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13 RIVER ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Town of — Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7"edition Building V\ Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Tit o-Fmnill,Duelling This Section For Official Use Only Building Permit Numb Date Applied: Signature: yea Building Commissioner/ Spector o(Buildings Date SECTION 1:SITE INFORMATION 1.1 Propert Address: 1.2 Assessors Map& Parcel Numbers Ma Number Parcel Number 1.1a Is this an accepted street?yes_ no. p 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(R) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L C.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public 13 Private ❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' 2.Iw/npr of Record: p�i�( 4�Vr'-'C-111V/ 0O''OAL Name(Print) Address for Sery 07- 0 -La /2 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ltera Id7 Ations) Addition ❑ Demolition ❑ Accessory Bldg. O Number of Units Other ❑ Specify: Brief Desenption of Proposed/Work': "�'2'y" �� "� R.-✓l' /J T SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building S I. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost"(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: E 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees: E Su ression Check No. _Check Amount: Cash Amount: 6.Total Project Cost: f 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licernsseed/Construction Supervisor(CSL) 9/10X7 �• p LQV07-'x,t License Number Expiration Date N4mc ol'CSL yIW�CO _� / List CSL TYPr(see k/3. l �/. AddressDescn tion T' Unresmc(edluR to 35,000 Cu. Ft.) Signature' Restricted I&2 Family Dwelling M Masonry Only RC Rcvdcntial Roofing Covering Teleph WS Residential Window and Siding �� '� SF Residential Solid Fuel Biming Appliance Installation I D I Residential Demolition 5.2 Rst�ed,Nomg Improvement Contractor(HIC) /f705p5 HIC Company Name or HIC HIC Registrant Name Regtstra ion umber �/J r11t 6k� ALC l�it.rxy' ./Sa.O/r27 9 �'+ Addim Expiration Date Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(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 AlTidavit Attached? Yes .......... A No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I• as Owner of the subject 3 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:OWNEW OR AUTHORIZED AGENT DECLARATION I• `� —`• /` ��� ,as Owner or ud orizc�dAgent reby declare that the statements and information on the foregoing application are true and accurate,tote est of my knowledge and behalf. Print Signature of Owner or Authorized Agent Date �l (Signed under the pains and penalties of perjury) NOTES: 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 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• CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT 0 I I I V'A 'l; \X. X1'8.-4_ •liL. Construction Debris Disposal Affidavit (rcyuited lin all demolition and renovation work) In accordance wth 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 # is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I 11. S I50A. The debris will be transported by: (name oChaulcr) I he debris will be disposed of in (name )I facility) - IaJdree<ul'lacility) - HLIIatulc ut penmt appl]cant ���/1-9 ! date CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ,.,I1'.M 11' Inhr .91 \1 o,A 11: Is r s inti rt, M.s\r.N In it I I.JII7^ Ii,1. 'O!-713-9545 • I s.x 97111-74C'is1h Workers' Compensation Insurance %friidavit: Builders/Contractors/Electricians/Plumbers %imucant Information Please Print Leeihly v:11T7C lnu.uwrvlhq]n v.16.1N1n/dn�u//luul l: 1.Idres�: FO r'07 67A sHL City,State.Zip n�72J?¢/ 1. O /9aJ 11hunc .%re you in employer'! Check the appropriate box: - l ype urprojcct(required): ,k 4 I am a general contractor and 1 6. New con,trucuun I.®-1 :un a employer with o� ❑ ❑ engrlu)ecs(lull inaL'ur part-tines).' have hired the still-contractors 2. C] I sot a sole proprietor or partner- listed on the attached sheet. ; 7. ❑ Remodeling ship and have no employees These subcontractors have S. ❑ Demolition working lits me in any capacity. workers' comp. Insurance. g. ❑ pudding addition No workers'cum insurance 5. ❑ We area cni7soratinn and its I P 10.❑ Electrical repairs or additions I required.) officer have exercised their 3. ❑ I ant it homeowner doing all work right of exemption per MGL 1 I.C] Plumbing repairs or additions myself. LKo workers' comp. c. 152, ¢1(3),and we have no 12.