Loading...
16 READ ST - BUILDING INSPECTION O GK IlOs The Commonwealth of Massachusetts Board of Building Regulations andStads�xlNAl CITY OF Massachusetts State Building Code,78 CMR SALEM � S�Q 1� 4 1�et�'sed Mar 2011 Building Permit Application To Construct,Repair,Reno a lisp a One-or Two-Family Dwelling 0) Thts Setd3on For O,mow Use .OW O 13uizling PBe ;Nuu Date Aid: 11. > ng eial(Pritd e) Sigaattra Data >jECTI(1Pi 1:S17E II+7�'ORMATIDiN " 1.1 Property A dress i 12 Assessors Map&Parcel Numbers r �j/ I 1.1 a Is this an accepted street?yes no Map Number Parcel Number I{�- 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(fl) 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: Zone: _ Outside Flood Zone? Municipal E3 On site disposal system 13Public Private❑ Check ifyes SECTION2 PROP$RT!9VVAiERSEDI 2.1 Ownert otRe�co/rd: K-1 fd Name(Print) City,State,ZIP p _ /6 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that aPPly) New Construction❑ Existing Buildin Owner-Occupied. Repays(s) ❑ Alteratioa(s) Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Sp�ecify:�at) -tR-CPLACE A seat Brief Description of Proposed Work7 P_ y : ��;C X7cJ� p KrZM6 -jA61 J4r — y" >e zo SECTION a:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials --- -- - 1.Building $ 1 Building Permit Fee:$ Indicate how fee is determined`, ❑Standard Cityfrown Application Fee 2.Electrical $ O Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ List.- 5. ist'5.Mechanical (Fire $ Total AH Fees:$ Su ression Check No. Cheek Amount: Cash Amount: 6.Total Project Cost: $ QQ' ❑p h�dl 13 Outstanding Balance pre: s crloiv s: CONSTxucr Mi MMICIM, y 5.1 Construction Supervisor License(CSL) r License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Unrestricted to 35 000 on-R aWSRC Restricted 1&2F Dwelling City/Town,State,ZIP Masonry Roofm Covering Window and SSolid Fuel Burning Appliances Insulation Tel hone Email addressDemolition/�Q 5.2 Registered Home Improvement Contractor(RIC) �Q a Z �O E3 HIC Registration Number Exp' 'on Date HIC Compeoy Name HIC R� tNa�pe t �V.1 sM15�nI RC2 .,rev 0 No.and Street( `!Nt Ly� 12.9 / 7� 3.3'�11/2, Ci /Town State ZIP Te] hone SECTION 6:®YORKERS'C( %PMATION I UR"CE AFFIDAVIT(J LG.L c.152.3 25CM) 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 ..........O No..........� SECTIt")I'i 7a OWNER AUTHORl7A T(O sE Ct)WLMIA WRiN OWNER'S ( COM IrMVM I,as Owner of the subject property,hereby authorize N] 62ri,� ivP-�c�4 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 b:OWNEW OR AUTH03UM 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 knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date 1. 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 can be found at www.mass.eov!oca Information on the Construction Supervisor License can be found at wwnv.mass gov/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 beating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth Massachusetts o use f trs Department of IndushialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. ` TO BE FRED WITH THE PERMITTING AUTHORITY,Applicant Information MIPlease Print Legibly Name(Business/Organization/Individual): C Address: rZ( L1 NCpL.If L2—n City/State/Zip: ��f/l.( ®l.' Phone#: g7Q Are you an employer?Check the appropriate box: Dn f project(required): I.RI am a employer with employees(full and/orpan-time)." ew construction 2.❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] emodeling 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t emolition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on ro roe I will uilding additionensure that all contractors either have workers'co emation insurance or are solery"'p lechical repairs or additionsproprietors with no employees. lumbing repairs or additions5.�I am a general contractor and I have hired the sub-contractors listed on the attached sheet.These sub-contractors have employees and have workers'comp.inso,mce.t oof r airs ^ �6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. ther/ (CX -t l�Ll�152,§1(4),and we have no employees.[No workers'comp.insurance required.] ,.•Any applicantthatchecks box#1 mustalso fill out the section below showin their workers'core ation.l t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit ea new affidavit indicating such. tContracors that check this box must attached an additional shoo showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide thein workers'comp.policy number. I am an employer.that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy Dumber and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 agaa violator.A c of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverag v 'ficatio I do he by rtijy u er th pains an ena/ties of erjury that the information provided ab e isfrue and correct Si am Phone M g 70 3 )/ Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person• Phone#' 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 sub-contractor(s)name(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 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 perrmt/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)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 dog license or