7 QUADRANT RD - BUILDING INSPECTIONr
A, ,
I File Commonwealth of Massachusetts
}� Board of Building Regulations and Standards CITY
t Massachusetts State Building Code, 730 CMR, 7'h eOF SALEM
dition
R, Revised Junuart,
Building Permit Applicalion'ro Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Tiro-Family Duelling
This Section For Official Use Only
Building Permit Nu Jer/� ate Applied: -7
Signature: V/l�ty+»✓ //1 y
Building Commission&inspector of BuiWih s Date
SECT O :SITE INFORMATION
1.1 P o arty dress` 1.2 Assessors Map& Parcel Numbers
ca/c /rte r
1.1 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 Il) Fruntage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provide)
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 13 Private❑ Check if es❑ Municipal 13 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownnee�t ff!//R/If�ecord:
�
Name(Print) ' Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': r� d
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S Q 1. Building Permit Fee:S Indicate how fie is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost'(Item 6)s multiplier x
3. Plumbing S 2. Other Fees: S x" ✓� lT.
4. Mechanical (IIVAC) S List: L, i
5. Mechanical (Fire S
Su ression Total All Fees:5
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
A.
e '
SECTION 5: CONSTRUCTION SERVICES
5.1 Lice sed Construction Supervisor(CSL)
�ih 0� .�_ License Number Expiration Date
N:mte of CSI - I IulJer
List CSL Type(see below)
f— -F%,Pc Description
:\JJress llI Unrestricted(tip to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
S1 wore M %1asonry Only
'3C RC Residential Roofing Coverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Reglstere o e Imp=j nt Contractor(HI ) /5/?
IIIC Cu any Nam or HIC egis - t Name Registration Nu/mbar
h
AJ es - G
�i� ���/�f�p� Expiration Date
Si r 'Fclephone
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 ..........13 No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , 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: OWNER'OR AUTHORIZED AGENT DECLARATION
1, //a/ ,as Owner or Authorized Agent hereby declare
that the statements and information on thetore omg application are true and accurate,to the best ot'my knowledge and
behalf.
Print Name
Signature ol'Owner or Aut onzcJ Date f` 6
(Signed under the pains and enalti )fperjury)
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. 1.12A.Other important information on the 1-11C Program and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations 110.116 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Tidal fours area(Sq.Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) I-labilable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hal0balhs
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted 6)r"Total Project Cost"
CITY OF SAt.&M U)sSACHUSETI'S
Bt;=LNG DEP.%RT%i&VT
120 WASHLNGToN SmET, 3n FLOOR
TEL (978)735-4595
FAx(978) 7411.9846
KIMI) ALEY DRISCOLL THOMASST.PMR18
MAYOR
DIRECTOR OF Pl:eLtC PROPERTY/BI:iLDNG CO%LN(ISSIOYER
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 At is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL o
111, S 150A.
The debris wiU be transported by:
(name of hauler)
!I The debris will be disposed of in :
(name of facility)
(address of facility)
signature of p tt applicant _
1 1 9^
date
Icbnvif Jk
n�lk
CITY OF SALEM
rt PUBLIC PROPRERTY
DEPARTMENT
1 W;N:I Y:ra1H:,n 1.
\LtYtta 12C WAsrn..M;ION51%ELT• 5AtEV,MAss.s(:nt it I Is 0197.
11.1,;978.713-9595 0 F%x. 978.710.1946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
r ylicant Information Please Print Le ibly
V J 1T1t. l BucukvsiOrganiGGratinN I nJtvrd/nal): O
:Address:
Ci1
ry�Slacc:7.ip: /� � Phunei.:
:\re au an •inployer' Check the • pproprlate box: 'Typo of project(required):
4. 1 am a general contractor and 1
I am a employer with ❑ 6. ❑ New construction
entploycias(full and/ur pun-unto).' have hired the sub-contractors
_.❑ I ;un a sole proprietor or partner-
listed on rhe attached sheet. �• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working lin me in any capacity. workers' comp. insurance. q. ❑ Building addition
No workers'comp. insurance 5. ❑ We are a corporation and its l0.❑Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 en a homeowner doing all work right of exemption per NIGL I I.[] Plumbing repairs or additions
myself.(No workers'corp. c. 152,§1(3),and we have no 12.0 Roof repairs
insurance required.) t employees. (No workers' 13.❑Other
comp. insurance required.)
'Airy apphcaut that chucks box nl mux!also till cut the action beluw showing Ihcir w•urkcri cuntpen"iws pulicy inturnuliun
'I lumeuwrwn who gibed this aMdavit indicating they me doing all work mud Then hire uulsido cwnraetorx mua.uhma a new AH'idavil indicting Mich.
-C„nirachrtv the chuck this box molt mtachud an additional.,hart,hawing lite nano of the sub�contrwlon and their,wrken'comp.rndicy infurmation.
