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B-19-892 - 0025 ALBION STREET - Building Permitr J` � ® c�� The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF 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 Offictal.Use Only Buildin Pemut Number Date plied . :: g 1 Building Official(Print Name) Signature Date SE.CTION.1.SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers I.I a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zonung 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 PROBERTY OWNERSHIP.'`;` ...... 2.1 Owner1 of Record: C5 R f)l )U a G o vy) m Nae(Priyit) City,State,ZIP k ss o.and Street Telephone Email Address SECTION 3 DESCRIPTION OF PROPOSED WORKZ(cheek all that apply) a; h' New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) It Alterations) ❑ �ditio'.i rG7 Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: > }i BriiefSDees��cription of Proposed Work2: —r ft __0 i Y .. .. Co •V. k S �r SECTION 4 ;EST IMATED:CONSTRUCTION COSTS Item Estimated Costs s (Labor and Mat enals) Official Use Only 1.Building $ �a0 1. Building,Pemut Fee $ Indicate how fee is determined 2.Electripal $ 01,Standard City/Town Application Fee I7 Total Proieci Costa(Item 6);x multiplier x 3.Plumbing $ !2. Other fees: $ 4.Mechanical (HVAC) $ Ztst. 5.Mechanical (Firebo $ Suppression) Total All Fees_$ 6.Total Project Cost: $ a Check No Check Amount Cash Amount. ❑Paid.m Full ❑Outstanding Balance Due. T) S_ - s7rI - 3 d! SECTION 5: CONSTRUCTION:SERVICES 51 Contraction Supervisor License(CSL) 0$? c0 3 AJ a License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description n U Unrestricted(Buildings u to 35,000 cu.ft. /' 4 go N � C 1 1 24e - Restricted 1&2 Family Dwelling City/Town,State,ZIP' M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances t9/0 ��►?a� I Insulation Telephone Email address -C7^ D Demolition 5..y2^Registered Home Improvement Contractor(HIC) �d!y K P�Nit O j Z / 77 AIch� HIC/Registration Number pirati Date ° HIC Compgny Nazpe or IYIC Registrant Name mav 0- No.and Street Email a ess PF `L, City/Town,State,ZIP Telephone ' SECTION 6r-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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"PLIES FOR —BUILDING PERMIT I,as Owner of the subject property,hereby authorize_ZZ L,.r U'&-L A t 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:OWNER'.OIL AUTHORIZED AGENT DECLARATION. By entering my name below,I hereby //01 att d the p d enalties of perjury that all of the information contained in this application is true and c t o the est f knowledge and understanding. _. &4714AIf � Print Owner's or Authorized gent's N ctr is Si r Date NOTES: 1. An Owner who obtains a boil ' permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home rovement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund un er M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.g_ov/dpss 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.). Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of haWbaths 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" �1 �►lti -CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) nstm 21201*9 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. 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 ' CONTACT Parente Insurance Agency Inc. NAME: Patti 94 Lynn Street PHONE 978-531-8854 _ y E MAIL°"-E`` --------- -- ------ i ac�:978-531-5587 PeabodyMA 01960 ADDRESS:pzirenteinsurance@gmaii.com @gmail.com _ ........—__._—..-_._INSURETS)AFFORDING COVERAGE NA_IC# INSURED INSURER A:Atlantic Casualty Insurance _ John Pantapas INSURERe_Travelers Indemnity Company PO Box 4065 INSURER C: _ 407 Lowell St. INSURER 0: Peabody MA 01960 .i _INSURER E COVERAGES INSURER F CERTIFICATE NUMBER: 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 NOTWITHSTANDINGANY 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. ILT R IADDL SUBRI - LTR TYPE GF INSURANCE V POLICY NUMBER I POLICY EFF POLICY EXP MMIDD/YYYY MMIDD/YYYY LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS MADE OCCUR DAMA 19� I PREMISES(Ea occurrence) $50,000 1_118001204 04/13/2019 04/13/2020 ( y p_) $5,000_ MEDEX_P An One erson & GEN'L AGGREGATE LIMIT APPLIES PER PERSONAL ADV INJURY $1,000,000 i 1'G—E'NERAL AGGREGATE $2,000,000 POLICY R ❑ LOC ' PRODUCTS-COMP/ OTHER: OPAGG $1,000,000 _ --- AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT $ ANY AUTO i I _(Ea accident.__ _ ----- --- OVWED f BODILY INJURY(Per person) $ SCHEDULED , AUTOS ONLY .AUTOS HIRED ) BODILY INJURY(Per accident) $ .NOWOWNED AUTOS ONLY AUTOS ONLY I - PROPERTY DAMAGE i (PeracatlenlL $ UMBRELLA LUi6 r S - - $ OCCUR RWORKERSCOMPENSATION CESS LIRB f EACH OCCURRENCE $ _ CLAIMS MADE; I _—..---------- ! AGGREGATE $— EO RETENTIONS _-- 13 $ AND EMPLOYERS'LIABILITY YIN ' I SPER TATUTE EORH ANYPROPRIETOR/PARTNER/EXECUTIVE I !UB-1 K5 95 8 27-1 8 i09/12/2018 09/12/2019 OFFICER/MEMBER EXCLUDED? !N/A y E.L.EACH ACCIDENT $100,000 (Mandatory in NH) I I t ---- If yes,describe under . I E.L.DISEASE-EA EMPLOYEE $1 OO,000 .DESCRIPTION OF OPERATIONS below I? ! E.L.DISEASE-POLICY LIMIT $600,000 DESCRIPTION OF OPERATIONS/LOCATIONSi/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Carpentry Contractor This replaces any prier certificate Issued to the certificate holder affecting workers comp coverage The workers compensation policy does not provide coverage for John Pantapas t CERTIFICATE HOLDER CANCELLATION Obdulio Gomez 25 Albion St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Patricia Guercio ACORD 25 2046/03 ©1988-2015 ACORD CORPORATION. All rights reserved. (. ) The ACORD name and logo are registered marks of ACORD Produied using Forms Boss Web Software.www.Formsaoss.com(c)Impressive Publishing 800.208.1977 f The Commonwealth.of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street,,Suite 100 Boston,MA 02114--2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Infonnafion I Please Print Lebly Name(Business/Organization/Individual): �J p Lly Address` City/State/Zip: . G Phone#: SS 3 e: - Are you an empluyer?.Check the appropriate box: Type of project(required): 1. I am a.employer with �` 4. ❑ I am a general contractor and I' 6. ❑New construction employees.(full and/or part-time).* have hued the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition and have workers'ees to ' working for me in any capacity. employees y 9. ❑Building addition [No workers'comp.insurance comp.insurance.) 10.❑Electrical repairs or additions re ed 5. ❑..We are a corporation and its P 3.El am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions right of exemption per MGL myself. [No workers'comp. 12�Roof repairs insurance required.]t c. 152,§1(4),and we have no. employees. [No workers'.. an Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'.compensation policy information. t Homeowners who subn ut 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 number, lam an`employer drat isproviding workers compensation insurance for my employees."Below is thepolicy and job site information. Insurance Company,Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'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$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. :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 certi und" the ai sad . alties o: 1!!!rjug that the in ormation provided above i true and correct: Signature: — ----- — Date Phone#: Official use only.''Do not write in this area,to be completed by.city or town official City or Town: _ Permit/License# Issuing Authority(circle one): ' 1.Board of Health 2.Building(Department l City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and 'Instruc. tions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. :. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance;construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required Additionally,MGL chapter 152;§25C(7)states"Neither the.commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been 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),address(es)and phone number(s)along with their certificate(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 does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a 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 Officials Please be sure that the affidavit is complete and 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. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license 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 or' " affidavit that has been officially stamped or marked b the city or town may be provided to the town . A copy of the affid y P Y pY . applicant as proof that a valid affidavit is on file for future 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.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. . The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Ofee Of invesfigiflons, 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext 406 or 1=877-MASSAFE Fax#617-727-7749 Revised 7-2010 wwvvrriass.gov/dia - 07Y OF SALEA MUSAM SE M BtDxpr 120 WASHQVMS98F.8T,3l RDM r .x 7kL(M)745-9595. DRIS�LL Fix -8 74LI 9846 ICI1Ml3FRtF_Y MAY®R sSv�01= DixEC1cat crrcauc /s a ss Construction Debris DisposalA idavit (required for all demolition and,.renovation work j In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40,S 54; Building Permit g is issued with the conddon that the debris resulting from this work shall be disposed of in a properly licensed waste,deposit facility as defined by MGL c 111,S 15-0A. The debris will be transported by: .fin:t T/12i? J (r�ame of hauler) The debris will be disposed of in: (mime of facility) " (addiess of facility) Vnature of applicantV Date - '�'�� ' Jauoissiwwo�• L8 tlW A408V3d S1/dV�NVd:NHOr } aaJlc( { -£OOL80-SO J J JOS!AI J SUOc) r x spiepueiS Pue suogelnbaa 6uIPImB PJeOB `aJnsuaa1l,leuoiss0 OJd 10 U01 ING . s�lasny?essey�}o yllean�uowwo� "v� ~�..:,._..:.gin.. rim..._ .jite C�srrintore��✓�l�o.�1e�j, _. •V~# Office of Consumer Affairs&i3usiness Regulation HOME IMPROVEMENT CONTRACTOR Individual EMkIfign JOHN F.PANS~ 04/25/2020 4 JOHN F.;PANTA 407 LOWELL STR � { PEABODY,MA 01961 Underseere t tary,