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60 VALIANT WAY - BUILDING INSPECTION t +' The Commonwealth of Massachusetts 1 Board of Building Regulations and Standards FO Massachusetts State Building Code. 780 CMR, 7n'edition MIINIUIPS '\1.1'1'1' Building Permit Application To Construct, Repair. Renovate Or Demolish a Rtri.rrd Junu,rn One-or Ttivo-Famihv Duelling This Sectio Official Use Only Building Permit Numb r: Dale Applied: ` I Signature: Building Commissioner/inspector of 0,0(11g; Date SECTION 1: SITE INFORMATION _J LI Propert- Address: 1.2 Assessors Map & Parcel Numbers � i C;ll��1-� 1.la Is this an accepted street'? yes ll no Map Number Parcel Number 1.3 Zoning Information: lA Property Dimensions: Zoning District Proposed Use Lot Area(sq Iq Frontage III) 1.5 Building Setbacks(ft) 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: 1 Zone: _ Outside Flood Zone? —/ Public Ea Private❑ Check if yes❑ Municipal L1}'On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2,Kwner of Record: 7 O,e\ C _k\et 100 L)IC4 I is ti wa y Name(Print) Address for Service: c. gt1�` 594 at Signure Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 91Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ 3cxx) 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier � i 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount' 6. Total Project Cost: $ _60W,01) 0 Paid in Full 0 Outstanding Balance Due: i SECTION 5: CONSTRUCTION SERVICES 5^.1 Licensed Construction Supervisor(CSL) 55IA(o S 'I Lo Ott. Cl 64 JeVfl�X7W Sl(J License Number Expiration Dale Name,o CIL- Holder 7 �G�1e Ot MA List CSL Type(see below) rcss �Q Type Description �-� U Unrestricted(LIP to 15.IX0 0 Cu. Ft.) R Restricted 1&2 Family D"c finL i store M Masonry Only RC Residential Roofing Covsm Telephone NS Residential Windo%% and Siding SF I Residential Solid Fuel Burning A t thanee IIUl.11lanun D Residential Demolition 5.7 �e�St4red I meI,bUW Sr(t nt Contractor(HIC) low q 9 HIC C}}oN� nc or HIC P any Registrant Name Registration Number l n6u f''1 (o � 9 � 2D1a ressP_ 0 0 q�g.»7 �{79 Z7 Expiration Date 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 prucide 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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, \ 't t GVH c A 1 ICA Y- lA�"0l as Owner of the subject property hereby authorizeChe�+F �Qvy IvLvA-, to act on my behalf, in all inauers relative to work authorized by this building permit application. aszQ� 12 -! 0 Signature of Owner Date `, SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1, "eS �CIM��W S VL- ,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 b Nalf.f. Sly rit am �� n Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) 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(HIC) 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 110.R6 and 110.R5, 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 Square Footage" may be substituted for-'Total Project Cost" CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT writnt R[F.Y 2)R!r[:tXl M utile 12L Mltserw'Tost STnttar a SttIW.14%saw a a i-m 0tm ThL M?45.eS" a F.vx:9MY449e41, Workers' Compensation insurance AMdavit: SaitdentCentrartontEiearidaiWPtnmbers A11011cant Information t Letibly VamC tHusia:s.rch•4al+iiruioNlmuv,Jtm1)� Q3� �%D,x17 F�Vr...��` Address ? � � CitylSt2Wzip• 1�,e Y W S Ke Yfle to eotployer3 Cseck the appropriate sox type otproject(re palrod): I.t7 t are a cmployat wits 2, 4. 0 1 am a Fearal contractor and 1 h. ❑New cion ompluycca(runt aruUur pan-time).• have hired the sub-cantractora 2.Q 1 ant a sale Proprietor or partner. listed on the attached sheat.t 7. Q Remodeling ship and have no employees These olb•eotttrsmra have Y ❑Demobtloa working far me in any capacity. warkents'comp.insurance. q, Q Building addition [No workers'comp. insurance S. Q We aro a corporation and its 10.0 E required) often have exercised theirElectrical repairs or addition 7.Q 1 am a homeowner doing all work right aroxemption par MGL I I.C] Plumbing repairs or additions myself.(Ao workers'comp. c. 1 S2,¢1(4).and we have no 12.