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B-19-1297 - 0057 AURORA AVENUE - Building Permit The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR -t Massachusetts State Building Code,780 CMR4r, aE-011 HAL MUNICIPALITY E•,MV. SSE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling • ' r {� This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers l.la 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: P Y Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP'2.1 0O Q P erg one J5� Q I 1 0 k � , Name(Print) City,State,ZIP 51 U r o CO— � 198 Z) 0/1y No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ElAlteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposgd Work2: vnOd e1 & CO ice. i C C r IN a1k SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ Z Qa() 1. Building Permit Fee:$ Indicate how fee is determined: 11 ❑Standard City/Town Application Fee 2.Electrical $ 130 ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ Z.S O 2. Other Fee i 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 151$(7� 0 Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �Ll SS� 1023 Htio 20 Z 1 1 Q y 1 'By ckes License Number ExpiDate Name of CSL Holder 19 n Q2.� List CSL Type(see below) No. d Street �1 UUU Type Description U Unrestricted(Buildings up to 35,000 cu.ft. ��11WJJ ! I 1 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC RoofingCoverin WS Window and Siding �5 �0 SF Solid Fuel Burning Appliances ��f @ SVI�C{(I I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) l v j 7-1 20 Z 0 &1 ICtr� V(1(�t he.5 HIC Registration Number gxpirhtion Date HIC Company a or HIC Registrant Name � 2e�zi std ��'1'�-2, No. d Stree Email address if��I A M ZY761 City/Town,Stale,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 lac OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize ZOCI�l 3()CJ,1 es to act on my behalf,in all matters relative to work authorized by this building permit applicatio 2u�L W A�tkl r) ►1 z� Print Owner's Name(Electronic Signature) Date 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. Print Owner's or Authorized Agent's Name(Electronic Signature) iate 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 www.mass. og v/oca 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"maybe substituted for"Total Project Cost" CITY OF SALEK MASSAaRJSEM Bu Dm DEPARTlaw 120 WAsuNGTON STREET,31D FLOOR TEL.(978)745-9595 FAX(978)74 M46 KIM BERLEY DRISCOLL MAYOR THQMAs ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BumDING OOIMMONBR 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: vim., Ca`-14 (name of hauler) The debris will be disposed of in: f-��a fif (name of facility) wss (address of facility) SignattA,e of pplicant 'N 9 (today's date CITY OF S�UEN4 1UNSSACHUSETTS BUIlMlI1G DEPARTaIENT ` 120 W 1SHINGTON STREET,3'FLOOR TEL (978)745-9595 FAX(978)7404846 KIMBERiEY DRISCOLL MAYOR THOMAS ST.PIERAB DIRECTOR OF PUBLIC PROPERTY/BUI DLNG CO,%L%aSSIONER Workers' Compensation Insurance Afl3davit: Builders/Contractors/Electricians/Plumbers Applicant Information /Pleaase Print Le ibl NaMe(Busirwss;'OrganizatiorulndividuW):�f 1 G n �d e�lt'S o4 � WP7(441) e ibectw) Fewe Address: I I a zzzg tzd _ City/State/Zip:&— �` /" 4 ON 01 S Phone Are you an employer?Check the appropriate box: Type of project(required): 1.EO I am a*employer with 3 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-tutu).• have hired the sub-contractors }� 2_❑ I am a sole proprietor or partner- listed on the attached sheet.2 ?•1FJ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work,' right of exemption per MGL l LCI Plumbing repairs or additions myself[No workers'comp. C. 152,41(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers, 13.❑`Other comp.insurance required.) Any applicant that checks box#1 must also fill out the section below stowing their workeW compensation policy infunnation. t I htmrowom who submit this affidavit indicating they,are doing all work and then hire outside eontroetom must submit a new affidavit indicating such. Cuntmnots that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy intimatim l um an employer that is providing workers'compensadon insurance for my employers. Below is the policy and job site infrmation. .Insurance Company Name: Policy#or Self-ins.Lie.#:_W C C 50"0 — S•U [3 7 --201$ 14 Expiration Date: l ZS Z0-Z Job Site Address: S7 r o rO(a- Are— City/State/Zip:_ Gt .p.T J ►/� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration slate). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a lane up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advi..wd that a copy of this statement.may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby certi y under the pains and enal!!es of perjury that the information provided bov is true and correeL •>n•1 tr �C Date: )1 -2 0 Dime OJrchd use only. Do not write in this area,to be completed by city or town offlc&L City or Town: _ PermittLicense# Issuing Authority(circle one): L Board of 1lealth 2.Building Department 3.CityJTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ACORU' OP ID:DAN CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) THIS CERTIFICATE IS ISSUED AS A 19 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 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 Segreve&Hall Insur.Assoc.lnc NAME: One Tech Drive,Suite 135 PHONE 978.975-1300 Andover,.MA 01810 A/c IL Et), AA/C EMAIL No):978-975-7596 Patrick D:Hall ADDRESS: PRODUCER COAST-6 CUSTOMER ID p: INSURED Brian Boches dba INSURER(S)AFFORDING COVERAGE NAIC A Coastline Construction INSURER A:Arbella Protection 41360 19 Rezza Rd. INSURER B:A.I.M.Mutual Ins.Co. 33758 Beverly,MA 01915 INSURER C: INSURER D: INSURER E: INSURER F COVERAGES 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. 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 LTR TYPE OF INSURANCE POLICY NUMBER tNMIDDnY MMIDD,Yy LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A COMMERCIAL GENERAL LIABILITY r8500061996 03/08/2019 03/08/2020 PREMISES Ea occurrence $ 100,000 CLAIMS-MADE OCCUR - MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRCT O LOC PRODUCTS-COMP/OP AGG $ 2.000.00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ SCHEDULED AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS (PER ACCIDENT) UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,00 CLAIMS-MADE A EXCESS LIAR 4600061997 03/08/2019 03/08/2020 AGGREGATE $ 2,000,000 DEDUCTIBLE RETENTION $ WORKERS COMPENSATION r$ 5.0 AND EMPLOYERS'LIABILITY *DISEASE - OTH B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N S X ER OFFICER/MEMBER EXCLUDED? ❑Y N/A DENT O,000 (Mandatory in NH)and CC-500-5018733-2018A 04/25/2019 04/25/2020EA EMPLOY0,000 Dyes,describe under DESCRIPTION OF OPERATIONS below OLICY LIMI0,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is req Job Location:81 Congress St Salem MA uired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 98 Washington Street Salem,MA 01970 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks ofACORD