/ane un eruyluyrr fha!lc pruviJing ivurkers'cmnpen.enrian iururnnrr jar Dry entplopeer. Below ix rhe pulicy and fob.cite
injunnurion /yy�� �
Inuuanuc Compauy slaine:
I'ulicy ii or Sclf•ins. Lic.13:. 0/ //yyrsExpIr tion Date:
Job Site :lddress: Z 1Lf/4(rRio PC/ Ciry,Jtute/Zip: ���•'�'� � GI��C
Attach it copy of lite workers'compensation policy declaration pulse(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A uf:vlGL c. 152 can lead to the imposition of criminal penalties of a
rine up to 51.5110.00 and/or one-year imprismmncnt•as well as civil penalties in the furan of a STOP WORK ORDER and a fine
of up at 5250.00 it day against the violator. Bc advi.lcd shut a copy of this siutcmenl may be lbrwarded to the O11tcc uf
In(vsugaunns ul'dle UTA for insur;uxc atvcrage tcrilic.uion.
/du hereby certify under file i .•an ter !tics ujper'ary that the iujunnutlon provided above is trite and correct.
ci�-aawre: __ . G ) Dat•:
Phi r•:1
Official use unly. Da not noire in this area,to be rump/eyed by city or town official
Citv or'I'mvn: Permit/License s.__._.
!swing Audurrily(circle one):
I. hoard of llcaldt 2. Building Department 3.Cil).Jomn Clerk a. Electrical Inspector i• Plumbing inspector
6. Ottier .
Contact Versurl: _ ._ Phone l:
IL�
Information and Instructions
.V assachusetts 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,
cv.press or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
d the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of :m individual,partnership,assocnancia 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 u 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 152, §25C(7)states"Neither the conunonwcaith 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 sub-contractor(s)nanme(s),address(es)and phone nunmber(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 of davit 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
he 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 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 Office of Investigations has to contact you regarding the applicant.
Phase 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 penniulicense applications in any given year,need only submit one affidavit indicating current
policy information(if 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. it dog license or permit.to burn leaves etc.)said person is NOT required to complete this affidavit.
I he t)tiice of investigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel, k 617-7274900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
5-26-05
www,mass.gov/din
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE1117/2010rrY)
TM.
PRODUCER Phone. (781)729-1080 Fez: (781)729.4460 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
SHIELDS&ASSOCIATES INSURANCE AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
175 WASHINGTON STREET SUITE B21 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
WINCHESTER MA 01890 ALTER TH ICIFS as
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Nautilus Ins.Co.
O'KEEFE BROTHERS CONSTRUCTION,INC. INSURER B: Chartis this.Co.
397 LINEBROOK ROAD INSURER G:
IPSWICH MA 01938 -
INSURER U'
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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR N70i TYPE OFINSURANCE POLICY NUMBER POLICY EFPECnw POLIMEXIM"TION LIMITS
LTR IN50. DATE(MMI DATE MMMD
GENERALUABIUTY NNO14121 0410910 04109!11 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY CAMAGETORENMD
PREMISES(Ed $ 100,000
omurenuel
CLAIMS MADE OCCUR MED.I(Any One porson) $ 5,000
A PERSONAL&ADV INJURY $ 1,000,000
GENERALAGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PROOUCTSGCMPIOPAGG. S 2,000,000
PR
POLICY JECTO-
l.00
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea BOutlenp $
Alt OWNED AUTOS BODILY INJURY
SCHEDULEDAUTOS (Per person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per acei0en0 $
PROPERTY DAMAGE $
(Per nowhere)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGO $
EXCESS t UMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR El CLAIMS MADE AGGREGATE S
a
DEDUCTIBLE ...^..�... $..
RETENTION 8 $
WORKERS COMPENSATION AND WC 742248810 04114110 0414111 TOn'TU.T. 9T1KR
EMPLOYERS'LIABILITY
B ANY PROPRIETORIPARTNER@XECUTIVE E.L.EACH ACCIDENT $_ 500,000
OFFMERm1EMBEREXCLUDED> EL DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under —
—
SPECIALPROMSIONSWid. E.L.DISEASE-POLICY LIMIT $ 500,000
OTHER: '
it
DESCRIPTION OF OPERATIONSJLOCATIONS7VEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS R
Evidence of Insurance
CERTIFICATE HOLDER CANCELLATION
Joanne Sims SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THF
7 Quadrant Rd. EXPIRATION DATE THEREOF,THE ISSUING INSURER HALL ENDEAVOR TO MAIL 10 DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO
Salem,MA 01970 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS
AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Attention: U +�{}tliCt.IAMS SHI
ACORD 25(2001108) Certificate# 5692 @ ACORD CORPORATION 1988