36 SETTLERS WAY - BUILDING INSPECTION (2) ewz
The Commonwealth of Massachusetts
Town of
�►� Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR. 7ib edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fumill Duelling
Section For OfTicial Use Only '
!Building Permit Numbe Date Applied:ure: � r /t
Bu- ng o o r 1 or of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: -1.2 Assessors Map& Parcel Numbers i
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: X1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq f)) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.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❑ Check if Xes13
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
r
TDemolition
Address for Service:
�d1 — L(( 3 — 1467
Telephone
CTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(slV Addition O
Accessory Bldg. ❑ Number of Units_ Other O Specify: CA'PO
Brief Description of Proposed Work':
4y
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Official Use Only
Item
Labor and Materials
I. Building S (p OppyeD I. Building Permit Fee: E Indicate how fee is determined:
G ❑Standard City/Town Application Fee
2. Electrical S �.�' ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 cla6.sr 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $ Total All Fees: S L
Su ression
Check No. _Check Amount: Cash Amount:
x 6. Total Project Cost: S 3,r S'dp r 6* ❑ Paid in Full ❑Outstanding Balance Due:
r \ 3S
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Es a/au/o Dat
N me u1'CSL- Hpldrr List CSL Type(see below)
Address T Description
U Unrestricted u to 35,000 Cu. Ft.)
R Restricted 1&2 FamilyDwelling
Sig Lure _ ]tet s-� ,bt %1ason Only
78 _ o"d� RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Con rector(HIC) 14 7 7rf-
HIC CompHIC y tya or laRe sq6tName Registration Number
al
Address oQ Cyt
L -7 Y-ob�' Ezpi tion ale
Signatur Telephone
S TION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 lssuan 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
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 penalties of perjury)
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 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 Syuare Footage"may be substituted for"Total Project Cost'
M1Y
CITY OF SALEM
PUBLIC PROPRERTY
DEPART'�IENT
I I I' '/'8.'J i.R45 1NC 'i�8.'J: 64.
Construction Debris Disposal .affidavit
(icyuired lir all demolition and renovation work)
In accordance \s ith the sixth edition of the Slate Building Code, 780 Ch1R section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
I11. S 150A.
The debris \vill be transported by:
�� •� ^A_
(nan of hauler)
I he debris will be disposed of in
O"
Mme of lacility)
4.
—V - vI
la Jres. of faclliryl
vgnatmc �( � nut .lpphcant
v
CITY OF S.0 E.NI, Axs&XCHL:SETTS
BUILDING DEPARTMENT
\ �e 120 WASHINGTON STREET, Sao FLOOR
TEI_ (978) 745-9595
F.kx(978) 740-9816
(UNBERIEY DRISCOLL
,MAYOR THoMAs ST.PmRu
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG C0.5sMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Nan)e (Busimx� Organizatiorvin�dividual)c:`--Q) . I � w- ��
Address: ? (tel 71r� r, . yl eve-
City/State/Zip: ►l �C n est r t a 6 Phone #:-...27F--77"(—7
Are yo employer?Check the appropriate box: Type of project(required):
I. 1 am a employer with �L-- 4. ❑ I am a general contractor and 1 6. El New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor ar partner- listed on the attached sheet. : 7. 101remodeling
ship and have no employees These sub-contractors have S. Demolition
working for me in any capacity, workers'comp. insurance. g, Building addition
(No workers'comp. insurance 5. E3 We are a corporation and its
required.[ officers have exercised their 10.❑ Electrical repairs or additions
3. 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0Other
comp. insurance required.]
Any applicant that checks bos al must also rill rut the session below showing their workai compensation policy informuion.
'Ihaneowrsas who submit this affidavit indicating they an,doing all work and then hire outside eontroetor most submit a new amdavit indicating suck
:47,mtra.•ton that chsek this box must anached an additional shun showing the name of the subcont actma and their worker,comp,polity inPomusim.
I am an employer that is providing workers'compensation insurance for my employees. Below Is the pollcy and fob rife
information.
Insurance Company Name:—&—t-C,-c a!`1 r r Jn w, Cg
Policy #ter Self-ins. Lic. N: �-�11�t1Z 6((0([N�q 3(09Exptr�alion Date: 101 6 Q 1
Job Site Address: to Se ift-Q Uo . J et`G Act City/State/Zip: i� � (7 -0
Attach a copy of the workers'compensation polity iecbr2tiOu 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
fine up to S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ol'the DIA for insurance coverage verification.
