13 RIVER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
SIX Town of
t Board of Building Regulations and Standards 'a
Massachusetts State Building Code, 780 CMR, 7'"edition Budding Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tivo-Faa ' u• !ling
This S on For Offici4 Use Only
Building Permit tuber: I IDIAA plie
Signature:
Building Commissione/Ins for of Buil Date
SECTION E INFORMATION
1.1 Property Ad ess: S� 1.2 Assessors Map& Parcel Numbers
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 ft) Frontage(ft)
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❑ On site disposal system ❑
Public 13 Private❑ al Check if es❑ P P y
[[{{
SECTION 2: PROPERTY OWNERSHIP'
l�„
2.1 Owr r2l` /Ly)x.4 //7 O nrL( GuNI /I/b,
Name(Print) Address for Se ice:
1G3 �-/ 97 `�� 1 �
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building 04 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': !dam%r�4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost (Item 6)x multiplier
3. Plumbing $ 2. Other Fees: $ T
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Su ression
Check No. _Check Amount: Cash Amount:_
6.Total Project Cost: $ �' 0. 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N:)mc:f CSL-rJHpWer 1 A G j�,-A r771 List CSL Type(see below)
Addres �� Type I Description
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Sig Lure G)� �/ M Masonry Only
R- Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2,:)Rip,istered H"e I91provSme Contra rHIC)
HIC Comp y Name or HIC Registrant Name Registration N tuber
C 9 f-- o S
Address Lj70 3
Expiration Date
Signature Telephone
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 . .......0 No........... ❑
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
W
O NER S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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:OWNEW OR AUTHORIZED AGENT DECLARATION
1, J Ge--y" 7 C rrs20/a ,as Owner or&thorized Agent ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf SS-,
Qr r
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 I l0.R6 and I I0.115, respectively.
2. When substantial work is planned,provide the information below:
Total Moors 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"
• . Page No. of Pages
GIRARD CONSTRUCTION
A Company You Can Count Onl
7 EDEN GLEN AVE.
DANVERS, MA 01923
(978) 423.3881 0 Fax (978) 774.1520
PROPOSAL SUBrill DTO PHONE DATE
\fie L y -
STREET JOB NAME
L/
CITY.ST"ZIP CODE JOB LOCATION
7 \ —
ARCHITECT 1 DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for: 1
� � �Yv� tE �',Gi��;�G 'r�c�- � 1 \c ter r� �-• ,tom ����t r6v� c7ec�
`Nl, ,\Lem -,.rr,.ce' \0e, -Iii: \tiG�e�Lih,Plci -Y ,4
J-(A F --1 6- \ C'ul%P .
- c
We Propose hereby to furnish material and labor— complete in accordance with above specifications, for the sum of:
G �A
dollars($
Payment to be made as follows,
en y�(U
All mate al as guamr.leed to be as �oeclfied. All work ;o de Comgy'�ly. workmanlike Authorize
manner according to sta chid mactees Any alteration or neveraM�,fN ha specifications
mvolvmg eava costs cnll be executed only uZan nntem orders. and 1111 became an extra Signatu
C,are over and above .he estimate. All agreemems contingent upon stnkesscreams or
-r aays beyond on, control Ormer to carry fire. tornado and career necessary insurance, Our Note:This proposal may be 7
:.or,ers are fully covered by'Norkmans Compensation Insurance, withdrawn by us if not accepted within / days.
Acceptance of Proposal —The above prices,specifications /
, g,
and conditions are satisfactory and are hereby accepted.You are authorized to do the Signatu ��� /� �M + . 1-
—
work as specified-Payment will be made as outlined above.
Date of Acceptance: Signature
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT, 311 FAX (978) 740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
0 Construction ❑ Moving
Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District McIntire
Address of Property: 13 River Street
Name of Record Owner: De1Rar LLC
Description of Work Proposed:
Replacement of existing roof to replicate existing(black, 3-tab). No changes in color, material, design or
outward appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: April 1, 2009 SALEM S I MMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM DD YYYY)
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.