[Q Roof repairs insurance required j t cmploycet.[No workers' ' 13.0 Other comp. insurance requital n,xy y plisant do[eixado boa Of mea 24a da w Ow aman Waver er showisa Their*wW venoemadon pdi67 infiawmiaw 'It.rw.nms who tubeit els antdwk iodiwi g dray an s*W at work and that his worlds cowawets mwl.ahmA a arra at"Vit isdtadina.arch. {•,,.urstsors dot ahxea Nis bet man amchoi of additimd.Awn ahowiy she saes of ON rcMcootrMies and thrix settles'mop.pdicy ilkealadaa. !ear un ernployrr that&provldlnq warkda'compensarlaa huamtrct far my rmpluyerx Below!;rhe puticy anJ fab site iacuranca Company Yame: �!"'t'' ,.Lf l/..i •!1-..� .. _. _. Policy a or Scif-ins.Lic.# W(2 ( )i t S t Jr 1. o f.7 Expiration Date GJ/[Of ZD t( Job Site Address: �() \JcL1Cytd� CityrSiateizip: �1_4tQtvt Artach a copy or the workers'compensation policy dociaratlea page(skewing the policy number and expiration date). Failure err secure coverage as required under Section 25A of.MGL c. 152 cora lead to the imposition of criminal penalties*(* tinc up to 51.500.00 indfor one-year imprisonment,is well as civil penalties is the form of a STOP WORK ORDER and a rens of up to 1230.00 h Jay ar:tiatt the riOlarOr. lk adviicd that a copy of thin oatcuem may be for*ardod to the OtTiee of lox'.ano t nos of t u DIA for wiurarce tuvcr3;u verification. l du herr�'Jy the pains andpenult/(��su/perfary that rhe inferwatka provided aboveis true and correct. _rt„r .rD�/h f1W✓"v Dem• O/Jlsid Yet unl)t An not write in this arra.to Ar ran y/dd by city or Mwn a/f itild City or'rawn: Pcrmitti.itease kiedag Aathurity (circle one): 1. lluard of iteuhh i. nuilding Department j. Cilylrowa Clerk 4. Electrical inspector S. Plumbing inspector G.other (.'uiltaet Person: _ _ Phone N. Information and Instructions ,%tassachusetu G awral Laws chapter 132 requires all employes to provide workers'compensation for their employaa Pursuant to this seatuto,an emplal ee is defined as"...every person is the service of another under any contract of hire. edcpress or implied,ural or written" ,1n aiyhhy+rr is telesis so"aa igdividuat,paebhership,sesoeiatioa,oorporatios or ether k7pl entity.at any two or moa Of the foregoing engaged in a joist enterprise,and including the legal representatives of a deceased employer,or the wAuvet or uustet of as individual,prrmarship,asaociaaua or odder egad ettity.empbywg anploy+ew. liowevor the owner of a dwelling bwa bsving alit rnare than tdme Apartments and who resides ehereie,or the occupant*(the dwelling house of anothat who employs persons to do maintenance.construction or repair work on sueh dwelling house du on rite grounds or building appurtenam Ibeteta shod nal becauu of vmb esdpleymmt bo deemed to bo nal eutployer." �fGL chapter 132,42SC(6)also stares that"every state or toed licensing agiseq shad withboltl the Issuance or resewd of a gcease ce persalt to operate a business or to construct budldlega in the comoaaw"M for any i applicant wife has sot prodead acceptable evidaa a of rawpraea with the Insurance coverage required." Additionally.MOL chapter 132,125CM stats"Neither the commonvrealth am any of in political subdfvipoa shall enter into soy contract for the performance of public work until acceptable evidence of compliance wish the insurance requirements of this chapter have hies 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)name(s),addtesa(es)and phone awnbac(a)along with their cettilicatc(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the membem or pa mem,am am required to carry workers'eompensuhoa kwaanee. If as LLC orLLP door have employees,a policy is required. Be advised than this afRdavit may be submitted to the Deparmtem of Industrial Accidents for confirmation of insurance coverage. Ababa sun tesign and date the affidavit, The atTidavit should be returned to the city or town tat the application for the permit or license is being requested, not the Department of Inoiusrial Au:ideats. Should you have any questions regarding the low or if you ase required to obtain a workers' compensation policy,plesse call the