69 SUMMER ST - BUILDING INSPECTION ,
The Commonwealth of Massachusetts
J t Board of Building Regulations and Standards FOR
n 1 MUNIC IP:UA I Y
>I/ Massachusetts State Building Code, 780 CMR, 7"'edition USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Rrrtsul Jmwan
One- or Tuvo-Family Duelling 1. 2008
his Section For Official Use Only
Building PermijNimbe . Date Applied: r 1, Cly
Signature: � ' r
Building Commissioner/Inspect[ dldings Date
SECTION 1: SITE INFORMATION J(J(J(
1.1 Propertyd
: ress: 1.2 Assessors Map & Parcel Numbers j L
b�,� ��� vr1 ft[
Lla Isjhis an accepted street? yes ✓ no_ Map Number Parcel Nunrher
1.3 Zoning Information: 1.4 Property Dimensions:-
Zoning
imensions_Zoning District Proposed Use Lot Area(sq tp Frontage('li)
1.5 Building Setbacks (f0
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
I
1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Puhlic B" Private❑ Check if yes❑ Municipal Von site Disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner o�Reco t° -h m e, c4 �+q le 6,1(`na < < § vee S 69 5u J t
Name(Print) Address for- p
Service: ?-8f)3
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) v I Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: t
Brief Description o posWorh�:
(J f 0 nnPiN�^ �n �' Yyt a
SECTION 4: ESTIMATED CONSTRUCTION COSTS
[tem Estimated Costs: Official Use Only
(Labor and Materials)
L Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
t). Total Project Cost: $ ��Q� r� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES J
5.1 Licensed Construction Supervisor (CSL) 5-5,4(0
`,16� 7_(D_�(v
CheJ fe, Je r,, bow SIy License Number Expiration Dale
Name of SL- Holder List CSL Type(see below)
Type Description
't:M � U Unrestricted Restricted
1 (u to Family
D0 Cu. Ft.)
�VVV[ ' i`Vxx�-i�-+i' Restricted INc'_ Famil Dstellin
Signature �N Masonr Only
RC Residential Routing Covet in
Telephone \VS Residential Window avid Siding,
SF Residential Solid Fuel 13urning, A t hancc Inswllati,m
D Residential Demolition
5.t= home 1 rovement Contractor(HIC) IhDOS�
HIC Cgqm�ny Nm or HIC �istrant Name Registration Numher
VA 6\P �O 1{ ' ZU10
s '"t� •�l •( j Expiration Date
0
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 .......... R"' No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Mosv, SkQU4/y��5, as Owner of the subject property hereby
authorize CIAC-J i IR,�&OIaS It to act on my behalf, in all matters
relative to work authorized by this building permit application.
S 31-05
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, , 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.
M tA&� � �
� e n s
n e 7r_O�
Signature of Owner or Aut orized Agent Date d
(Signed under the 2ains and penalties of eer u )
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 IO.R6 and I IO.RS, respectively.
1 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 Square Footage" may be substituted for "Total Project Cosi'
r �
1
HEY INOUSIP IES r INC , -3
LA
`� Tribute
-G 2,11 KrFlp Sunl;lean/SPI
National Fenestrafion I IR 1BDH INLRGY
Raring Coin1lo 0035-02697512-00 0040 PIDS (lUR1S1F TO
IAR
S-03 24 5/06/2009
ENERGY PERFORMANCE RATINGS
U-Factor(U.S./I-P) Solar Neat Gain Coefficient
0 - 20 0 - 19
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance Air Leakage(U.S./I-P)
0 . 32 ----
Manufacturersfipulates that these rafings conform to applicable NFRC procedures for determining whole
product pertotmance.NFRC ratings are determined for a two net of ermronmentat core ithm s and a
specific product sive.NFRC does not recommend any product and does not warrant the su'dability of any
product for any specific use.Consult manufacturers literature for other product pedarmance infortnatiort
wwwAIM.Dlp
I
O�e a orBoya4ug� �t� �
Boar a Building Regulat ons an Standar s
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 100096
Type: DBA
Expiration: 6/9/2010 Trit 267306
CHET`S CARPENTRY
Chester Dembowski - —v—"-
2 VALLEY ROAD ---
Danvers, MA 01923 --
Update Address and return card.Mark reason for change.