BeverlyNFL 01915- INSURERS AFFORDING COVERAGE NAIC Y
INSURED
INSURER A:Zurich
.Scott Girard INSURER B'.safe
7 Eden Glen Avenue INSURER C'
INSURER 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 DD' POLICY EFFECTIVE PODGY RATION
LTR IN8R TYPE OF INSURANCE POLICY NUMBER DATE MWDD DATE MYR) LIMITS
GENERAL LIABILITY EACH OCCURRENCE E
COMMERCIAL GENERAL LIABILITY DAMAGE TO Ea omErrenm f
CLAIMS MADE D OCCUR / / / / MED EXP A one arson $
PERSONAL S ADV INJURY E
GENERAL AGGREGATE f
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO-
POLICY LOC
PRODUCTS-COMP/OPAGG f
JECT
B
[AUTOMOBILE UABIUTY 005001990 04/06/2008 04/08/2009 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident)ALL OWNED AUTOS / / / / BODILY INJURY
SCHEDULED AUTOS (Per parson) E 100,000
HIRED AUTOS / / / / BODILY INJURY
NON-OWNED AUTOS (Paracdaent) E 300,000
1997 DODGE RAM / / / /
PROPERTY DAMAGE f 100,000
(Per accident) ,
GARAGE LIABILITY
AUTO ONLY-EA ACCIDENT S
ANY AUTO / / 01 ERTHAN EA ACC f
AUTO ONLY
AGO E
RESSIUMBRELLA LIABILITY / / EACH OCCURRENCE f
OCCUR CLAIMS MADE AGGREGATE f
E
DEDUCTIBLE
RETENTION f E
A WORKEREMPLOYSCOYPBILITY )NAND 6ZZOR-071BL21-5-07 07/10/2008 07/19/2009 X WCSTATU- OTH-
EMPLOYER&LIABILITY TORY LIMITS ER
ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT E 100.000
OFFICER/MEMBER EXCLUDED?
If yes,desEnbe under / / / / E.L.DISEASE-EA EMPLOYEE$
100,000
SPECIAL PROVISIONS below
OTHER E.L.DISEASE-POLICY LIMIT f 500,000
/ / / /
DESCRIPTION OF OPERATION&LOCATIONSN HICLES/EI(CLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
( ) - (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL 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 LIABILITY OF ANY KIND UPON THE
Building Inspector INSURER,ITS AGENTS OR REPRESENTA ES.
120 Washington Street ATNORQED REPRESENTATIVE /�
Salem NFL 01970- / I L �r�
AaCORD 25(2001108) ®ACORD C P RATION 7988
VE w INS0251ome)oe ELECTRONIC LASER FORMS,INC.-(800)327-0545
Page 1 of 2
CITY OF SALEM
max. I PUBLIC PROPRERTY
ff
DEPARTMENT
.5.1P'.K'I\ 'Kilt 1-11
W,%111\(;I,)\SI:(LLI a SAtI'yt, MAs1.0 III it I I,3197
11:1. 9711-,'15.95'13 • 1',.v 974.74G it 46
liYorkers' Compensation Insurunce Affidavit: Builders/Contractors/Electricians/Plumbers
It1 )licaut Information Please Print Le ihly
V;Ilnt:tnu.ulewl)rpanlralinn,lndn oluull: r'Vv J�.//��
ell, nr c 7
City,Slaw.Zip 0n^�r /' M- ®/ `13 I'huncr �/ �1%27,7EV
Are)nu an employer:' Check the appropriate bus: '1•)pe of project(required):
I.a I anti �with employer 4 ❑ 1 :nn a general contractor and 1
h. [3 New construction
cmploycea(full unLL'ur part-tune).' have hired the suh-contracture
2.❑ I ant a sole pmprictty or parencr- listed on the anachcd.sheet. ® Remodeling
,hip and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. g, ❑ Building addition
1Nn workers*comp. insurance 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions
Irequired.) officers have csercixcd their
3. ❑ 1 ant a homeowner doing all work right ofcxcntption per NIGL 11.❑ Plumbing repairs or additions
myself.[No workers' cutup. c. 152, g 1(4),and we have no 12.® Rtwf repairs
insurance required.) r employers. [No workers' U.❑Other
eomp. insurance required.)
•,u. .yphcaut dull checks btu el must alai fill out the wc1son Wow,huwiny IMr wurkui cun,penauivo Iwhcy ndimnutiva
' I lumeuwtwrs whu Mimi this affidavit indieuina they its Joint'all work wul Ihen hire wiside cu eraeton must auhmil a new al r,davit indiobng such.
4'.•ntrxuKs thm,hat this bo:mim machsrl en add.lional sheet.ho my ale name of the tubtontrwlors and then wurkers'amp,puhcy mfurmado,
l aor un employer that is pravidfne worlers'curnpenrntiun insurance jar my enrpluyees. Behnv is the policy ant!/ob.vie
inforrnurion ^7
Ir.,orancc Company Name: 9
1'ulicy H or Self-inn. Lic. it: �ZZ4/-7— U'/1 41` b 7 Enpiraoon Date: �F Q/
r r
)ul) lite -\ddress: 17 'xrw,7 V— C'Ity:StateaZlp:
.\ttach it copy of the workers' corepensathm policy declaration page (showing the policy number and expiration date).
