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2 ROSEDALE AVE - BUILDING INSPECTION The Commonwealth of Massachusetts K CITY OF Board of Building Regulations and Stand�$E�Tt at 'SALEM Massachusetts State Building Code,780 CMR Revised Mar 2011 OBuilding Permit Application To Construct,Repair,RenoviS"MUisA . 50 N , One-or Two-Family Dwelling TIeS Section Fsx Of :Use. Building Permit;l� Die 6.1'p1i IEhldiag Ot)l�t(Prb6 e) "_: ,_ SfgeaNrre - - SECTION I:SITE INIrORMATIDN 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers �— R0SEOF�t.� AVG L la Is this an accepted street?yes_ no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(1t) 1.5 Building Setbacks(ft) _ Front Yard Side Yards Rear Yard S Required Provided Required 7FloodZone? Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Info1.8 Sewage Disposal System: Zone: _ Outside Municipal❑ On site disposal system ❑Public❑ Private❑ Check ia- SECITON2: PROPISRSflB' O V 2.Qo�o/)Aloc�ef f. Name(Print), t // �J �- �Cicty7,"State,ZIP Z-��Olie� AWL 1707 P3ab' S'�lIlS>:DI1.C�tr� "J ( No.and Street). _ .. t Telephone .� t. Em ' ddressi N SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply) New Construction❑ Existing Building 13Owner-Occupied E3Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: * Br''efDescn 'on of Proposed Worie: e a e_ Q t9 r^ h e a" W ori � ti1e� tvti,n c� � w plzv .. . CTION 4:EsTpACTED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and nqs*teals) -- 1. Buikilmg Permit Fen $ Indicate how fee is determined: 1.Building l y 7 U� 1�AJ -- q Standard Cityfrown Application FIN 2.Electrical $ 16, 200 ❑Total Project Costa(Itern 6)x multiplier x 3.Plumbing $ 16400 2. Other Fees; 4.Mechanical (HVAC) $ Lam: 5.Mechanical (Fire $ Total All Fees:$ Su cession Check No. Cheek Amount Cash Amount:. 6.Total Project Cost:,)QU()'10 13Paid in Full ElOutstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor license(CSL) ,) 044 —I 37� 6 S �i/\ License Number Expiration Date Name of CSL Holder 5� List CSL Type(see below) Q-7 V l No.and Street I T k I Description Unrestricted 'din to 35,000 cu.R �J ZRC Restricted 1&2 F Dwelling City/1'own,State,ZIP Masonry RoofinCovernS Window and Siding Solid Fuel Burning Appliances 360 G 60 551 .� � Insulation Tel hone Email address Demolition 5.2 Re istered Home p g1vement Contractor(MC) 17-76 � ' I�f�`,L�� '��\�y An HIC Registration Number itau Date H cTpang ane or HIC Registrant Nage F of l V�C>C'lMtAy� S,3 Ouse �AI C Email address Ci /town State ZIP Tel hoce SECTION k WORKERW COMPENSATION PMRANCE AFFIDAVIT(ALG.-6.152.3 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 ..........❑ No...........O SECTION 7a:OWNER Alit'HORIZA TO BL COB&LETEI)WHEN QwNEIt'S OR CQ OR_ \.k MING ],as Owner of the subject property,hereby authorize ©bP$—'C a J 10 l 1 y` to act on my behalf,in all matters relative to work authorized by this building permit application. (UC)C-rVXArN �obes--�S `1 a 16 Print Owner's Name(Electronic Signature) ? Date 7 SECTION 7b:OWNEW OR AUTHORIZED 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 appli 'o .s true and accurate to the best of my knowledge and understanding. pa6 � c Print Owner's o uthorized Agent' Name(Electronic Signature) Date NOTES; c 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.Qov,'oca Information on the Construction Supervisor License can be found at wwwmass.eov/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 halFbaths 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" '\ The Commonwealth of Massachusetts Department of IndustrialAccidents a I Congress Street, Suite 100 s Boston,MA 02114-2017 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print --Lrr e2ibly Business/Organization Name: r45 Re-�� .r l^j 06h� SojkSA CO✓� �/ SK.Ict�c�T Address: a 'I Y1It)CfVV\,6^ $A p City/State/Zip: MAC-bleCa _ { Phone#: '3 Are you an employer?Check the appropriate box: Business Type(required): L Ld I am a employer with_�- employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.El Manufacturing no employees. [No workers' comp. insurance required]* 11.[] Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. ant an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:. G 04 i Insurer's Address: ` — �P. - Q t �QoS'y+1 A✓� 'J City/State/Zip: ty\ y k4p 9 Lf S Policy#or Self-ins.Lie.# lTi4 C sa��I Expiration Date: Ia 3' tic Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a I 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 against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify r th/eppin d penalties of perjury that the information provided above is true and correct Sienaturt / Date: Phone#: 6 L) Q Official use only. Do trot write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.inass.gov/dia 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 your insurance company's name,address and phone number along with a certificate 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 permit/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). 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 burn 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Fenn Revised 02-23-15 CERTIFICATE OF LIABILITY INSURANCE 09//26/2016°"YYY) 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(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certainpolicies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. _ PRODUCER CONTACT Paychex insurance Agency Inc PAYCHEX INSURANCE AGENCY,INC. FAx PHONE 150 SAWGRASS DRIVE . 877-266-6650 . 565-389-7426 ROCHESTER,NY 14620 E-MAIL Cerls@paychex.com INSURER(S)AFFORDING COVERAGE NAIC N VSURED INSURER A:AmGUARD Insurance Company 42390 3ASHOUSE INC. INSURERS:NorGUARD insurance Company 31470 SBA SULLIVAN CONSTRUCTION INSURER C: 27 Norman Street INSURER D: Marblehead, MA 01945 INSURER E: INSURER F: :OVERAGES 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. SA TYPE OF INSURANCE DOL UDR POLICY NUMBER POLICY EFF POLICY EXP LIMITS rR INSR MM/DO/YYYY (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $1,000,000 X I COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $500 000 E=)CLAIMS-MADEQ CCUR MED EXP(Any one person) $5,000 GABP700002 01/24/2016 01/24/2017 PERSONAL&ADVINJURY $INCLUDED GENERAL AGGREGATE s2,000,000 N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 :K POLICY =PROJEOT=LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY ALL OWNED SCHEDULED (Per Person) $AVrO / OS HIRMD NUa�TrNJ ApWNED BODILY INJURY HIRED AUTOS ARa (Per accident) $ PROPERTY DAMAGE $ (Per acciderd) $ UMBRELLA UAO =OCCUR EACH OCCURRENCE $ E%CESS LIAR =CLAIM&MADE AGGREGATE $ OED RETENTION$ $ WORMIISCOMPENSAMNAND WCbTATU- X OTH- Mn. E EMPLOYERS LIABIL" E.L.EACH ACCIDENT $ 500,000 i ANYPROPEMBERIPARTNERIEXECUTNE GAWC652881 E.L.DISEASE-EAEMPLOYEE $500,000 OPFCERJ InNIQ E%CLUDEDi 12/03/2015 12/03/2016 ryandslwyln NM N NIA E.L.DISEASE-POLICY LIMIT $ 500000 aym.a oa aiaa 'ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AddiNanal Remarks Schedule,N more apace is required) 'ERTIFICATE HOLDER CANCELLATION SHOULD ANY PROOF OF INSURANCE DATE THEREOF,ONOTICE WILL 13E DELIVERED I POLICIES THE ABOVE DESCRIBED EXPIRATION N ACCORDANCE WITH T14E POLICY PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE WORD 25(2010/05) 01988.2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 7 Massachusetts Department of Public Safety - �: Board of Building Regulations and Standards License: CS-049371 Construction Supervisor ROBERT P SULLIVAN JR - 27 NORMAN ST MARBLEHEAD MA 01846'_ . �..nn Expiration: Commissioner 0610612018 6/214 wonn"no"uoecrllfi'o�CJlI ,15a [i:3elldi, _ Office of Consumer Affairs&Business Regulation ME IMPROVE _- _ - -on: 177649 Type: xpiration: 21172018;;_ Individual - , ROBERTSULLIVAN _ . "- - ROBERT SULLIVAN" 27 NORMAN ST - MARBLEHEAD,MA 01945` Undersecretary r. (by OPSALEM MASSAmmi 120WAgANOaws.;30FL" BL"74 -M- $»�BIttBY1 L Fex 740-NO 7tmusumm Dmumma'PURc 'r/Bummacammm v Construction Debris Disposo/Afftdit* (required thrall deMolldon and renovation worki In aorordma with the sbrth edwon of the stege euMW code, 780OUX Secdon ULS Debri and the providmm of MGL o10,S54;BW dkg Perndt d is hrsued wddr the conoiffan that the debris resulting from this work shag be disposed W in a properly Uoensed waste deposk bcU tyas defined by MGL c 111,S L%& The debris will be transported Iv. GcAvy\ f cJ d- «„q-V-� (name of hauler) The debris will be disposed of in: (name of fadlity) fy e s�- S luxe cis�u (address of facility) Signature of applicant Date 31 LOT 263 SACCO :RWAY RD. 7D FENCE f PROPERTY LINE N 345 23 E 48.35' 9,p MAP 31 LOT 264 > AREA = 8178 t S.F. J =ck LIN o A (Tr existing o. tet en \°o 13* to remain , ,) 6 bulk ° o ea 9 28 NI endW ed porc \ D. �j 6' 2 1/2 story to remoo ved existing dwelling garage & landing 2 £o m $S \ p to be removed � 0 +� Ionding mp 15' hontyaM setback M W N 115.00' N 1 S 46'48'40" W S 57'29'00" E WOOD FENCE ~ 3.27' 3.5't OFF PROPERTY LINE ROSEDALE AVENUE /� nim n�1A" — MAP 31 LOT 263 JEAN SACCO 1 RIVERWAY RD. WOOD n¢ 2.r: OFT PROPERTY UNE � E N 34'5513 45.35 41 9q MAP 31 LOT 264 SCI. AREA = 8178 t S.F. 0 �F o v; .wms � e� f WIF 0 MAP 31 LOT 328 ^� WILLIAM PANZINI EDNA PANZINI gx n=F.R'°a - 3 RIVERWAY RD. 11 6 2 1/2 story por&a ,I m dwdIIRg s^•osa a m.e.s #2 �.. m e..mio..e \ � it� Imam q n mis'1.o—ipre w.a — — m 115.00' Ln 5/ 46'48'40' W S 57'2900' E O Nce 3.27' 1s4 OFF PROPERTY UNE ROSEDALE AVENUE C 6/s ZONING DISTRICT— R1 B ENTRANCE CORRIDOR OVERLAY PROPOSED REWIRm EMISDNG ADDITION LOT AREA 15,000 8175 5175 LOT FRONTAGE 1D0 115.00' 115.w FRONT 15 19.5' 21'* SIDE 10 9.7 y* REAR 30 4&V 41'* PLAN OF LAND LOT COVERAGE 30% lsx 15.7% 2 ROSEDALE AVENUE SALEM PROPERTY OF NORMAN M. ROBERTS. JR. I CERTIFY THAT THE BUILDINGS MARGARET J. ROBERTS HEREON ARE LOCATED ON THE GROUND AS SHOWN, SCALE 1' = 20' JUNE 13, 2016 NORTH SHORE SURVEY CORPORATION 14 BROWN STREET — SALEM, MA DATE PROFESSIONAL LAND SURVEYOR 978-744-4800 /4256