DPSCAi 0 50MoV07,P0e+390 [] Address [] Renewal 7 Employment Lost Card
?LessachuscU. - Dcpartmcnt ul' Public Safe(%
Board of Building Rcgulatinn. and Standards .
Construction Supervisor License
License: CS 5546.4
Restricted to: 143
CHESTER J DEMBOWSKI
2 VALLEY RD
DANVERS, MA 01923
Expiration: 7/10!2010
('anwi..ioucr Tra: 28312
A-C71:nSurance
CERTIFICATE OF LIABILITY INSURANCE 01/2 1/2009
0
[aUrpey
� 774-8040 FAX (978)774-3581 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Group Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1 Maple (Rt 62)-Snits 304 - HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGg AFFORDED BY THE POU CIES BELOW.
0 Box 183 -
Ianvers, MA 01923-'0383 INSURERS AFFORDING COVERAGE MAIC#
:URED het De owski INSURER Penn- Amer ca
P.O. Box 412 - INSURER o: Safety Insurance Co 39454
i
Danvers, MA 01923 INSURER Liberty Mutual Ins Co
'. INSURER D:
WSUHER E:
QVERAGES
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 CLAIMS,
SR D• TYPEOFINSURANCE POLICY NUMBER POLICY FF£OnDA MOM9 POLICY IXPIRATTON DAIS D'm_ OMITS
mt= GENERAL LIABILITY PAC6789605 07/01/2008 07/01/2009 EACH OCCURRENCE S 11000.00
X COMMERCU,LGENERALUABILITY DAMAGE TO RENTED S 50,00
CLAIMS MADE [K OCCUR MEDEXP(Am/mCp, ) S 5.00
'{ PERSONA-A ADV INJURY $ 1.,000,00
GENERAL AGGREGATE $ 21000,00
GEN'L AGGREGATE UMrr APPLIES PER: PRODUCTS•COMPIOP AGO S I„000 00
POLICY ECT LOC
oF
AUTOMOBILE LWIILITY 1613082 01/29/2009 01/29/2010 COMBINED SINGLE LIMIT
fEe q.� eri0 $
ANY Aurp 1,000,00
A6L OWNED AUTOS BODILY INJURY
X SCHEULEO AUTOS (Per parson) $
B X HIRED AUTOS
- BODILY INJURY S
X NON-OWNED AUTOS (P.,*C enl) -
PROPERTY DAMAGE S
(PM Wd danl) -
GARAGE UASIU Y - AUTO ONLY.EA ACCIDC14T 5
ANY AUTO OTHERTHAN �M'C S
AUTO ONLY:, AGG S
IXCESSIUMBR£LLA LIABILITY - EACH OCCURRENCE S'
OCCUR M CLAIMS MADE - AGGREGATE 5��.
S
DEDUCTIBLE -_ 5--
RETENTION $ 1 IS
WORKERS COMPENSATION AND WC1315321511028-AR 06/10/2008 06/10/2009 WCS ATu- O H-
EMPLOVERT LIABILITY E.L.EACH ACCIDENT S 100,000
C ANY PROPRIETORIPARfNEP=9CUTNE
OFFICERIMEMBER EXCLUDED? EI,DISEASE-CA EMPLOYE S 100,00
XYee'Va�mbewdar E.L DISEASE-POLICY LIMB S 500.00
SPECIAL PROVISIUr bakes
orn£a
OESCW PTION OF OPERATIONS i LOCATIONS J VEHICLES i EXCLUSIONS ADDEO BY ENOOR5E0ENT1 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
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
SUT FAILURE TO MAIL SUCH NOTICE SHALT.IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIM,
AUTHORIZEO REPRESENTATIVE
James Tare , CTC, V Pres
ACORD 25(2001108) FAX: (978)777-7397 WACORD CORPORATION 1988
T00€n sNaANBQ SNI AgIHVS T85C VLL 9L6 Xd3 9C:9T 6007,/T7,iTIl -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
;.,.tnratr.Y tnttsa:txt.
