12 SHORE AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
1(1 This Section For Official Use Only,
Building Permit Number:, - Date pplied: .
Ffi-
!!�1 BuildingOfficial(PrintName) Signature --
�y SECTION 1:SITE INFORMATION
1.1Property A dress: 1.2 Assessors Map&Parcel Numbers
i',l sWrf 1�
1.l 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:
Public)k Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2: PROPERTYOW
21 Owner'ofpc
(Ord:
ame(Print) City,State, P
I1�ant�d Sueet C r Telephone Email Address
Z
SECTION 3:DESCRIPTION.OF PROPOSED WORK, (check all thatapply)
New Construction❑ Existing Building❑ Owner-Occupied 1kr Repairs(s) Alteration(s)T Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ pecify:
Brief ption of pos4o Work':
SECTION 4:ESTIMATED.CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials o0
1.Building $ 1. Building Permit Fee $JNIndicate how fee-is determined:
2.Electrical $ ❑Standard Citynown Application Fee -
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List-.
5.Mechanical (Fire
Suppression)
$ Tdtal All Fees:$
7 Check No Check Amount: Cash Amount:
6.Total Project Cost: $ d o
/ ❑Paid in Full' ❑Outstanding Balance Due:
1'llr\IL. G � Z tl
SECTION 5: 'CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)C �� 1�
6� C7.� � icens Nmbe
ur Expiration ate
Name 4f CSL
o_der I
List CSL Type(see below) l�
Y-\ 14 .Type _ Description
Nd'.-and et
U Unrestricted(Buildings up to 35,000 cu.ft.
n V R Restricted 1&2 Family Dwelling
City7l7own,Stat ZIP M Masonry
RC Roofing Covering-
WS Window and Siding
,, y,0.- t SF Solid Fuel Burning Appliances
T InQ A 6Wb Insulation
ale hon Email address D Demolition
5..2n Registered Home Improve eat Contractor(HIC)
U-1 fr, 1 ie lC-1� l �CIXrn�nt(�'1 f+'�'� I,C.t egistratiHI o /��u�mb�e�r Exp tion Dale
me r HIC
V\Reg'
and Street—t Email address
Ci /Town State ZIP 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 ..........A No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGEN.OR CONTRACTOR APPLIES`'FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this bu' ding permit application.
Print Owner's Name(Electronic Signature) ` Iba&
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of a 'ury that all of the information
contained in this application is tore and acc t to the best of my edge an)l understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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(RIC)Program),will not have access to the arbitration
program or guaranty find under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SALEM, 1NIASSACHUSETTS
BU;ILDIING DEPARTMENT
120 WASHINGTON STREET, 3"°FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
iCI.,tBFRi F.Y DRISCOLL
MAYOR T1 oiwST.PmRm
DIRECTOR OF PUBLIC PROPERTY/BU UMLNG camaSSIONER
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 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 be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
N� (s r
(name of hauler)
The debris will be disposed of in
-IJA 4A�
(name of facility�—
(address of facility)
signature bf permit applicant
z/ la )1�
t date
JcbmuffA e
CITY OF SmEm, iNLkSSACHUSETTS
a
But wLNG DEPART%m,4 r
120 WASHINGTON STREET,3m FLOOR
Imo.. (978) 745-9595
FAX(978) 740-9846
KINIBERI EY DRISCOLL
MAYOR IIiOM�s ST.PDSRRl3
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CMMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Businassorganizatiomindividuap: AMR RUA IA Ll
Address: ag- SA
City/State/Zip: V•eG 1'qhone #:
Are you an employer?Check the ppropriate box: T of
1A, 6
1 am a employer with 4. ❑ 1 am a general contractor and 1 Type project(required):
employees(full and/or part-time).* have hired the sub-contractors . ❑Ne row construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7•JX Remodeling
ship and have no employees These sub-contractors have 11. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.[]Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. [No workers' 13C1Other
comp. insurance required.)