permit to bum 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, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia 07Y OF SALEK MASSACHUSE7T artuEIMDarAF3MW 120 Wnstme;7 NS"NEr MFt t Bt ����s-mss. • A�BRiEYI, FAA AD.M b AUYCCR 71tan�SSl.P�taF Dmacac#t cH+FnWWPXaMlY/BUMVMaMW9t HSR Construction Debris Disposa/Affidavit (required forall demolition and.renovation work) In aorordarm with the sbA edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL oW,S 54; BuIlOW Permit fi is ismW with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111,S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) SignatLire of applicant z11b Date From:Arthur S Page Insurance 978 462 0890 09/12/2016 10:05 #787 P.003/006 GANSALI OP ID:KQ A�O� OATE(MNIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 09/12/2016 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(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 endorsemen s. PRODUCER CONNONE None CT Arthur S Page Insurance Agency NAME; 57 State St 978-4653301 1 IWAX.Ne, 978.462.0890 Newburyport,MA 01950 None ADDRESS, INSURER(SI AFFORDING COVERAGE NAICY INSURER A:Western World Ins Co INSURED Alan ansen ergberg INSURER B: dba Lincoln berg Construction 21 Lincoln Rd. INSURER C: Salem,MA 01970 INSURER 0: INauRea E: INSURER R: 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. ILTR TWEOFINSURANCE POLICY NUMBER MWD NPOLICY EFF NI EV UNITS A X COMMERCMLGENERN.LIABILITY EACH OCCURRENCE a 1,000,00 CLAIMS-MADE a OCCUR NPPS315642 06103/2016 06/03/2017 p EMISES Ea. .l S 100,0 MED EXP(Ary one ) S 5, PERSONAL&ADV INJURY S 1,000,0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE IT 2,000100 POLICY[I PET LOC PRODUCTS-COMP/OP AGO S 1,000,00 OTHER: S AUTOMOBILE LIABILITY COR11IRffl)MINGUELIMITMe eccft S ANY AUTO BODILY INJURY(Par prim) a AAUUTOOS SCHEDULED SODILYINJURY(Psew) S HNEDAUTOS �O.OWNED p S S UMBRELLA LAB OCCUR EACH OCCURRENCE a MCESS LIAR CLAIMSM40E AGGREGATE S DED I RETENTION $ RSCOMPENSATION AND EMPLOYPR$LIABILITY YIN II- ER ANY PROPRIETORNAATNEWEXECUTIVE E.L.EACH ACCIDENT S OFFICERMEMSER EXCLUDEW El NIA fhlwde ryN NH) E.L DISEASE-EA EMPLOYEE B tl yyee&&6%bo antler 0 SCRU'TION OF OPERATIONS W. EL DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AdtRIMW ftm Schedule,may MatacMU 1/mon apace Is Ipulntl) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street Salem,MA 01970 TH AUTHORRED REPRESENTATIVE ' 0198&2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD From:Arthur S Page Insurance 978 462 0890 09/12/2016 10:05 #787 P.005/006 ACC)Rd CERTIFICATE OF LIABILITY INSURANCE MM(MMMWY"") 09/12/2016 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 INSUREII AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the polloy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,Certain policies may require an endomemem. A statement On this cerWkate does not Confer rights to the Certificate holder In lieu of such endoreemen a. PROWLER -EAME: Jacqueline Pae ARTHUR S. PAGE INSURANCE AGENCYP "E ' 978 465-5301 L ackie anhu m a e.coII 57 STATE ST. INSURER(S)AFFORDING COVERAGE stuns ! NEWBURYPORT MA 01950 IM !ERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: GANSENBERG ALAN DBA GANSBERG CONSTRUCTION INSURERC: WNURER D: 21 LINCOLN RD a1SURLat E: SALEM MA 01970 NSUREt F: COVERAGES CERTIFICATE NUMBER: 83901 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY"AVE BEEN REDUCED BY PAID CLAIMS. Let TYPEOFINSURANCEPOLICYEFF PO Y PODGVNUNBER MNO M LaViS P—ME MRCULGENERALLIABILITY EACH OCCURRENCE _ $ CLAIMS-MADE ❑OCCUR S Ee6m E MED El(P(My are w) E NIA PERSONAL a AW INJURY E GENL AGGREGATE LINT APPLIES PER: GENERALAGGREGATE E POLICY ElJECTT 7 LOG PROWCTS-COMPIOPAGG S OTHER: S AUTOMOBILEUASI ITY COMSI em,cZES S NY - AAUTO - EEBODILYINJURY(Pwr ar ) S OD SCULED N/A BODILY INJRY(Persotoerd) $ATTED HIRED AUTOS NON4MED PROPER S AUTOS em S UMBRELLAWIBOCCUR EACH OCCURRENCE S EXCESS DAB CLAIMSMADE WA AGGREGATE S DED I I R ENTION$ $ MOWERS COMPENSATIONX A E TH- ANDEMPLOYERa'W&L YIN A OFFICEMEMBERMWOED'/ECVR � ILIA MIA WA 6HUB9F7458OA18 06/03/2016 06/03/2017 VE EL EACH ACCIDENT $ 100,000 (Andebryln NH) EL DISEASE-EA EMPLOYEE S 100,000 N Yah, ufh dees udder DESCRIPTION OF OPERATIONS below E.LDISEASE-POUCYUMIT S 500,000 N/A MSCCPTIONOFOPERATIOM/LOCATIONS!VEHICLES(ACORD101,Adr MIRecordsacheWle,mymele N=Mapaeehrepue M Workers'Compersadon benefits WIII be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 OB B,no authorization Is given to pay claims for benefits to employees in states other than Masseenusetts H the insured hires,or has hired those employees outside of Massachusetts. This osnificats of Insurance shows the policy In force on the date that this oertlecete was Issued(unless the expiration date on the above policy precedes the issue date of this oeraRcats of insurance). The status of this coverage can be monhored dally by some;Nng the Proof of Coverage-Coverage VedBcagon Search tool al www.mass.gmnwdAmrkel mpensationfinvesUgatbns/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street A`UTTHHORQ/1ED REPRESENTATIVE Salem MA 01970 `niel C�_/1_ Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1968.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD