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0007WHEATLAND STREET - BPA 09-783 The Commonwealth of Massachusetts --� Board of Building Regulations and Standards Town of Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a Orre- r Ti vu-Fawrrily Dwe/ling This ection For Official Use Only Building Permit Number Date Applied: i1 Signature: Building Co missioner/I ctor of Buildings Date SECTION 1: SITE INFORMATION 1.1 Prerty Address: n 1.2 Assessors Map& Parcel Numbers 1.1 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 Il) Frontage(R) 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es[3 SECTION 2: PROPERTY OWNERSHIP` 2.1q0wnerjofReco 11t [ � ,e-,I jgg�l �Ge .¢- rl Name(Print) / Address for Service: q-V Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Btdg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed W rkT: .p c7ct qi !F'. ECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OMelal Use Only Labor and Materials 1. Building $ 9,67C1. Building Permit Fee: S Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost(Item 6)x multiplier x 3. Plumbing S 2, Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S Check No. _Check Amount: Cash Amount: 6. Total Project Cost: S �7 3WU 0 paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES �7//���/ 5.1 Licensed Construction (CSL) C S L,�`'�Q�O �y b r r �/Y I /Smj7 License Number Enpirano Date N,�mc I C L 11F rList CSL Type(xe below)AJJress VilGv T Descn tion , U Unrestricted(up to 35,000 Cu. Ft.) R Restricted 1&2 Family Dwelling Sign�{urG.,� M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel ElunjLnj Appliance Installation D Residential Demolition 5.2 Registered T=orjn7t Contractor(HIC) d�R�9 HIC Company Name or HIC Registrant Name gistration Number i Address �d apir ion Date Signature Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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: OWNER' 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 ofperjury) 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 Square Footage"may be substituted for"Total Project Cosi' ��� ���� -� wc��- ��,, $�— O�w�- �-� p�l�r �.� �t,�c� ��iti�'� 5 .� �C �� � i < I �- �� �� � , �' �, ,� 0 ��� �� �- �� � � � � � � co v® , CERTIFICATE OF LIABILITY INSURANCE °"'E'3 09 PROIAOER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Phil Richard S Associates ONLY 'AND CONFERS NO RIGHTS UPON THE CERTIFICATE .HOLDER. THIS'CERTIFICATE-DOES NOT AMEND, EXTEND OR 491 Maple Street - ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 102 Danvers, MA 01923 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA.SCOTTSDALE INSURANCE COMPANY ' Pearson Builders, Inc. - INSURER& Arbella .Protection 150R Winona Street IrSURERa Granite State Ins AIG - Peabody, MA 01960- INSURER' INSURER E: - COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICkMD.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 HEREN ISSUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADO' POLICY NUMBER - POUCY EFFECTIVE POLICY EXPDATE mwponnnm IRATION. UMTS GENERALLUUDLRY - EACH OCCURRENCE S 1'000'000 _ 'AMA TO RENTED- -- A X COAI+IERCIALGENEMLLIABILITY CLS1445653 11/28/08 11/28/09 wl 100 000 CIAIMS'MADE a OC:UR MED EXP(Ary oreFenian) S 5 000' PERSONAL&ADV INJURY $ 1.000.000 < . GENERAL AGGREGATE $ 2-0-0-0-0-0-0 GENLAGGREGATE LIMIT APPLIES PER PRODUCrs-CIDMPA7PAGG S 2,000,000 €. X POLICY PR0. LOC AUTOMOBIUUABUTY COMBINED SINGLE LIMIT B ANYAUTO 37262400001 7/18/08 7/18/09 (Ea accident) $ ALLOWNEDAUrOS - 'BODILY INJURY X SCHEDULEDAUrOS (Pepe ) S RSO,000 HIREDAUTOS - BODILY INJURY $ 500,000, NON-OWFEDAUTOS pare . - PROPERTY DAMAGE $ 100,000 (Peraadded) + GARAGGARAGE UABILNTY - � AUTO ONLY-fiA ACCIDENT 8 ANY AUTO - - OTHERTHAN EAACC $ E 3 AUTO ONLY: AGO $ EXCESS I UMBRELLA LIABUTY - EACH OCCURRENCE $ OCCUR _CLAIMS MADE AGGREGATE _ $ S DEDUCTIBLE _ $ RETENTION - - S MARKERS COMPENSATION - X TO WC STATLL ATM- f AND EMPLOYERS UASIUTVE C . ANY PIROPRIETORIPARTNEREXECITNE Y� TBD 3/17/09 3/17/10 E.L.EACHACaD_Nr - .S 100.000t OFFICErVMEMSEREXCLLDEDT - - (MartlebryInNH) EL.DISEASE-EA EMPLOYE S SOO OO Ifyas=Ibe ander - O' O0O SPE(.1 IONSbd w EL.DISEASE-POUCYLIMIT S 50 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXOLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS - EVIDENCE OF INSURANCE . . .. CERTIFICATE HOLDER - - CANCELLATION S HOULD ANY OFT HIS ABOVE DESCRIBEDPOUCIES BECANDELLED BEFORE THEN ', TO WHOM- IT MAY CONCERN.. - DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR W MAIL 1A.-,..DAYs VT„IaTTB* NOTICE TO THECERTINCAIE HOLDER NAMED TOTHE LEFT.BUT FAIWRDI!kW 336SHALL IMPOSE NO OBLIGATION OR LWBIUTY OF ANY:IUNO IPON;THE INSUR T S AGBPTB OR . z, . REPRESENTATIVES. ...-o,-"' AUTHORIZED.REPRESENTATW - :. 988 2008 ORPORAMN. All rights til fr♦:d:'- The ACOW rome and o0o"ro Q marks 04 - - - CITY OF SALEM , ! PUBLIC PROPRERTY DEPARTMENT �I,•l at I!: W.,,e it�,.I,^i I.4LG r s 3.urw.M.it,,.ut u , r, ti-.t. Pt Jti.•ri'+3 • F,s vlit,7,1 •su. Yorkers' Cumpensation insurance lifftdaait: builders/Contracturs/Clectricians/Plumbers itt ificant Information Please Print Le ihlr �l;nrtcti},r,,,warrh�anrrannnindn�.lualf: � ©ri /.%C 1ddIVS\: cf 4r city,Stacc.%ip 6�2Cf k&17 Phone f!' 72E` / 5 j5 ,4 3 .\re)"u an cmployer7 Check the appropriate but: Type of project(required): a 1 am a;(cncral coulractor and 1 1.Q t .tat a employer with ❑ 6. Q New construction anyilo)ccs(full antL'ur part-ome)_• have hired the suh•cunrcacturt 2.❑ t .tilt a sole propriettx or part»cr- listed on rhe anachcd sheet. t 7. Q Remodeling ship anti have no employee% These sub-contractors have V. Q Demolition working flit im in . , kt ' an Ca ,uit . asrsComp. insurance. y_ Q Building addition No workers'comp. insurance S e are a corporation and its fequircd.] office"have clie,ti.. their IO.Q Electrical repairs or additions 3,0 1 aoi a homeowner doing all work right oretemption per hfOl. 11.0 Plumbing repairs or additions myself. (No workcrs•comp, c. 132,j 1(3)•arsd we hove no t2.0 Roof'repair$ insurance required.) r cinpluyces. (No workers' 13.0 Other crnnp. in.urancc required.) •Sin ..,,tsLa+,A d,N<rtek%baa of nwst Alta,till aur lItt:wv ar,Iwluw a,uw,nt e1w,r worhas a;un,penwaiwt(vd,ay.utiumati.al. 'c lumauw.wn who,,djmil this atlfJavil indic,,Ms Ihey am awAv ell,.art mw d,cn hire willde casur:tcru l mua+.uFnit a newatr:,lava Inai".nV vwh. G.n,a.uw+dial abed tin bo%mist nt:lied..n addnla,nal,Iwrf.howmji nw umw of the mb<onumi as and theiruurtoo'eanp.Ivd,ay im0,rn,annn /aril un canpluyer alio!lr pruridinq rvorkers'turn r"arrion in.rurnncr fur my unployeer. Belory is rhe policy n"d jab the iufururottirn. /��fJ �7 q..,� Ir.,urancc Company Natne��— v/Tif�_t'�_ !L•..rgs^/'3�.'—+�! 5d/ Jf� _(�l•nli:y y rScltim. ic. t+: , C/ Enpirunun Date: /,)u Site kkrass: ` Ctty:staluLtp:ynlhCo .Utach is Vilify of the workers'eutnpenrutlun policy declaration pine(showing the policy cumber and v%piratiun date). I'alturc to wvurc cuaerage as required under Section 25A vi'}KiL c. 152 can lead to the imposition or criminal.penalties of a ria,.• up to 1L50,00 and/or uoe•year nnprisunmcnt,as ,tell as cis if pcnallws int the form of a STO WORK ORDER and a rine of op to i'_50 00.1 Jay .tguutst flit tolmorno ad%l.icd that a copy of this alalc"tent Inay be turwarded to the 0111ce„f I:n:>n'vtaaa ut :lw DIA :Or o5,aa.UXt..rtcf.l4C to rli'llmi. /,ht ha reby,.rfifv wider the tar" aed tient, •s o jury that the irrfurarottom provid d ub`o,ee is true au,t correct. til. ,.P•n a _ r7 ��-y}�+^!J "" DiS_.... / C G F"):1, the o+tly. 11a net wrrYe r"this urea.to Air s uoryirtrd by.vtyw mrvn ufj4 tial litrmil/Lick-ntc 1t luthurfly (ciraie, rcl:'d llv.dlln !. quddin� ItquruucW L t.illAu,.0 Clerk J. Llcclrical hi,pcclor i, plumbing( Impeelort'tr uo: _ Phonc to: Information and Instructions s l.u>.n hu.cua Genesi Lawi dlapwr I i2 rc•quue% all cmplo)cis to pro%Ide workers compensation tar their colpluy'eea. I`ono.mr ro l:us ,l itule, in emploiee is defined as " cl cry pawn in the icrvt,c of anuiher ml.ler.illy cunnact of hire, c%pre ii it unplii& oral or wlnten. ' %n :mp/u)vv l% Jefincd as"an individual, parmer>hlp, .i"caclatiuu. corpora un or other legal entity, or any two or more ..r the I.,rcguu:g engaged .n a joint cnrcrpn%c. and mOuding the :.gal represeurauves of a Jecea,ed cmplu.�cr, or the rc,c,%cr or trustee of or nldlridual, pwtncr>htp,association or other legal cnmy,employing :nlplo)ccs. However the owner of dwelling house having not more than three apartments and who resides therein. or the occupant of the .h%cllolg huu,c of another who employs persons to Jo maintenance,cun,truction or repair work on such Jwclhng house or.nl the.-rounds or budding appurtenant thereto%hall not because of such employment be declined to be in emplu)er " 7 i (hut 'ever state or local licensing agency shall withhold the issuance or �IGL chapter I S_. s_5C(b)also itatea y R l Y renewal ore license air permit to uperate a business or to construct buildings in the commonwealth for any applicant who has nor produced acceptable evidence of compliance with the insurance coverage required." %iditwnally. MGL chapter 152, 425CM -cites"Neither the commonwealth nor any of its political subdivisions;hall enter into any contract for the performance ul'puhlic work until acceptable e%idence of cumpliance with the insurance requirements of this chapter have been preserved 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), addre is(es)and phone number(s) along with their certificatc(s)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 cmployees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial .Nceidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The allidavit should be returned to the city or town that the application for the permit or license is being requested, not the M-partment of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain it 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 Omdals ['lease be sure that the affidavit is complete:md printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. 111:asv be sure to till in the pennitvlicense number which will be u,ed as a reference number. In addition, an applicant that must submit multiple pennitllicmise 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 locations in (city ur 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 life for future petmits or licenses. A new atlidavit must be filled out each veru. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (l.c. a Jug license or permit to burn leaves cte.)said person is NOT required to complete thn affidavit. 11, ,llii:c of luvc,u.-atium ,could h;.e to thank )uu in ad%ancc fur your Cuoperatlon and shlould \'till Ila%c .illy queatiolli, plea,.- Jo nul hesiratc to give m a call. fhc D)r.unncnl's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgadons 600 Washington Street Boston, MA 02111 Tel. q 617-7274900 ext 406 or 1-877-MASSAFE c.•. ..� > ,l, lis Fax 0 617-727-7749 www.mass.gov/dia s CITY OF SALEM a PUBLIC PROPRERTY �. DEPART' IENT I'. U ",u•a.. I J;-1; '1'N V: '1i Jo Construction Debris Disposal .affidavit (required lilt all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5 Dcbris, and the provisions of MGL c 40, S 54: Building Permit It is issued with the condition that the debris resulting from this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will be transported by: Inamc of harder) the debris will be disposed ot'in (name uI ISnhmy) .,gnomic of p:mmrt .rpphcanl ,latr