Department at the number Hand below. Setif-insumd companies should enter their self-insurance license number oa ton approprlste line. City or Tows Of iclah Peau Ile sure that the affidavit is complete and printed legibly. The Department has provided a space at the botmn. of the affidavit for you to rill out in the event the Office of investigations has to contact you regarding the applicant Piaase be sure to till in the punnit(Iicense number which will be used as a reference number. In addition,an applies= that must submit multiple pormit/ticenm applications in any given year,need only submit one affidavit indicating current policy information I if necessary)and under"Job Site Address"the applicant should write"all locations in +_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be pro-,ided to the. applicant as proof that a valid affidavit is on file for finite 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 i.e.a dog license or permit to bum leaves clic.)said person is NOT required to complete thus affidovit Iltc c)tlicu of Gtvestigatiuns would lice to thank you in advance for your cooperation and should you have any questions, d;cabe Ju nut hesitate to give us a oall. The Department's address. telephone and fax number: "the Comatonwealtht of Massachusetts Depamnent of Industrial Accidents OMM of Investigation 600 Washlinolln Street Boston.MA 02111 Tel. q 617-7274900 elft 406 or 1-877-MASSAFE Fax 0 617-727-7749 wWw.mon.gov/dia ACORD CERTIFICATE OF LIABILITY INSURANCE °"'�'M"1D°'YY"Y) TM 06/23/2010 PRODUCER 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 491 Maple St (Rt 62)-Suite 304 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 183 Danvers, MA 01923-0383 INSURERS AFFORDING COVERAGE NAIC# INSURED Chet Dembowski INSURERA: Gotham Insurance Company P.O. Box 412 INSURER B: Safety Insurance Co 39454 Danvers, MA 01923 INSURER c: Liberty Mutual Ins Co 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. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/OD/YYYY DATEI M M /DLIMITS GENERAL LIABILITY GLOO116709 07/01/2010 07/01/2011 EACHOCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY PREMISES IEa occurrence $ 50,00 CLAIMS MADE [Xj OCCUR MED EXP(Any one Person) $ S'000 A PERSONAL$ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY JET LOC AUTOMOBILE LIABILITY 1613082 01/29/2010 01/29/2011 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) 1,000,000 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per Person) $ B X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Par accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-FAACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ 8 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC131S321S13020-AR 06/10/2010 06/10/2011 X TORYLIMIrs ER AND EMPLOYERS'LIABILITY IN ANY PROPRIETOR/PARTNER/EXECUTIVEYE.L.EACH ACCIDENT $ 100,00 C OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLONTE1$ 100,00 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I $ 500,00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS les idential General Contracting 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,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Chester Dembowski General Contracting REPAESSI{TA PO Box 412 AU RrLEP' EPRE TAP Danvers, MA 01923 James-' irr, e , ACORD 25(2009/01) c ©'1988-2009 A R RPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 9� - �� Office of Consumer Affairs and usiness Regulation 10 Park Plaza- Suite 5170 Boston, Massac setts 02116 Home Improvement r for Registration Registration: 100098 Type: DBA `^ s Expiration: 6/9/2012 Tr# 297379 - CHET'S CARPENTRY W Chester Dembowski 2 VALLEY ROAD (ti Danvers, MA 01923 a Update Address and return card.Mark reason fur change. �-Address El.Renewal ❑ Employment Lost Card :CAI 8 5OM-04104-6101216 Massachusetts- Department of Public Satoh Board of Building Regulations and Stand trds Construction Supervisor License One-and Two-Family Dwellings License: CS 55465 a CHESTER J DEMBOWSKI 2 VALLEY RD1 DANVERS, MA 01923 'Expiration: 711012012 ('ommissioner Tr#: 28971 -