1iLlYttt 12C W.tsm-1 o v-ris,0147*
ThL_V&745,49S a F.tx:97s AOM4a
Workers' Compensation insurance Attldavit: StdldeniCantrectors/Electe-id*t s/PMmbers
ann)icant information Please Prlat Legibly
Name tkkuuncsslc(kbfanin{tjieNln,I,v,Juul):1,,�f I QJ'YV ,�!Mid w3 �o
Address!
Cityismauzip ,Y , ) .5 /h� 1'hoaeq: � 7Sl`7�7C7�Z7
%rree,y�oou an employer"Cheek the appropriate best: Typs of prisjoct(required)'
I.tyd't sura a empbyor with -2- 4• Q 1 am a general contracuir and 1 d. Q New conAruction
empluyc-cx(full arullur part-time).* have hist the sub•ctxuractors
2.Q 1 am a sok proprietor or pamper- listed on the attached sheet. = 7. Q Remodeling
ship and have no cmplayc" Them sub-contractors have g. Q Demolition
working for me in any capacity. worker' comp. insurance. 4. Q Building addition
(Ko w rkera'comp. insurance S. 0 Wo are a corporation and its
rcquirceil officers have excrcised their 10.❑ Electrical repairs or additions
3.Q 1 am a homeowner doing all wont right of axempidon per MGL 11.0 Plumbing repairs or additions
myself.(No workers'camp. e. 152,¢1(4),and we have no 12.Q Ruof repairs
su
inrance required.) r empbyccs. (Ko workers' 13.0 Other
camp.inwratux rcquw xLj
•nen app4"al err churtu 11011 01 met alae flaw aw ws."below dnwioe,4Yir awrtaa'cwnPp Wive pulw.y tafiun odea
'tl,,lnrwwwnwa urea s,elalit rale a!lleavx iadto mmo they are,164to On tout and no tans oarntla co m otom mast oubmir a esu arnaavie inJwaaina rxi.
:Cararuwn not rind raw box mule amelias an aeditwwW Jwm 4awiry tae meta of the mb-coaaaran gad heir wurkma'mwaI policy inbanmoe.
1 err on etupiayer that 4 pruvlding workers'compertradon lnsuronce for my emplayeet Below is rhe pulfry and fob sire
irywaewiwa j` i
Im urancic Company Name: (J
1
Policy a of Self / �ins. Lic. b: `-'�`- 13 ✓ Z `.5 1_3P-,- •• 'tllf�pinajon Date: (9-to -0c"(
Job Site .Address: (o9" y110111/ 34— Cayislaturtp: Sq/¢, U IV 76
tetach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
i�ailurc w wcum coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
.s{up to 5250.00 a Jay ag'rinst the violator. Ile advised that a copy urthis statement maybe fur*ardcd to the Oilice of
Imvaaugauanx of du: DIA for insurance anera;c vuificmiun.
I do Ilen•b ify der t i liar and .dries a perjury that the infoa mw/oer provided above is ere and correct.
ii••:,:a1,r,; Data• _t-0
0/)kid au awllt 40 ear write in this ane,to tar ratsrpJdasf by city Of lower afJlclal
City or Town: Pcrmitlt keast g_ __
Issulag,latharily(circle one)-
1. Iluard of Ilealth 2. Building Dcpartmeut J.City fora Clerk 3.Electrical Inspector 5. Plumbing Inspector
L.Other
C.nuaet Person: _ Phone p: