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77 PROCTOR ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of Massachusetts State Building Code, 780 CMR, 7'"edition lsseamw Buildi ngDept Building Permit Application To Construct, Repair, Renovate Or Demolish a �fiUMsl► v One-or Tiro-Family Dwelling �� This Section For Official Use Only Building Permit Nu Beer:: Date Applied: Signature: 0" Building Commissionctilospector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers !zJ Pit,00—'7oQ rT L I 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 II) Frontage(it) 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: Public❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: �«1to CAc.rLe SZ— Name(Print) Ar Address for Service: Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction D Existing Building Owner-Occupied ❑ f Repairs(s) I Alteration(s) ❑ Addition ❑ Demolition Accessory Bldgq Number of Units Z I Other ❑ Specify: Brief Description of Proposed Work', c CRoV SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Labor and Materials) Ofticlal Use Only . Building �Der_c�. 5 1. Building Permit Fee: S Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost(Item 6)x multiplier x 3. Plumbing E 2. Other Fees: S , , \V 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Su ression Total All Fees: E y Check No. _Check Amount: Cash Amount:_ c 6. Total Project Cost: E oo— ❑ Paid in Full C3 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) en us JLiccnseNumber 5 0Q.?ar�qniqn er Ea ❑uuon DateN4mc ofCSL-Helder A aztsS2 '7 Irl i�'&0U!✓ /f!� /he Uri( pq l ce b luw) Address //nn � Descri honestricted u to 35 000 CuFttrictedgnature son On' idential RoofiTelephone identialWidential Solid Fuel Burnins A22liance Installation D I Residential Demolition 5.1 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Addresl9.27 v th OF t i* N Expiration Date Signature / I Telephon _ ? _y23 SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 ..........0 No...........0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, C. �/m„ - ww to Y 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. / 2—Lo g Si nature of Owner Date SECTION 7b:OWNEW 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 Signature of Owner 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 110.116 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' I ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE( 2/200 0 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TODAYS INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 60 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Peabody, MA 01960 (978) 532-3555 INSURERS AFFORDING COVERAGE NAIC# INSURED RODRIGO GUIMARES INSURER A: ATLANTIC INS. CO PO BOR 963 INSURER B: SALEM MA 01970 INSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INsa ADVIL I POLICY EFFECTIVE POLICY EXPIRATION LT0. INSRD TYPE OF INSI IRANCF POLICY NUMBER DATE MWDDIYY DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $ 1D0,000 �I CLAIMSMADE OCCUR MED EXP(Any one person) $ 5,000 L143000284 07/08/08 07/08/09 PERSONAL&ADV INJURY $ 500,0001 GENERAL AGGREGATE $ 500, 0001 GEN'L AGGREGATE LIMIT APPLIES PER: L PRODUCTS-COMP/OP AGO $ INC POLICY PRO- OC ECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANYAUTO (Eaaccitlent) ALL OW NED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNEDAUTOS (Peraccident) PROPERTY DAMAGE $ (Peraccident) GARAGGARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANVAUTO EAACC $ E THAN AUTOONLV: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR C CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERSCOMPENSATIONAND WCSTATU- TH- EMPLOYERS'LIABILITY TORVLIMITS ER ANY PROPRIEiDiWARTNEPoE%ECUrIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ SYes,tlesc ROVISer SPECIAL PROVISIONS belm E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL21 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 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ' ACORD25(2001108) ©ACORD CORPORATION 1988 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ,iai'. N'I) 1Nit.4a vlo`at 1!� WAMII\t:la\SGt Lb I' • 5n uvt, M.t�sst of a I Is vl�7� fcf. 17e-713-9595 • I tx 974.74, J146 Workers' Compensation Insurance litIftdoxit: lfuilders/Contractors/Electricians/Plumbers \pplicant Information MugnPrint LeCibly Name llhnuxvsia)r�anlr.atioNlnJlsuluul): `-' UI � �C'Q�S coW' 0S'(1� Ro �"� r Address: 2C tZi''s,9O ST. S ri City,State,lip: Sm er-\ It Milk (q?o Phone ;: QZ3 -7 .%re you alt.mployer'! Check the appropriate box: Type of project(required): LQ I una employer with 4 QImn a eroncral contractor and 1 6. Q New construction 2.�2c mployces(full and,ur part-tune).' have hired the sub-amtractors I am a sole pmpriettar or partner- listed on rhe anachcd sheet. 7• Remodeling ship:std have no employees These sub-contractor have g. Q Demolition working for me in any capacity. workers' comp. Insurance. 9. Q Building addition INo workers'comp. insurance 5. Q We arc a eolporation and its IrcyuircJ.) officers have exercised their 10.❑ Electrical repairs or additions 3.Q 1 ant it homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions myseif.(No wnrken' comp, c. 152, ¢I(4),and we have no 12.Q Ruuf repairs insurance required.) t anployces. [No workers' 13.Q Other comp. insurance required] •s n. .yq+heat that checks box til must alas fill wu Ihu scams Wow showing Ihau wurkod cunlpensati.m Iwlmy mtirt anusiturc ' I I.Imeuwnen whu submit this affidavit moicafina they arc Joint'all work a.W Ihun him outside cwuraaors most auhmil a new Ar.davit fndi"mi;."It, -C.mtcxu,n Ihuf check this box mswt auached.m addlfiurul alxel.hawing flw m n a:or tha sub-coanractan and their wurkers'evmp.pulley mfurmantm. /urtr an employer that is pr„vidirrg warners'c•unpleavation insuraytce for any empfuyeem. Be/nm,is rhe pu//ry and fob vfte injunumd"m Imurancc Cumpauy Vmne: q Lt4✓�hQC_ (•t.JS/ -- - '------_.- polity it or Self-ins. Lige. w it: L 143 0 2 � t' 7 . _ ___ Eepiratwn Dater � _ Job lite Address: / Pk4C-Co a—_ 517- S A-Le^ City;Slatc/Zfp: - qGt?,.. �'"t%A G(I0i \trach n copy of the workers'cumilcmitiun policy declaration page(showing the policy number and expiration date). Padure to secure cos erage as required under SecltUn 25A uf.%lGL c. 152 can lead to the imposition of criminal penalties of a ' tine up ria 51.500.00 umb'ur une-year imprisonment,a4 well as civil Ixnuihcs in the I'utm of a STOP WORK ORDER and a fine nftill to 1250 A0 a Jay.against the violmor. lie advLu:d that a espy uflhis sfutancni may be forwarded to the 011ice of los.'ase':au tib of-tic MA :qr uhw doe, ,awcrage senli,aUun. /Jo hervby t,rrify mider the point mud penulricr u/perjury Thur the information provided above is true used correct. F)/jirto ase only Oil not write 3-u dii.t arca, to be ruu,y/rlyd by City ser mrvn a//iris/. I City urIbwn: —__ _ Pur mifiLicc rise 0_ I Is.uing Aufhurily (circle msec 1. H.'ard of Ilcalllt !. Iiuddiu;; Mpamitcal 1. City.-fora Clerk 1. Electrical lumpucror ;, plumbing Imitcecor b. Oilier _ C�.nnac1 i'crsun: -_ .- Phone d: Information and Instructions N l.usadm.cctu G:ncraI Laws chapter I i2 tcquires all enil lo)ers to provide workers' cumpensatnm for their employees, Pt.r.o.uu to this slatute,in rmprgree Is detoud as" c.cr), pcnson in the sors we of another under any contract of hire. :vpre ss or imp hed, oral or written." .\n rmPG,}•rr n detined.as"in individual,purtnership, issociatlou,corporation or tither legal entity,or any two or more ..r the toregomg engaged u A print enterprise, and including the !c gal represenwm tives of a deceased cptu)er, or the re:ciser or trustee us sur individual,pasmership,association or other legal:only,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the ,tw:llrng house of another who employs persons to do maintenance,construction or repair work on such,Jwclling house o - ,it the grountts or building appurtenant thereto shall not because of such employment be deemed to be in employer " SiGL chapter 152, ;25C(6)also states that"every state or local licensing Agency shall withhold the issuance or renewal of it license or permit to Operate a business or to construct buildings in the communweultb for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." .kddinunalty, SIGL dtapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall anter into any:ururact 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." -ppticants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contructor(s)numc(s), addresses)and phone nunber(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no empkoyecs 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 .stccidenls for confinnation of insurance coverage. Also be sure to sign and dale the affidavit. The atlidavit should Lie retuned 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 Onlclals Please he 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 0171ce of Investigations has to contact you regarding the applicant. t'l.osc be.sure to tilt in the pennit/hcense number which will be used as a reference number. In addition,an applicant that must submit multiple pennit:licelse applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant ihould write"all lueations in tcily or town)." it 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 permit.or licenses. A new affidavit must be filled out each year. Where a hume 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 ll: t it ti:c of In%,Cltlgattoni would Ilse to think )'ou in advalrce fur your cooperation and should)on hale .tny questions, please do not hesitate to give us a call. fhe Mpartincot's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, MA 02111 Tel. q 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY '��• DEPAR'I''v1ENT Construction Debris Disposal Affidavit (required for all demolition and rcnovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of NIGL c 40, S 54; Building Permit N is issued with the condition that the debris resulting front this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c I 11. S 150A. The debris will be transported by: col C1,( F - Pt3Posac (name of hauler) I he debris will be disposed of in (name of facility) IST I S at tA t; IadJress nl'I'aalitvl �Ignalurc of >enoit applicant date _ Acf(o5 C Ful Veli A[ A CONCH �®� S Lai J RE;7`� +p�l��t�� oY*'►�g3 t S o M pos T 1 Nord _ D � h�.�/y_X_C �— — i - l n� 5 �cP2'X_ � _moo�!�_o4J F Jv4 Nei° i i c RL 12 S t !i v Lll,.11l �� D;�<«- � , � i e._.t c), --� Y + 1 � _ '_}-+ •--- t -} t i « e 1 � r;;Ver s7nete�Q: — i — 170 CQkc�hepi y CA �o J l STS I � • I i 1 LLL W Nt& Gt+T � St FLou0� 36 i N N k t h�oDeL r41•Dr - I �- 1 a� - 1. - /� t 6f o'c r 1 4 A- 1 J . t. , t a� 1 �— f 1 —4 t + t U ~° �bXo j a ' N rl rn l .vl - — Gtw1t T- + P-Q r�Aa `,kn i %'h AA»x q h f kv' v: II D ❑ fill II If 1411 ° I I �I I LEFT ELEVATION w � i .l i I