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B-20-783 - 0016 BALCOMB STREET - Building Permit The Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY M RJMassachusetts State Building Code,780 CMR SA Revised Mar Mar 2011 06 Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only _ Building Pemit.Number: -Date Applied, Bui ldin g Official(Pruit Name) Srgna Date SECTION;1.SITE"INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 16 &Jcomh .o. 1.1a 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 Yazd , 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'OWNERSHIPI; 2.1 Owned of Record: T^Am Ce.►ro.� �Ja �tr'^ I'H 6'� Name(Print) City,State,ZIP _ !b Ncoftk V. 9-28 em g x 76 No.and Street Telephone Email Address SECTION 3:DESCRIPTION-0O PROP"OSED WORK. (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) V Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed WorkZ: 4 _ . SECTION 4-ESTIMATED'CONSTRUCTION COSTS Item Official Use:Onl Estimated Costs: (Labor and Materials Y 1.Building $ •' 1 uil Bdmg.Permit Fee $ Indreate how fee is deternuned- ❑ Standard City/Town Application Fee 2.Electrical $ ❑Total Project Lose(Item 6)x.multiplier. x 3.Plumbing $ 2 Oiher Fees: $ 4.Mechanical (fIVAC) $ Lrst: 5.Mechanical (Fire $ Suppression) Total All Fees;,$ •. Check No Check Amount Cash Amount: 6. Total Project Cost: $ '�0, ❑pard mFull: ❑Outstanding Balance.Due' JUL 30 AM11:45 JUL SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 65-086 7-0 o 1 ITO T 1 4 C411.,b melo License Number Expiration Date Name of CSL Holder List CSL Type(see below) A# 34 J tKNJ"!g3 chr No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. kbod o/96 Q R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding ^ SF Solid Fuel Burning Appliances 978 53108011 iw,e1.i—�t�b�y4�eo.C6,•� I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) me%'s cLc I08gS3 oslz /�� HIC Registration Number ' Expiration Date HIC Company Name or HIC Registrant Name ] 1 W TtA'At✓ fds No. d Street �-T Email adrlEma dress -obody 14 o g71S31 0$11 City/Town, State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(IVLG.L c. 152.g 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 ..........ill 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 dr RM3 Pig Mf�1 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'OR AUTHORIZED AGENT DECLARATION. By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contain e'd in this application is true and accurate to the best of my knowledge and understanding. neF wS-i%7 e &/10 Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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.maaLgov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dgss 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" Commonwealth of Massachusetts Construction Supervisor Division of Professional Licensure- Restricted to: Board of Building Regulations and Standards Unreshicted-Buildings Of any use group which contain Const,r t6i"tbogrvisor less than 35,000 cubic fleet(991 cubic meters)of `r enclosed space. CS-080393 � pires 03/01/2021 - FAUSTINO N_MELO 34 JENNINGS CJRCLE :� r PEABODY MA 04960 ' bfy lam, Failure to Possess current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner CL DPS t.icensing information visit:WWW.MASS.GOV/DPS �inirrairaeall�o�✓1'�a-�sa�u�c!!: - Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: -:.TYPE::LLC Office of Consumer Affairs and Business Registration_ Expiration Regulation =_t08953: 08/27/2020 10 Part:Plaza-Suite 5170 MELO'S CONST,_RUCTION L`_C Boston,MA 02116 FAUSTINO N.MELQ_TT 34 JENNINGS CIR: PEABODY,MA 01960 Undersecretary —" --� ��----- — i�iot valid without signature a ,. DATE(MM/DDNYYY) . CERTIFICATE OF LIABILITY INSURANCEF1%. 12/11/19 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 NAME: North Shore Travel 8;Insurance,Inc. PHCCN o.E,th 978-531-2755 AIc No): 978-531-2228 111 Foster St ADDRESS: Peabody,MA 01960 INSURERS)AFFORDING COVERAGE NAIC# INSURERA: Northfield Insurance Company INSURED INSURERB: Progressive Casualty Melos Construction LLC INSURER c: Nautilus Insurance Company 34 Jennings Circle INSURER o: Travelers Indemnity of America Peabody,MA 01960 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 CONTRACTOR 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 VOL SUORPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE NSD POLICY NUMBER MMIDD MMIDD LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any