire, Smoke& Water Restoration Residential&Commercial Cleaning &Construction Service Operato�„nom Insured: R \l� 5�� 4N0 Z Adjuster: c; Claim#: "F E 71,47 Col q Deductible:T I (we) hereby author' a E.J. ODELL to perfo restoration service at my(our)property at ')3 r.\ �-\bo�a l_ S0. Mass and with respect to items that fleed to be restored at a remote location, to remove and restore such items. I (we) authorize .R. 4 � e-,% ©� l�ss 1 Insurance Company to pay E.J. ODELL directly for that portion of the work covered by insurance. If for any reason the check for payment should come to me(us), I (we)hereby agree to pay E.J. ODELL immediately upon receipt of the check from the insurance company. I (we)understand that E.J. ODELL is working for me (us) and not the insurance company or adjuster. I(we) agree to pay E.J. ODELL directly for any amounts not covered by insurance company. It is fully understood that the CUSTOMER is personally responsible for any and all deductible, depreciation or any other charges or costs not covered by insurance. The liability of E.J. ODELL is expressly limited to the total amount of the services authorized herein and in no event shall E.J. ODELL, its agents or assigns, be liable for consequential damages of any kind. E.J. Odell will not be responsible for the disappearance of any personal or business property not specifically listed on the inventory. In the event that legal proceedings must be instituted to recover any due amount, E.J. ODELL shall be entitled to recover the cost of collection including reasonable attorneys fees. Additional Terms: Deductible paid with check # for $ on Signature: Date: Signature: Date: _ 4)Y= 4o - 9846 CITY OF SALEM }L, PUBLIC PROPRERTY a DEPARTMENT Nusufl 1WASHING IONSrslkT • SAlLN,MASSACI11vl;1 aG197� lbl.:979-7t3-9595 • 1:%X.979.74V M46 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers knnlicant Information p1 r Please Print Lecibiv V.IITt:lBucnwpvy)rnNlnJrviduu4:� in Address: o Q CrJ dt 0 � �a— City;StWei%ip: Phuneif: :kre you an employer!Check the appropriate box: 'Type of project(required): 1. am a employer with $— 4. ❑ 1 am a general contractor and t /,, ❑ New construction entploycus(full and/or part-time).` have hired the sub-contractors _.❑ I :un a sole proprietor or partner- listed on the anached sheet. 7• ❑ Remodeling ship and have no cmployccs These sub-contractors have S. ❑ Detnalirion working liar me in any capacity, workers'comp. insurance. 9. ❑ Building addition 1 No workers'cutup. insurance 5. ❑ Weare a corporation and its egtu 10.[] Electrical repairs or additions ir. officers rJ.J ofcers have exercised their 3.❑ I am a homeowner doing all work right of exanption pdr MGL I I.[] I lambing repairs or additions mysclLjNo workers'comp. C. 152,¢1(4),and we have no 12.❑ Ruufrepairs insurance required.] t cmployccs. [No workers' comp. insurance required.] •.nip:ipplicaul that checks boa ill nlusl also IIII wl the wch Nl wow fhowisig lhcir workas'1unipuna ioii policy Inhninatio . 'I temuuwrwn whu matmit this affidavit indicating They are doing all wurk mol then hire outside"llrxron most.uhmil a new alfdavit indi"ing awh. 4.mtr ax.that check.this box must ailwhe l.m addilional.hoer%howing the nanne of aha subsaniracars and their wurken'comp.policy information. 1 tun an eulpfoyer lhut it pruvidit•g workers'c•oinpensntion insur(utce jar sty enlployeer. Below is the policy dead job.lite i i/ornwfion. (� In.urauce Company Name: ttthe— H22t-,11L . f Policy 4 or Self-ins.Lie.#: t313 Expiranon Date: lobsite.Address: ,1 2) /��E–I�vt–on3h s � C'ity;StateiZip: Se_\- It Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under SCCllon 25A of>lGL c. 152 call lead to the imposition of criminal penalties of a fins up to 51.5110.00 and/or nue-year imprisonment,as well as civil pcnullies in the f'unn of a STOP WORK ORDER and a fine of up to 5250.00,t day against the violator. lie advised that a copy of this statement may be forwarded to the Office of Invrsttgau'ms ufthe UTA for wittrance coverage aciilicaliun. /do hereby certify under the pains and penuflics•of per/Lry that dee inJ'urinudon provided above is true and correct. [[liciul use duly. Donor u•rfre fn this arra,to be cumpleled by city or rarvn oJJiriu/. t ty or Town: __ . Permit/Licensc�._ _.__ _ lssuing Aulhorily (circle one): Board of lleallh 2. Building Mimil icul .l.CityiRavin Clerk 4. Electrical inspector 5. Plumbing luspectorOuter Cunlact 1'cnuu: .. Phone.J: Information and Instructions .