I do hereby certify under At rd peuahles of perjurythat the hrformadon provided above
piss true and carrecc
Si,•n t ¢e' I)atc: STI(J�___
?hon X: t t�"' 7i{— �• Y-
OJjeial use duly. Do nor write in this area,to be completed by=5.
City orTuwn: PIssuing Authority (circle oney
I. Board of Ileallh 2. Duilding Department 1.City/town Clepector 5. Plumbing Inspector6.Other
Contact Person:
ACORq CERTIFICATE OF LIABILITY INSURANCE DATE(MNYDO YYYYI
04/29/2009
PRODUeso (978)774-8040 FAX (978)774-3581 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Tarpey Insurance Group Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
491 Maple St (Rt 62)-Suite 304 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 183
Danvers, MA 01923-0383 INSURERS AFFORDING COVERAGE NAIC#
WsuREo Built Wel Bulli ng Remodeling Inc. INSUReRA: Miscellanous Companies _
DBA: Bob Carroll INSUREAB: Safety Insurance Co _ 3945.4
3 Old Stonewall Ave. INSURER c:-American-Zurich Insurance Co. _
Danvers, MA 01923 INSURER O: -
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 CLAMS. LJCy
PTR N9
TYPE OFINSURANCE POLICYNUMBER DA YI WE DATE MPIAIRATTKY UNITS
GENERAL LIABILITY TBA 01/10/2009 01/10/2010 EACH OCCURRENCE f 1,000 00
X COMMERCIAL GENERALLMBAITV 0lEMMISES aAcaA,tllC $ 50,66
CLAIM MADE O OCCUR MED ETN(Are aIle man) f _ S'00
A PERSONAL E ACV INJURY S 1,000 00
- GENERAL AGGREGATE _ s 2,000,00(
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG s 1.000 00
--. POLICY PRC LOC
AUTOMOBILE LIABILITY 2434161 10/10/2008 10/30/2009 COMBINED SINGLE LIMIT f
My AUTO (Ea a¢dex) 1.0001001
ALL OVMED AUTOS BODILY INJURY S —
X SCHEDULED AUTOS IFY PdrobD
X HIRED AUTOS BODILY INJURY S
X NON-OYHED AUTOS IPMS rdj
_........ PROPERTY DAMAGE S
(Pnr aepApnD
GARAGE LABILITY AUTO ONLY.CA ACCIDENT S
ANY AUTO OTHER THAN EA ACG S .. ..AUTO ONLY! ADD S
UCE551 UMBRELLA LIABILITY EACH OCCURRENCE f
OCCUR u CLAIMS MADE AGGREGATE S
3
DEDUCTIBLE
RETENTION f S
WORKERS COMPENSATION 6ZZUB04061443609-AR 10/06/2008 10/06/2009 J 1w vUMR ER
AND EMPLOYERS'GABIUTV
ANY PROPRIETOwPARTN£RUEAECUTIVEY❑ L_fE CN ACCIDENT i -100,0
C OFFICERMEMBER EXCLUDED?
F.
(II�,Aabry in NN) .L DISEASE-PA EMPLOYEE f 100 O
I TOA IAIIN EL.DR3PASE-POLICY LIMIT f 500 00
SPECIAL PROVISIONS W.
OTHER
DESCRIPTION Of OPERATIONS I LOCATIONS I VEIUCLES I EXCLUSIONS ADDED BT ENDORSEMENT I SPECIAL PROVISIONS
Residential General Contractor
CERTIFICATE HOLDER CANCELLATION
/^ �C t �'[��(_�_^'I�`�^ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
(�-1/ Q� �JjL,( `+�(' \� DATE THEREOF.THE ISSUP10 INSURER WILL ENDEAVOR To WUL 10 DAYS WRITTEN
ala S I(]1 en NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT.BUT FAILURE TO DO 50 SMALL
en IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TWE INSURER,ITS AGENTS OR
t J •lC�` 4. REPRESENTATWES.
AUTHORIZED REPRESENTATIVE
James TarCI09C, V Pres
ACORD 25(2009101) ®1988-20ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
TAA rill S713ANYO SNI A34[8Y.L TBSC PLL 8L6 IY3 4c;L0 600Z/