B-20-645 - 0001 ARBELM ROAD - Building Permit The Commonwealth of Massachusetts' =a
Board of Building Regulations and Standards Clfi"OSALEMF
Massachusetts State Building Code,780 CMR 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 pplied
Buildmg.Official(Pant Name) Signature Dat
SECTION l SITE^;INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes 1'1�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❑ Privat Zone: _ Outside Flood Zone?
' Check if yes❑ Municipar f On site disposal system ❑
;SECTION 2 PROPERTY OWNERSI`iIP' >_.
2.1 Owner'of Record:
Name(Print) City,State,ZIP
\M, \-(A30
No.and Street Telephone Email Addres
SECTION 3 DESCRIPTION OF PROPOSED WORKZ(check all that apply_)
New Construction❑ Existing Building❑• Owner-Occupied' 13 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.0 Number of Units' Other ❑ Specify:
Brief Description of Proposed WorkZ: �pra�� pd S{r(or ' ,, pad cr�1
V00 s(_ �'- % 'P 40 $ SNC%IrO001 po
—� �• CA r.6 1 s �i n
- � SECTION 4 ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs
(Labor and Materials) Official Use Only
y 1.Building $ �� 1 Buildmg Permit Fee $ Indicate how fee is determined ".
❑Standard CitylTown:Apphcation Fee
2.Electrical $ j� 0
• " `❑Total Pro ecY-Costa Item 6 x multt'her x.. �
3.Plumbing $ 2 Other Fees "$
L 4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Su cession Total All Fees ;$
Check:No Check Amount Cash Amount =
6.Total Project Cost: $ 13 s(Jo ❑paid 1n Full-_, ❑Outstanding Balance Due
i
SECTION 5: 'CONSTRUCTION SERVICES'
5.1 Construction Supervisor License(CSL)
0 License Number Expiration Date
Name of CSIL Holder
A A o r �� n List CSL Type(see below)
No.and Street (� Type ' Description
„� M� O 1 U Unrestricted(Buildings u to 35,000 cu.ft.
ni, 7 v 1 l— R Restricted 1&2 Family Dwelling
City/Town,State,ZlkJ M Masonry
RC. Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
\-A zL, D� So.A Esso- Co.
H HIC Registration Number Expiration Date
IC Company Name or HIC Registrant Name
"C" '1—
No.and Street �\ � n � n � �3,
tv` "1 � � °� Email address
City/Town,Sta't ,ZIP 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 ..........❑ 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 t 's building permit application.
Atko(4s, M ICti
PM Owner's Name(Electronic ignature) D to
SECTION.7b:OWNER.OR AUTHORIZED AGENT DECLARATION.
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
\— vo U/
Print er's or Authorized Agen s Name(Electronic gnature) ate
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. 142A.Other important information on the HIC Program can be found at
t www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,fmished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms. g- Number of half/baths
"Type of heating system l Number of decks/porches
Type of cooling system Enclosed Open
3. Total Project Square Footage" a ua o m be substituted for Total Project Cost"
_ J q g Y J
Estimate
On time.Done right?
Client Name:
Nick Murphy May 1,2020
1 Arbella Rd
Salem MA 01970
Page 1
DESCRIPTION OF WORK PERFORMED
Exterior
Remove rotted trim around sun room area.Replace with composite '
trim as allowed.Relead wood gutter to seal
Remove and replace back stairs
Remove and replace exterior door with 3'0 x 7'0 wood exterior door
paint exterior and stain interior
replace 7 windows with white Harvey slim line replacement windows
remove carpet and install luxury vinyl flooring
paint existing ceiling
dispose of all debris
pull appropriate building permit with city of Salem
Deposit required 50%: 25%due halfway through project
remainder due upon final sign off
any additional work will be billed at$104 per hour
TOTAL
Any undiscovered or hidden problems could result in additional charges and
will be brought to the clients attention immediately upon discovery.
Payment is due upon receipt of final invoice. We accept as means of payment Cash,Check, Visa,MasterCard,Discover,and American
Express. Any current discount offers in affect at the time of this estimate have been applied and no additional discount offers may be
If pays e,*, not made upon completion of the job and payment is not tendered within 10 days,interest will accrue at a rate of 2%per
month from the date of completion. Inn th dv it of legal action in the process of collections,lire client agrees to pay all costs and
9
Client Si natureL C
Signature: c..bl� hen S. I>A rad, President
2 De Bush Ave
Unit C-2
Middleton, MA 01949
(P)978 5315939 HIC#147809/MA CSL# 0947624
i
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.
A _licant Information Please Print Le .bi'
Name(Business/Organization/Individual): 1�� J•S , o �iGP�sS 1 y1
Address: a _t>Q
City/State/Zip: `��^ t��Ox5`(N Phone#: Cl1 .9 TJ i Sc 5`1
Are you an employer?Check the appropriate box: Type Of project(required):
1.�a employer with employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. remodeling
any capacity.[No workers'comp.insurance required.)
3. I am a homeowner doing all work myself No workers'coin .insurance 9. ❑Demolition
❑ g y [ p � required.]f
10[]Building addition
4.❑I am 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 I I.[]Electrical repairs or additions
proprietors wim no employees. 12. Plumbing repairs or additions
5.❑1 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.insunowe.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152.§1(4),and we have no employees.[No workers'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 submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: v'--...e_a 1.�5�.r�✓,
Policy#or Self-ins.Lic.#: C6`3 L o-6 cam.5 5 "t Expiration Date: +
Job Site Address: a"(-\o e City/State/Zip:,
ryn M
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
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 the pains and penalties ofper•jury that the information provided above is true and correct:
Si nature: C . Date: - : c�, J �0
Phone.#: .
Official use only. Do not write in this area,to be completed by city or town official
City or Town: _ Permit/L)cense#
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#: __
b' CITY OF SALEM, MASSACHUSETTS
i
BUILDING DEPARTMENT
98 WASHINGTON STREET,2ND FLOOR
TEL: 978-745-9595
KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUMDING COMMISSIONER
Construction Debris Disposal Affidavit
(requiredfor 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 c40,554; Building Permit# I .I,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:
(name of hauler)
The debris will be disposed of in:
e ) w L
t�5 5 _
(name of facilit
(addres f facility)
. . .
Si re 2off appli
_3 L-0
(today' date)
ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY)
07/31/2019
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.B'(,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 endorseme s).
PRODUCER CONTACT
Nee Insurance Agency, Inc. NAME: Geoff Reef ,,
1225 Tri State Parkway PHONE (847) 623-0456 No:(847) 623.5600
E-MAIL
Gurnee IL 60031 ADDRESS: Jennyoweatinsurance.com �.
INSURE S AFFORDING COVERAGE NAICII
INSURERA:Philadelphia Indemnity Insuran 1805E
INSURED INSURERS:Inter and Insurance 31470
Columbus Property Services, Inc dba Mr.
Handyman of South Essex County INSURERC:
2 De Bush Ave Unit B2 INSURERD:
Middleton NA 01949 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER:Cart ID 8243 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.
LT R ADDLSUBTYPE OF INSURANCE R POLICY NUMBER POLICY EFF POLICYMWODNYYYI MI EXP DIYYYYI LIMITS
• g COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ 11000,000
CLAIMS MADE OCCUR P8P&2017920 08/01/2019 08/01/2020 PREMISES Ea occurrence $AMAGE TO RENTEI5__ 100,000
MED EXP Any oneperson) $ 51000
PERSONAL&ADV INJURY $ 11000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
g POLICY❑PRO- ❑
JECT LOC PRODUCTS-COMP/OPAGG b 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBIN D SINGLE LIMIT
Ea accident $ 11000,000
A g ANY AUTO PUPK2017924 08/01/2019 08/01/2020 BODILY INJURY(Per person) $
OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
b
A X UMBRELLA UAB X OCCUR PMM687739 08/01/2019 08/01/2020 EACH OCCURRENCE $ 11000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION PER T -
B AND EMPLOYERS*LIABILITY YIN COWCO86994 06/09/2019 08/09/2020 E STATUTE I ER
ANYPROPRIETOR/PARTNER/EXECUTIVE 0 E.L.EACH ACCIDENT $ 500,000
OFFICER/MEMBEREXCLUDED? N/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,000
A Crime PRPX2017920 08/01/2019 08/01/2020 Employee Theft $ 25,000
A Crime PHPK2017920 08/01/2019 08/01/2020 Theft of Client $ 25,000
Property
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addidonal Remaft Schedule,may be attached d more space Is required)
For Display Purposes Only
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Columbus Property Services, Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
For Display Purposes Only
,j AUTHORUEDREPRESENTATNE
01988-2015 ACORD CORPORATION. All rights reserved. /
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
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