❑ Rouf repuirt insurance required.) t anpluyecs. LNO.vorkers' 13.0 Other comp. insurance rcquircd.1 •rte phciut that checks box al marl.1130 Till out the.wood lwluw shuwma Thur wurkmv'cumprnr:diun pulicy mliurtutium ' I L+meuwnen whu WWnj1 this affidavit indiuTina Ihe)arc duiny all work mW Then hire uutrlde coniraetun must.uhmit i new afrda.it:ndie:dlny."ch. 11IirwmtN That check this box mtut anachcd an eeddional.duet showing nes nanw of the sub<ontfaeton and their wurkeni comp.puhcy Inrurmanun lam un employer that i.s pruvidin,q workers'campenrndon insurance for my empluyetm Below is rhe pulicy and job site infurnturiun / z( Ar!/ Imorancc Company Name: �/ ---- .- - -------- I'uli::v it ur Sclf-ins. Lic. r<: ZZ!" Expiranun Date:rI y/ o,Itmay�� Jou Site Addrvss: — _ city,Stateizip: '/'2A� 1 ' 0/99)/ Attach it copy of the workers'cumpenutlon policy declaration pale(showing the policy number and expiration date). hat lure to secure cos erage as required under Sec(lUn 25:\ul'.\IGL a 151 can lead to the imposition ofcriminal penalties of a fine op to'0.500.00 an&'ur mile-)'ear❑Ilprlx.Itnncnt, at wtiil is cis ll (ICttaIncs til the I'unn of a STOP WORK ORDER and a fine Of up to S250.00 is Jay against the violator lie advised that a copy of this swicincrit may be forwarded to the Office f 111% uCamma ul :hc DIA :or o,u, jrcc oncrage ,c,ilicat:un. l to hereby,.rtifv trader polos a•r u rjary that the information provider//,o0ove it rue turd correct. I)f1ie'iul ore unly. Du not Ivrire its fhA arra, tube cwnpleled by city up town u//iriul- I ( its, or fno'n: _._ __. Permit/License 0 I,ruing .Isulhurily (circle otic): I. Doard of Ilv.dlh Z. Ilwldio� ncparllucni I. I.itsAti n Clerk J. Electrical luipector 5. Plumbing Impccior G. Other _ C.+nisei femur: .. Phone 1: Information and Instructions V.u;admsetu Genesi Laws chapter 132 requires all ewnplel)crs 10 provide workers' compensation for their employees. 1sur.u.ut to Rus ,latute, an empJOree is defined as" .ewcD Pelson in the service of another mider any contract of hire, e%press or Implied. oral or sur ltten." \n e,nplu)s•r rt defined as"an Individual, partnership, .issocianou,corporation or other legal entity,or any two or more It Its torcgoing engaged Ili a Joint cmerpr,se. and Including the regal representatives of a deceased cmpluycr, or the _ f eCeiv Cr or trustee of .ui Indavldual, paitlier>hlp,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 ,Iwellmg house of another who employs persons to do maintenance,construction or repair work on such dwelling house shall not because of such employment be deemed to be an employer." or or. the growuis or budding appurtenant thereto .'.tGL chapter 152, $25C(6)also states that "every state or local licensing agency shall withhold the issuance or renewal of u license for permit to operate a business or to construct buildings in the communweulth for any applicant 1.110 has not produced acceptable evidence of compliance with the insurance coverage required." kJdiuunally, MGIL chapter 152. a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall zrotor into any Contract for the pertomlance of puhlic wurk until acceptable cV Iden LC 01 L'u111P1ia11CC 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 dale the affidavit. The affidavit should ha rctmled to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you liave any question regarding the law or If yuti 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'rown Ofnelals please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit fur you to fill not in the event the Office of Investigations has to contact you regarding the applicant. I'lo:uc be sure to fill in the penniulicense number which will be used as a reference number. In addition,an applicant that must submit multiple Perin i0iceose 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 Koine owner or citizen is obtaining a license or permit not related to any business or commercial venture t i.e. a Jug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I h.: I)(tice of would like to thank you in advance fur your cooperation and should)'all llawc .my questions, please Ju out hesirate to give us a call. rhe DJ parnmcru's address, telephone and fax number' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. b 617-727-4900 ext 406 or 1-877-MASSAFE Fax M 617-727-7749 www.mass.gov/dia �l assachuseu,- Delnu-tment of Public Sat'etc - -Board of Building Regulations and Staodurds Construction Supervisor Specialty License License: CS SL 101070 Restricted to: RF SCOTT GIRARD k 7 EDEN GLEN AVENUE DANVERS, MA 01923 Expiration: 11/16/2011 ('.,......i��ner Tr=: 101070 ✓die ,,{ioawmoxeoea,�l�z �./�¢aaar<eaoeda Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration. 