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B-20-574 - 0009 1/2 ALBION STREET - Building Permit a 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 This Section.For Official Use Only. Building Permit Number: Date Applied: U •aa uilding Official(Pant Name) Signature Date SECTION 1: SITE INFORMA ON 1.1 ropprty Ad rels:�o ]__ 1.2 Assessors Map&Parcel Numbers � �- t o s l.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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) City,State,ZIP n Tl G �t No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) [i Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Propppsed Work 2 AF_�o i Gx� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ O Q 1. Building Permit Fee`.$ Indicate how fee is determined: ",701 ❑Standard City/Town Application Fee 2. Electrical $ 60 ❑Total.Project Cost'(Item 6)x multiplier x f 3.Plumbing $ a DOC) 2. Other Fees:. $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ v ❑ Paid in Full ❑ Outstanding Balance Due: CN t JON 19 HM11,07 /24z/.0_791�� JUG! va , SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �ey /33� to to ©S� V �C— License Number Expiration Date Name of CSL Holder G List CSL Type(see below) o.and Street Tye Description Unrestricted(Buildings up to 35,000 cu.ft.) Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding ��/��^ � vl—���!'W SF Solid Fuel Burning Appliances CI�J l V %'�I'"'► o,con, I Insulation Telephone — —� Email address I D Demolition 5.2 Registered Home Improvement Contractor(HIC) ' &+301—q U(Q S050�--- YA 0^S HIC Registration Number Expiration Date HIC Compa y Name or HIC Registra t Nan a� t woo !A- .v rk ctkoo.C,o Nq.and Ir N, ,MN o,)L�f t G�^ �� �� Email address City/Town,State,ZIP �T TTelephone 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 .......... ❑ No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT 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 building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION entering my name below,I hereby attest under the pains and penalties of perjury that all of the information [By ontained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 Tinprovement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other impoitant information on the HIC Program can be found at www.mass, o�Information on the Construction Supervisor License can be found at www.mass.gov/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"may be substituted for"Total Project Cost" ,r� The Commonwealth of Massachusetts Department of IndustrialAccidents > I Congress Street,Suite 100 Boston,MA 02114-2017 www,massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organi2ati n/Individual): v\ N 0Y\ CO Address: \��� City/State/Zip: Lc�,\ ��� 119K Nb Phone#: Are you an employer?Check the appropriate box: Type of project(required): l. 1 nmployer with employees(full and/or part-time).• 7. EJ New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, U R modeling any capacity.[No workers'comp.insurance requited.) 9. El Demolition 3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4.❑1 sm a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,f 1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy numher. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:� dG n�&J jn_��� �Q C6 M96 n Y Policy#or Self-ins.Lic.#: TS ...�Q _... �._ _ Expiration Date: 09. Job Site Address: �I/ It(::�> �� City/StateJZtp: �rC YY1 MA- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expir tion da e). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation•punishable by a fine up to$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$250.00 a day against the violator.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 thepains and penalties ofperjury that the information provided above is true and correct Signature: �cS e A [-Y'f(A S Date: G / J Phone#: Official use only. Do not write in this area,to be completed by city or town ofjuial. 1 '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#: CITY OF SALEM, MASSACHUSETTS t BUILDING DEPARTMENT 98 WASHINGTON STREET,2ND FLOOR TEL: 978-745-9595 KIMBERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING CONMSSIONER Construction Debris Disposal Affidavit (required for all demolition & renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris, and the provisions of MGL c40,S54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licenses waste deposit facility as defined by MGL c 111, S150A. The debris will be transported by: 3/j s- i (name of hauler) The debris w'll be disposed of in: L,16 v0StC l (name of facility) - ,�econ S` L very, (address of facility) Uri e4, Signature of applicant (today's date) O�� I'ro,/F,AA� AA *;�/r�a�t gulattion j pffice of + -orisumer''�Affsiars ,, HOME IMPROV MEN7'`CONTRACTOt`t `����I'ndiyidualy �� T't Expiration Re"ist � /� (n� ](� :^3 t./ ��` r� 09/06/2QZ r ,rJy 'Gii' j ✓ l 6101,16 ; ' : 0U ilA r g b s r fi jr{ " xs ram'. . a} >" �G 44 .31 j <s%t .r JO .�.r„ t ,vR � ,•� +' z_ w7 '�✓fl�t`���y't gg - �" W, t � `i SS4� E ALE : MX p2148U�ndersecrota' ; A,d r n: r �. 4 $ ' @s x4 spa r aON W ': ._, s f +h"3 �.t � r vj AWli, a �v4'rea 10a, rr� , rv`* � :awl - . x ' 5 4A." 'v &n t +fie F R,O, p m!� M ¢', rMIMI a1 . MQ Division of Profes a a t L censu e Bard of Buis n Red iafians Stand. 'r r Iz ��• J3 "t`•'� � � d'� �` � °'� 4 yw y �� � �� r ^fit WAi a3 II i4 x • xg ta X. �y i I AL ;m N., v a MIM vlk�va y aasv, J a x ^rw k , d T'f:+.b,ro,a�, • .°y "' b- ,'m aaa,ea,n F 4' t° „* .#x a•e, r ® DATE(M IXYYYY) ACCORV CERTIFICATE OF LIABILITY- INSURANCE os/i�i2o26 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE.CERTIFICATE HOLDER. I , IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COT—' NAME: Automatic Data Processing Insurance Agency,Inc. PZONN FAX A No E-MAIL ADDRESS: 1 Adp Boulevard INSURERS AFFORDING COVERAGE NAIC# Roseland NJ 07Q68 INSURER A: His—Insurance Company Inc. 10200 INSURED INSURER W. NorGUARD Insurance Company., 31470 JJ CONSTRUCTION CORP INSURER C: 23 HAZELWOOD ST APT 1 INSURER D: ' X _ INSURER E: a Malden MA 02148 INSURERF: COVERAGES CERTIFICATE NUMBER: 1233953 REVISION NUMBER: THIS IS'TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSO POLICY NUMBER MMIDD/YYY MMIDO/YYY X,, COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 GE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 1,00,000 MED EXP(Any one person) $ 5,000 UDC-4213639-CGL-19 7/11/2019 07/11/2020 PERSONAL&ADV INJURY $ 1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 -POLICY JECT PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: ' $ AUTOMOBILE LIABILITY - C MB NED SING E LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident UMBRE,L'L11:LIAB OCCUR EACH OCCURRENCE $ r-.EXCESS,LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION R - AND EMPLOYERS'LIABILITY STATUTE EE R Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $.100,000 A OFFICER/MEMBEREXCLUDED? N/A N JJWC105835 05/25/2020 05/25/2021 E.LDISEASE-EAEMPLOYE $`100,000 (Mandatory In NH) It yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) 'CUSTOMER GOOF,Is listed as additional insured on General Liability CERTIFICATE HOLDER CANCELLATION 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CUSTOMER COPY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Your Confirmation number is 202006191028480 Date of Confirmation:6/19/2020 NOTE:When paying by ACH(Checking)it will take two business days for the payment to be debited from your bank account.Your account number is not verified until this payment is presented to your bank.They have the right to return this payment if unable to process this transaction against your account. Your request for payment(s)of$248.00 has been received and is subject to approval by your financial institution. No email was entered so a confirmation was not sent. Account Information Payment Information Name: JOSE A URIAS Payment Type: Credit Card Note: PAY TRANSACTION QUICK Payer Name: JOSE A URIAS Q Card Number: **************3871 Transaction Information Transaction Quantity Amount Fee Payment Type City of Salem-Inspectional Services 1 $238.00 $10.00 Credit Card Building Permit First Name:jose Last Name:urias DBA/Company Name,if applicable:jj comtructio Name of permitted/inspected property: 91/2 albion street Address of permitted/inspected property:91/2 albion st Phone#:617-648-7964 Contact Email Address: j.urias37@yahoo.com Total:$248.00