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29 SABLE RD - BUILDING INSPECTION The Commonwealth of Massachusetts } Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, Tu edition OF SALEM� Revised Junuury Building Permit Application"ro Construct,Repair, Renovate Or Demolish a 1. :008 One-or Ttvo-Fumily Dwelling This Section For Official Use Only J Building Permit No er. Date Applied:' /O Signature: -rn, Building Commissioner nspector of s Date SEC 1 1: ITE INFORMATION 1.1 Property Address• 1.2 Assessors Map& Parcel Numbers �9 Sp RIF �r1 1.la 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 It) Frontage(Il) 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'? Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'ofcord: 1 0b5J§-T agrtg� Name(Print) I Address for Service: Signature 'relephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) &I Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Bri==t of Proposed Work': K1 c try �,a � — n � t fap� .n .w�� \ N A � l8 Q{L� met SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only I Labor and Materials I. Building S L Building Permit Fee: S Indicate how tee is determined: ❑Standard Cityrrown Application Fee 2. Electrical S • �a ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: S JI r 00 ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) to 5- Ja/as � ',// I.iccnse Number Expiration Date Name 1 CSL-IIuIJer �V�— List CSL Type(see below)J2:WJress -B Description 3 11 IinrestricteJ(tip to 35,000 Cu. Ft. It Restricted l&2 Family Dwellin Si atarw: Ni Nluson Only RC Residential Rooting Covering I elcphone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation / - 66 / a D Residential Demolition 2 Re istere HomeImprovementContractor(HIC) / g�// UI� T egisoant me Registration Number I IST wL f 1�IC�'R air AA ms p -t�$-7�n(o'w��rQd Expiration Date Signet Telephone ECTI N : 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 ..........❑ No...........❑ ' SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'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 I, as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the pains and pertaities orperjury) 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(1-1IC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, 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.) Ilabitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half7baths Type of heating system Number of decks/porches Type ofcooling system Enclosed Open 3. "Total Project Square Footage"may he substituted for"Total Project Cost" CITY OF SALEM n*tlirk PUBLIC PROPRERTY DEPARTMENT \I sun !!�^\VnsntNt:nuN 573lt:T 0 5,vu:s4,Man.u:nn it-ru 0197. 11..1.:'178.7ii9595 • 1:%.X,Wil-740-M46 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricianil PIumbers konlicaut Information Please Print Leeibly s1111TC(lluwwssiQr�miratiaNlndrvuluuq: \J[VvIe- -\'Ul_� K3,M Address: 7�LRtLgt T �,4$ City,Statei/sip: U%aQS MR Monet?': q!'R' tm,4 r9180 sre,ou art employer?Check the appropriate box: 'Type orpraject(required): I.❑ I :tat a er with employer 4. ❑ 1 atn a general contractor and 1 6. P Y ❑ New construction 1ployces(full and/or part-6111C).' have hired the sub-ctmtracturs 2. 1 ant a sole proprietor or partner- listed on the anachcd sheet. 7. emodeline ship and have no clnployccs These iub-contractors have 8. ❑ Demolition working lin me in any capacity. workers' comp. insurance. 9, ❑ Building addition No workers'comp. insurance 5. ❑ Weare a corporation and its 10.C]Electrical repairs or additions required.] officers have exercised their ( 3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I,[] Plumbing repairs or additions myself. (No workers'comp. c. 152,q I(4),and we have no 12.❑ Roof repairs insurance required.) t employees. (No workers' 13.❑Other comp. insurance required.] -Any.yl,hc.nl chat checks boa of must also lilt mn the suaiun Iwluw showing diuir wotkus'cumpunuaiwt pulicy intiam6un ' I lumeuwnvn Au submit this affidavit indicating they are doing all work and then hire outside connxton must auhmit a new an'fdavit indicating mich. 4',mrrwuu that chnk this box mtwt mtachad an additional shuef showing the name of the sub-contrxt as and their wurken'comp.policy information. /our an employer dont/s providing workers'conipensarian insurance fir my employees. Below is the policy and job site infornmtion. Insurance CompanyVame: —_.._. __.—._._-_----- Policy 4 or Sclf-ins. Lie.N: ... __.._ Expirunon Date: Job Site Address: City;Stateizip: Attach It copy of Ilse workers'compensation policy declaration page(showing;the policy number and expiration date). I;ailurc a)secure coverage as required under Secliun 25A ul':vIGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51.5110.00 and/or one-year intprisonincnt,xi well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 it day against the violator. Be adviacd that a copy of this siutement may be forwarded to the Office of Illccnngjimos ul the DIA for insurance coverage seritication. l do hereby terrify under a pai1194 r u/lie /'perjury that the infonnution provided above is true and correct. tiic:rnnrc: _ — — Date: A21pe(r�/)/d -- Official use only. Do not write in this area, to be cuarpleted by city or town o/jiciuL _ i City or Torn: PcnnitiLicense N._ Issuing;Authority(circle out): I. Inward of Ilcaldr 2. Building Dcpartutcnt 3.Cili.town Clerk 4. Electrical Inspector 5. Plumbing; Impector 6. Other Contact VC(suit: _ _ I'hmte y: Information and Instructions .Massachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an emplgree is defiled as"...every pcn:son in the service of another under any cuntmct 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 �r the toregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee ul lul Individual,partnership,association or odor 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 Jr Lill 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 commonweulth for any applicant who has not produced acceptable evidence of compllance'with the Insurance coverage required." Additionally. NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract f tr the perfomlance of public work until acceptable evidence of compliance w ith 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)nume(.$),address(es)and phone number(s)along with their certificates)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 docs have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for con f innation 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 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 till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pcnnitilicense 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 lucations 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 tits(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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he of Incl'of investigations would like to thank you in advance fur your cooperation and should you have sly questions, plea.w do not hesitate to give us a call. rhe Daparunent's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Ofilce of Investigations 600 Washington Street Boston, MA 02111 'Pel. k 617-7274900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 i.:;. d 'r,-us www.mass.gov/dia CITY OF &U.&M. NLL-kSSACHUSETTS BLLWLNG DEPART &NT ' 130 W.ASHLYGTON STREU, 3iO FLOOR TEL (978) 745-9595 FAX(978) 740.9846 Kt.,%t13ERLEY DRISCOLL MAYOR TiO.�tAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BCILDLNG COMMISSIONER 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 l 11.5 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 be disposed of in a properly licensed waste disposal facility as dcfincd by MGL c (11, S I50A. The debris will be transported by:(name of hauler) The debris will be disposed of in V116 - (name of facility) (address of facility) sign re of permit applicant Za�/�[i7DlC) date 1'bnaif�M: ACORDM CERTIFICATE OF LIABILITY INSURANCE °12/21/20 o) PRODUCER (978)777-6344 FAX (978)777-9804 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION John J Doyle Insurance Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 85 Constitution Lane HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Danvers, MA 01923 INSURERS AFFORDING COVERAGE NAIC# INSURED David Deluca Home Improvement INSURERA: Safety Insurance 39454 3 Pleasant Ave INSURER B: Danvers, MA 01923 INSURER C: INSURER D: 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. INSRkDD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY BP00013477 03/05/2010 03/05/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADE O OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ POLICY PRO LOC ECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR O CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTN- CRYEMPLOVERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERJMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ It yes,describe under SPECIAL PROVISIONS bele. E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 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, Robert Boyd BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 29 Sable Road OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHORIZED REPRESENTATIVE John Doyle ACORD 25(2001/08) ©ACORD CORPORATION 1988