I'allurc to,ccuru cuserage as required wider ScLiiun 25A of>IOL c. 152 can lead to the imposition of criminal penalties of a
rine up (o.i1.500.00 andlur one-year ilnprisomncnt, us welt is cn it penalties in the form of a STOP WORK ORDER and a fine
of op to 5.250.00 it day against the violator. Re advL+cd that a copy of thu statement may be fur%arded to the Office of
I'a;en,amnb of:hc DIA :'r)r so,ut.mce a,veal,c ,ei ifiLAImn.
l du Iterrhy c.rrify under dm -is wt _ ••y of a".try their rhe in/brinut/on provided above is
true and correct.
tJ/jiciu/use mdy. Od mat ''rife I"lis mcu, m he cuutpletrd by tiny,ur Imvn,r1jiriu/. j
( ity ur fawn: __. Pcrmitil.icense 4
Issuing .\uthurity (circle nuc):
1. 14,ard of llc.dllt /. Buddin;� 0cpartancuf 3. Cits.'luwn C'lcrk 4. Electrical Inspector i, Plumbing Inspector
6. Other _
Cl ul t ad Pvrsuu: -. _ I'hwnc h:
Information and Instructions
Lus.ichu.:ems Gcneral Laws chapter I i2 requires all ewplo)crs to provide workers' compensation for their employees.
1'urnu.mt to this .ramie,an emplutee is defined as .e%er) pc)son in the service of anuhlier under any contract of hire,
c.pre,s or nnpI ied. oral or wri Uen...
.\n einpluper t<defined as"an individual, partnership, ssociallou.corporation or other legal entity,or any two or more
,,I the t„regoo;g engaged nh a joint enterprise, and including the !cgal representatives of a deceased emplu)cr, or the
teens er or(rusice of.m individual, panmershnp, association or other legal entity,employing emplo)ees. However the
owner of a dwelling house having not snore than three apartments and who resides therein, or the occupant of the
,Iwclluhg Ihouse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or oh the.-rounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL chapter 152. $25C(6)also states chit"every state or local licensing;agency shall withhold the issuance or
renewal of a license lir 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."
k.ldiuonully. MGL chapter 152, §25C(7),rates"Neither the commonwealth nor any of its political subdivisions shall
anter into any contract for the performance uf'puhlic work until acceptable cvidence ufcompliance with the insurance
requirements of this chapter have been presented to the contracting authority."
applicants
Phase fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)nartic(s), address(es)and phone number(s)along with their cerftlicute(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
\ccidents for confirmation of insurance coverage. Also be sure to sign and dule the affidavit. The affidavit should
be Ieunrned no 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. Sclf-insured companies should enter their
elf-insurance license number on the appropriate line.
City or Town Offlclals
Please be 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 out in the event the Otlice of Investigations has to contact you regarding the applicant.
111,iise be sure to till in the pcnnidlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitaicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Jab 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. Anew 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
;n dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I h. 1l lice of hive's❑gatnons would Ione to thank )'ou in advance fur your cooperation and should sou hacc any questions,
please do not hesitate to give us a call.
fhc Dcpanmcnu's address. telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMCC of lovelidgetlons
600 Washington Street
Boston, MA 02111
Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mass.gov/dia
>ln.:;xnu.ett,- Department of Public Safetc
Board of Building Re>ulations and Standard. -
Construction: Supervisor Specialty License
License: CS SL 101070 '
Restricted to: RE --
SCOTT GIRARD x
7 EDEN GLEN AVENUE
DANVERS, MA 01923
=zpiration: 11/16/2011
Tr=: 101070
. \ Board of Building Regulations and Standards -
PB2,1% - HOME IMPROVEMENT CONTRACTOR
� Registration: 157099
Expiration: 9/5/2009 Tr# 258889
. .Type: DBA'
GIRARD CONSTRUCTION -
SCOTT GIRARD
7 EDEN GLEN AVE.. ..
DANVERS, MA 01923 - Administrator
CITY OF SALEM
y
:l p
r a PUBLIC PROPRERTY
e
DEPART':1IENT
L'; q.\,1 'Ntirs l:rr 0 tial I m. Nh.;
I I I'7's 'i; '%,1-'J:9i4ig
Construction Debris Disposal Affidavit
(required litr all demolition and tunovation work)
In accordance wth the sixth edition of the Slate Building Code, 780 CNIR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
96.eV-1 //µd,
(name of hauler)
Ilie debris will be disposed of in :
(name of to dity)
J .?'ve a ii/. Cyt
(address nl lacilit_vl '/////
,Iguaturc of permit upplicant
date