157099 - Expiratlon: 9/5/2009 Tr# 258889 ,Type DBA, GIRARD CONSTRUCTION SCOTT GIRARD 7 EDEN GLEN AVE DANVERS,MA 01923 -- - Administrator ACORD CERTIFICATE OF LIABILITY INSURANCE DATE 06/2009 04/06/2009 PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Lauranzano Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIC INSURED INSURER A:Zurich Scott Girard INSURER B:Safety 7 Eden Glen Avenue INSURER C: NSURER D: Danvers MA 01923- 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. INSR ADWL POLICY EFFECTIVE POLICY EXPIRATION LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE MWD DATE MMM UNITS GENERALLIAB JTY / / / / EACH OCCURRENCE E COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence E CLAIMS MADE ❑OCCUR / / / / MED EXP(Any one efson E PERSONAL S ADV INJURY E GENERAL AGGREGATE f GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG E POLICY PRO- LOC H AUTOMOBILE LIABILITY 005001990 04/06/2008 04/08/2009 COMBINED SINGLE LIMIT ANY AUTO (Ea actlEenp E ALL OVMED AUTOS BODILY INJURY SCHEDULEDAUTOS (PwParsee) E 100,000 HIRED AUTOS / / / / BODILY INJURY E 300,000 NON-OWNED AUTOS (Pel ecdaeni) X 1997 DODGE PAM / / / / PROPERTY DAMAGE f 100 000 (Per acdeent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT E ANYAUTO / / / / OTHER THAN EA ACC E AUTO ONLY: AGG E EXCESBUMBRELLA LIABILITY / / / / EACH OCCURRENCE E OCCUR EICLAIMS MADE AGGREGATE E E DEDUCTIBLE / / / / E RETENTION E E A WORKER$COMPENBIITpNAND EMPLOYERS'LIABILITY 6EZDa-071BL21-5-07 07/18/2008 07/18/2009 X roRvuMiis I I CER" ANY PROPRIETOWPARTNERIEXECUTIVE E.L.EACH ACCIDENT E 100.000 OFFICERIMEMBER EXCLUDED? If yea.aeWbe under / / / / E.L.DISEASE-EA EMPLOYEE E 100,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT E 500,000 DESCRIPTION OF OPERATIONSILOCATIONStVENICLESMXCLUSIONS ADDED BY ENDORSEMENTISPECAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ( ) - (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER VALL ENDEAVOR TO MAIL _ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City Of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABIUTY OF ANY KIND UPON THE Building Inspector INSURE ITS AGENTS OR REPRESENTA 3. 120 Washington Street AUTHORIZED REPRESENTATIVE �/' Salem IAL 01970- ACORD 25(2001108) ®ACORD CP RATION 1988 q.,,-INS025 rotnBl o5 ELECTRONIC LASER FORMS,INC. (800)]21-0545 Page 1 of 2 �MUNSPLU9 (978)531444 � • • " Page No. of Pages GIRARD CONSTRUCTION 61 r L""� A Company You Can Count Oni /'4 txa> / 7 EDEN GLEN AVE. C D , 01923 (978) 423.38813881 * Fax (978) 7741520 l} PROPOSAL SU ITTEO ZL PHONE /�� / DATE STREET CITY,STATE antl ZIP CODE JOB LOCATION Lr ARCHITEECT DATE OF PLANS JOS PHONE We hereby jsubmit specifications and estimates for: � .r 6 r!r/fy i/fi'✓1 owe 7 lan, f 'y`1ifR-ILAnC! We Propose I`areby to furnish mater and labor — complete in accordance with above specifications, for the sum of: --- — Peym to he_natle uo:rs: �--- - �- -. .._ -- ---- - dollars fS r Authorized _ r5 r s II c e d my o n e las no. II ro e en va Signature -ia n �iN_we., a � aha a n 'In" ""'a" .� Note This Proposal may be .rl �o } C .,_r .io.i ,vrance withdrawn by us if not accepted within _— days. V Acceptance of Proposal —The above prices. specifications and conditions are satisfactory and are hereby accepted. You are authoraed io do the Signature .vork as =peafied. Payment tell made)s outlined above. Salem Historical Commission 1110 WASHINGTON STREET. SALEM. MASSACHUSETTS 01970 ,978) 745-9595 EXT. 011 FAX 1978) 730-0304 CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Moving ❑ Construction Alteration ❑ Reconstruction Painting ❑ Demolition ❑ Other work El Signage as described below will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntirr Address of Propert Name of Record Owner: Del ar LLC Description of Work Proposed: Paint colors. Body— California Paints Langdon Dove Trim (including cornerboards and window surrounds) — California Paints Jewett White Doors — Black Raise roujq/'rear addition approximately 12-18'•. Rakes, cornerboards and watertable lobe addedlo match existing found under mahouse shingles. Windows and doors to remain, Rolled rubber roof Datcd: /\pril16. 2009 SAL • ISTORICAL COMMISSION /`'` / I lie homeowner has the option not to continence the work (unless it relates to resohing all outstanding elation). \II work commenced must he completed within one year from this date unless otherwise indicated. l l IIS IS NOT :A (WILDING PERMIT. Please be sure to obtain the appropriate permits f onm the Inspector of BUildines (or ane other necessary permits or approvals) prior to commencing work.