•Any applicant that Checks box#1 must also fill out the section below showing their wotkm'compeneuion pulley information
'I lnmeownm who submit this affidavit indicating they are doing all work and then him outside eontmcim,most submit a new affidavit indicating sushi.
=C.mtn ctom that check this box must attached an additional shot showing the name of nor sub ommctom and their worlmrs'comp.policy information.
I am an employer that Isproviding workers'compensation Insurance for my employer's. Below is the pollay and Job site
information. (�� 1 `— \'1
Insurance Company Name:, 9--,St 116,L5 OLI/C��G
Policy nor Self-ins. Lica#: '° Expiration Dater
Job Site Address: I �e�)f1��T_City/State/Zip:_
Attach a copy of the worlun'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
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 of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sisnature: Date,
Phone#:
OJJicial use only. Do not write in this area,to be completed by city or town ofcl it
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#
R j Berkshire Hathaway GUARD
P.O. Box A-H • 16 S. River Street
�V,Berkshire Hathaway Wilkes-Barre, PA 18703-0020
465)
.,AA, GUARD Companies Insurance 570-825-9900 (Toll-FreeFAX 57068232059
www.guard.com
June 22, 2016
AMR BUILDERS LLC Agent: CARMEN-KIMBALL INSURANCE AGENCY, INC.
35 ASHTON STREET 48 Beckford Street
BEVERLY, MA 01915 Beverly, MA 01915
Phone.: 978-922-0086; Fax: 978-922-2328
Binder #: 1088182 Note: A binder from the Workers'
Policy #: R2WC744882 Compensation Plan Administrator, which
Policy Period: 05/26/2016 - 05/26/2017 you may have already received or will be
receiving shortly, serves as your proof of
coverage until cancelled or your policy is
issued.
WELCOME TO Berkshire Hathaway GUARD!
As the servicing carrier selected by the state to handle your policy, Berkshire Hathaway GUARD Insurance
Companies (specifically, our subsidiary, AmGUARD Insurance Company) is pleased to have the opportunity
to provide you with the superior customer services you deserve. If you have a question about your
Workers' Compensation coverage or have a particular need, our professional staff and automated
resources will be available to assist you.
Our Customer Service Department is available by phone at 800-673-2465 Monday through Friday,
8:00 AM to 5:00 PM EST. After hours, you can leave a voice mail, send an e-mail (csr@iGUARD.com), FAX
us (570-823-2059), or complete an on-line form (accessible from the Customer Service section of our
Policyholder Service Center at www.guard.com). Our mailing address is listed in the upper right
corner.
To make a Payment:
We accept payment via check, bank check, direct draft (EFT), and credit card. Payments can be mailed to
PO Box 785410, Philadelphia, PA 19178-5410.
To report a claim or loss:
Call us immediately at 888-NEW-CLMS(888-639-2567) — 24 hours a day, seven days a week.
To report fraud:
Call our Fraud Special Investigative Unit via our Fraud Hotline at 800-673-2465, ext. TIPS — 24 hours
a day, seven days a week.
To request Certificates of Insurance:
You can either fax us at 570-823-2059 or call our Customer Service Department at 800-673-2465.
Either way, be prepared to provide the company name, address, fax number, and contact person of the
entity requesting the certificate.
To obtain service from a specific discipline:
You can feel free to address your issue to the attention of the following individuals.
Department Contact Name Email Address Extension Fax Number
Billing Lori Decker csr@guard.com 1300 570-825-6211
Audit Dawn Aigeldinger csr@guard.com 1300 570-829-4587
Loss Prevention John Bohn csr@guard.com 1300 570-825-2990
Underwriting Dawn Aigeldinger csr@guard.com 1300 570-820-7968
Claims Lisa Krzywicki csr@guard.com 1300 570-825-0611
We look forward to having this opportunity to serve your insurance needs. Please keep a copy of this
letter with your Berkshire Hathaway GUARD Insurance Companies policy for future reference.
HQ: MA/wc Your Business is Our Business =m
DECTO I