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55 MEMORIAL DR - BUILDING INSPECTION (2) X25 r ,� cK. 52-720 ; s� Tle Commonwealth of Massachusetts " 4' Board of Building Regulations and Standards =`r ' �Polar X. 'QF Massachusetts State Building Code,780 CMR SALEM gev d 2011 Building Permit Application To Construct,Repair,Renovate t�A"h"a4 A One-or Two-Family Dwelling Tis Simon For 4Yllor$1;Use (� Penarit Number; Date adi 644 1 1lailding ,.scat fPrin#I3amej Sigasaus .9 _. ` S�'CI7t1R41:SIT1'r HVP'ORlt7ATCON' 1.1 Property ddress: 1.2 Assessors Map&Parcel Numbers cm=;z C �(tst ,V`0 t 1.1 a Is this as accepted .yes no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (UG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone- — Outside Flood Zone? Check M13 Municipal❑ On site disposal system ❑ SFCPION 2. PROPRRTY OWNS] mo ' 2.1 Owner of It co-d- 7 `07 Scat-eyv\ Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 9:DESCRIPTION OF PROFOSM WORW(eboa all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify: 2 OX Brief Description of Proposed Work: a x —tti�,ntie v� SIrCTtON 4:EST1WATEIS COiYSTRUG3 /3N a OS1 S Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ 1. Btulding Permit Pee:$ indicate hoivfee is dotsimirted 2.Electrical $ ❑Standard Clty/1 own Application Fee l3 Total Project Cos4'(flan 5)x multiplier x 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ S.Mechanical (Fire $ S resSion Total A1f Fees:$ / C heck No. Cheek Amount Cash Amount' 6.Total Project Cost: $ 19 O Paid in Pull L1 O,utsian ' Balance Due: $ I►(� n(n t c t�u� TO My "CEr Ka t'�t S n SECTION 5: IX#V$TRUMON VICES 5.1 Construction Supervisor License(C � License Number Expiration Date Name of CSL Holder '� List CSL Type(see below) No.and Street Dea�Iptioa ' U Unrestricted to 35.000 cu.ft. R Restricted l&2 Family City/town,State,ZIP M MasomY RC Roofm Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address Ci /Town State ZE Telephone SECTION&WORKERS'COMPENISATION V4URANCE A"MAV T(NLG L e 152.3 25") 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 .......... No...........D SECTBJIN Tai OVMM AUTH R17A T8 BE LETEA WOEiN OWNERS AUNT QR QR AM*§.FQR Otapm PERM f I,as Owner of the subject property,hereby authorize�Ala to -\-CLn to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION Tit:OWNEW OR AUTHOR=D AGENT DECLARATW N 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. co_ �— \ Print Owner's or Autho' d Agent!s Name(Electronic Sigoature) Date 1. An Owner who obtains a building permit to do hisw9ph w an owner whdFl9m an unregistered contractor (not registered in the Home Improvement Contror C) ogram),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 wtivsv.mass.eovr'oca Information on the Construction Supervisor License can be found at wmv.ntass e0v/dos 2. When substantial work is planned,provide the information below: Total floor 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"maybe substituted for"Total Project Cost" J f, aw CALIFORNIA� DEPARTMENT ,OF FgREST,RY .and FIRE-",PROTECTION. IT OFFICE OF THE5TATE FIRE . MARSHAL T . REGISTERED FLAME RESISTANT PRODUCT Product. Registration" Noe T 'G00TEIN Product, Marketed °By ,TENT AND, TABLEXOM, LLC 2845 BAILEYT` AVE, BUFFALO; TTNY .147!15 Thisproduct meets the mimmum requiremenCs of flame resistance established by'the Galifoiria State Fite Marshal,for.products;identified iu Section 13115, California Health and Safety Code, The scope of the approved,use of.this product;ts provided ' the current edition of the CALIFORNIA APPROVED LIST OF'FLAME RETARDANT CIIEMIGALS AND FABRICS,GENERAL,AND LIMITED APPLICATIONS CONCERNS published by the California Sate Fire Marshal ' _ Expire 6/30/2014 �— D.epu ' Sfiate Fire a ha'.l -- 'Pft-8 , ./� NORTSHO-51 LCARUSO CERTIFICATE OF LIABILITY INSURANCE DATE 8/3/2016 TYYY) 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 endomement(s). PRODUCER CONTACT NAME: Salem Five Insurance Services,LLC PHONE (781 933-3100 VC ) (7 ) 445 Main Street ac No Eat: ) Arc.No: 81 933-9048 Woburn,MA 01801 AUL ADDRESS: insurance.services@salemfive.com INSURER(S)AFFORDING COVERAGE NAICA INSURER A:AIM Mutual Insurance Co. 0913 INSURED INSURER B North Shore Events Inc dba Marblehead Tent INSURER C: 5 Bank Court INSURER D: Marblehead,MA 01945 INSURER E: INSURER F: 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. 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. INSR I rypE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LTR INSR MD POLICY NUMBER MMIDD/YYYY MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE ❑OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F7PROJECT F7 LOC PRODUCTS-COMP/OP AGO 8 OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accidentl ANY AUTO BODILY INJURY(Per Person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peracciden[ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE Eft A ANY PROPRIETOwPARrNEIVEXEcurivE YIN VWC10060202302016A 08/04/2016 08/04/2017 EL EACH ACCIDENT $ 100,000 OFFICEWMEMBER EXCLUDED? NIA (Mandatory in NH) E DISEASE-EA EMPLOYEE $ 100,000 If yas,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Insurance Purpose Only 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(2014/01) The ACORD name and logo are registered marks of ACORD q� CERTIFICATE OF LIABILITY INSURANCE -DATE Y) 8�9w2O16 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 certificateholder is an ADDITIONAL INSURED, the policy(fes) 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). PRODUCER CONTACT Neal Hutchins NAME: Archer Insurance Agency PH2NE , (978)922-4600 FAX Na: (979)922-9276 271 Cabot Street EMAIL ADORE S: INSURi AFFORDING COVERAGE MAIC# Beverly MA 01915 INSURERAMelamon INSURED INSURER B: North Shore Events Inc dba Marblehead Tent INSURER C: 5 Bank Court INSURER D: INSURER E: P Marblehead MA 01945 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL16B101864 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. NOR ADDL SUSIR POLICY EFF POLICY EXP LTR TYPE OF INSURANCEI=Jma POLICYNUMBER MMDDNYYY) (MM1DDNYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMSMADEOCCUR DAMAGETO EI PREMISES 100,000 PREMISES ioccurrence $ TI NN657491 5/17/2016 5/17/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 11000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[::] PRO-JECT ❑ LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: Employee Benefits $ AUTOMOBILE LIABILITY COMBINED S N LE LIMIT $ Ea aooident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Par accident) $ AUTOS AUTOS NED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccitlenl UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ OED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMSER EXCLUDED? NIA (Mandatory In Ni E.L.DISEASE-EA EMPLOYE $ H yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem City Hall ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street Salem, MA 01970 AUTHORIZED REPRESENTATIVE Neal Hutchins/NEAL ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401)