%lassachusens General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this mutute, an employee is defined as"...every person in the service of another under any contract of hire, ckpress or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or tither legal entity,or any two or more . r the 6xeguing engaged in ajoint 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." `IGL 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,NIGL chapter 151, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perforiance ofpublic work until acceptable evidence of'compliunce with the insurance requirements of this chapter have been presented to the contracting authority." .applicants Please till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractors) namc(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 dale the affidavit. The atlidavit 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 due 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 ut the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be.cure to till in the permit/license number which will be used as s reference number. In addition,an applicant that must Submit multiple pennitilicense applications in any given year,need only submit one affidavit indicating current policy information of 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 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I lie 0I lice of Investigations would like to thank you in advance fur your cooperation and Should you have any questions, Please do nut heskam to give us a call. The Dcparnnent's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston, MA 02111 Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE Fax It 617-727-7749 www.mass.gov/dia l CITY OF &U.&M. UxsSACHUSE"I'I'S Bt:mDLNG DEPARTMENT ' 130 WASHLNGTON STREET, Yo FLOOR TEL (978) 74S-959S FAX(978) 740-9846 KI\BERLEY DRISCOIL MAYOR T komA.4 ST.P[Eaag DIRECTOR OF PUBLIC PROPERTY/aum=NG CONNISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris,and the provisions of MGL c 40, S 54; Building Permit t1 is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: S ) oC-0V^I �e— (name of hauler) The debris will be disposed of in R� �---A «ri cct t—rn {1 (nampe Doff facility) I A , (address of fact ty) J s nature of permit applicant date a.n�,�rfa.x JAN-05-2011 WED 02:5.8 PM FAX N0. P. 01 JO E Ite tfr: 5326 PAYE(MMIDP/fYYT) r-AMDH Q;�ERTIFICATE OF LIABILITY INSURANCE 110512011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ranCO C 1 Dup,Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR StreetALTER THE COVERAGE AFFORDED BY 7HE POt.IC1ES BELOW.INSURERS AFFORDING COVERAGE NAIL 0 A 011e( 1-2804 INSURERh The Hartford .J.O'D III1 INSURER M 50 Grata.hY Road INSU�C.O.Bo:c B22 INSURER a, Groton,VIA 01450 INsuRERE: COVERAGES INSURED NAMED jHF POLICIES OF REQUIREMENT.Y[IM OR GOND TION OF ANY CONTRACT R OTHEUETO R DOCUMENT WITH RESPECQTTO WHICHLTHIS CER PIICATE MAY BE 1 SUED NOTWITHSTANDING R DIN MAY PERTAIN,THE I TE IRANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN 16 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH pOLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCEDBY PAID CLAI Motu E ECT E PeL UPI LuaRB TYPE O F INSURANCE POLICY NUMBER EACH OCCURRENCE $10000 O 07102110 07102111 A GENERAL LAO R•RY OSSBAVY2192 DAMAGE TD RENreD $3 00 0 X COMMERCIJJ.GENERALLIPOUTY MED EXP AM-&Kenn) S10000 CLAIIA3 MADE OOCCUR PERSONAL E ADV INJURY 51000000 GENERAL AGGREGATE 52 000 000 PRODMUS-COMPEAGG s2000000 GEN-6 AGCFE''AYE LIMIT APPLIES PER' X FOL{CI_. PRO. LOC_ COMBINED SINGLE LIMIT $ AUTOMM111:LIABILITY (Eaacadenl) ANY AUT J BODILY INJURY S ALLOW E)AUTOS (Pw"wn) SCHEOUdI D AUTOS BODILY INJURY (P $ HIRED 0..1OS er euiden1l NON-OMNfDAUTOS PROPERTY DAMAGE S (pereWdenD _ AUTO ONLY-EA ACCIDENT E UARAGE LW BI LITY OTHER THAN EAACC $ ANYAUV) AUTO ONLY. AGO S EACH OCCURRENCE $ EKCESSNM al IELLA LIABILITY AGGREGATE S OCCUF �CLAIMS MAGE $ S DfDUf•Y BLE 5 RFTE.PQN $ WC STAY0. OTH- 04129H0 04129111 X A WORKERS CPSEVE°ISATION AND DOW C153736 ELSACH ACCIDENT $100000 EMPLOYERS'LIA DUTY EL.DISEASE-EA EMPLOYEE $100000 MY ?ECUTIVE OFFICERIMEMI fa;XCLUDRO EL.DISEASE POLICY LIMIT $00000 6Od6, LM-!j N5 OTHER OEBC0.IPTION DF OPPe P.�LTIONB 1 LOCATIONS/VEHICLES I EXCLUSIONS ADOEO BY ENDORSEMENT I SPECIAL PROVISIONS Re:Job at 17.1 Iltarlborough Street,Salem,MA CANCELLATION 10 nava for Non.p- ment CERTIFICATE H11I_DER SHOULD ART OF THE MOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,ME188UING INSURER WILL ENDEAVORTO GAUL In GAYS WRRTEN C:IIY Of Salem NOTICE TO THE CERTIFCAYE HOLOER NAMED TO THE LEFT.BUT FAILURE To 00 So SHALL Fw(0 978.740-9846 IMPOSE NO OBLIGATION OR LUIBILITY OF ANY KIND UPON THE INSURER,RS AGENTS OR REPRESENTATIVES. pUTHORIZEOREPREBENrAT1`/E `/''11��111 fAAP��ALw SILT 0 ACORD CORPORATION 1988 ACORD 25(2011V08)1 of 2 #S1396511M139650 -