oneperson) $ 5,000 A MPB26983 12/04119 12/ 4120 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JECT PRI LOG PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E,,cadent $ 1,000,000 x ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED id P 02383499-0 09/21/19 09/21/20 BODILY INJURY(Per accent AUTOS ONLY AUTOS ( ) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 C x EXCESS LIAB CLAIMS-MADE AN052012 05/03/19 05103/20 AGGREGATE $ 1,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY y I N STATUTE ER D OFFICERIME BEANY RPEXCLUDED?ECUTIVE❑ NIA UB-7J282133-17-42-G 12104/19 12/04/20 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROV SONS. AUTHORIZED REPRESENTATIVE l/ ©1988-20. 'CORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of AG D` Lh- 34 Jenrtln& xddVt MA 01SOt3 EEs�C3i1tsrl®f E3TQ''$3 f-�E3't f �* rtatirto Nf ttras; C�t6PttarYit i4�t�wng r. E xeet+sE:F'UM41zttrECtMato�rr�gr,CfiirYP Nfcsti ataaE,Moto.Ganorat g tinagae �rwraytt,�3tsnpty��As�Ers��f�tte�<t,t�rtt. Unr4sti7oted Mras s BUIlders LtO&MIa Rlc9.t�F339 U 1_�Y F�Q contractors 06glatratio"'hlo. to a8s3 t Y'Sesege t3 .. proposat Submitted To: Date of proposal: • � r� Job Location: phone."&mber& Entail: SEibmit Speci cations and Esritnates'fdr the ittstatfatic�rt of a stew rO0 7o tpt�. �t�� M We Hereby a Tarps will be used to cover the sid�ttg,f�usFtes3 aattd grass doting r'etttr3tt�i homeowners proA rty sfapi � •"� All layers of roofing wEFC be striped, and aCl< rotrudErtg netEs,seresEvs ,arts es v�ttiibe reo�te�c#. � #,t C�4 feet of ice'and•.water shield vvr l then be installed,-A Pita battc�Et r of a�( edges,aroEfnd sti r:Ettt�rt+� /ist ,c�� wi .the be enstatot ta,atoofweEtbnstaliecantc�ai�otft3reeatis=rt , 8„a umirteurMn edcte S 3 ¢ � � 1 f > i es wi Cabe covered with new rubber ftEctges Shtngltoofi gwitiibfast 'ted*ntk drrE �tcS ;z The=ekistrrr p P. ,;s . u r roofing naets r � - � r n fTrarena.. t to be timed .:, r is respgnslb a ar; ,,a �e c ortb a°t erdcbo c <fy F The Ftorrreowne,; 5, �, £. z Zit , . rr -- ebrts wilt;beicCeaned artd pro erly dtspp„c�red.o on�a dal y:bgs�s nnagn®t brooms wE�N V�e{u sc} ; f tte d trout o"url pxope e rfirt©t$�ece gyresnsibt�t °far, o �essC ns`EttystcYea:Y .e t ra t � �;. �_ o atttc}ai�a�; �t.�sto�ner shau ra�eci persdt��Ek�e�.ai E11 a�t�vtl �ttl�" tC�te�, Clti�� ,�� , .., eblrs�aflli� ,�frtf`�� 6.9 � MG�os�r 0. _ NN!"S" WE � +W O� {7'IR tc�a C� PI CC((7!riCd d fnirllb e r ep ter' rlE trzc�Udi�ctt t{b rl ra z k a u etY► is Ul- t� cue _ thc ]etepernsa4lrtety �rr road'eto s t l`n t' ,'' v uncap 5 ¢ntG9$ s �darlta"I�IU4 # nfaori6 r: a a ce ': 4 trj s'r= -.fit wn fi. 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CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 98 WASHINGTON STREET,2ND FLOOR TEL: 978-745-9595 KIMBERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER Construction Debris Disposal Affidavit it (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,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: rv�Won L C < (name of hauler) The debris will be disposed of in: (name of facility) 41,/t 9 36 Aver., ri Aftwiy (address of facility) r Signature of applicant (today's date) The Commonwealth of Massachusetts Department of IndustrialAccidents > 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PER1V1MING AUTHORITY. _Applicant Information. Please Print Leaibl' Name(Business/Organization/Indwidual): f-tQ1 Ois Address'_ 3 T�Kit i n%oFS City/State/Zip: _ b� Phone#: Are you an employer.'Check the appropriate box: Type of project(required): 1.Wl am a employer with employees(full and/or part-time).* 7. [J New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in $. Q Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required. t 9. ❑Demolition 10 Building addition 4.0 1 am a homeowner and will behiring contractors to conduct all workon my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 I.[]Electrical repairs or additions proprietors with no employees 12.0 Plumbing repairs or additions 5.Q I on geneal contractor and I have hiied the sub-contractors listed on the attached sheet. 13.®Roof repairs These sub-contractors have employees and have worleers'comp.insurance t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152.§1(4),and we have no employees.[No workers'comp.imuntruce required.) *Any applicara that checks box#1 must also fill out the.section below showing their workers'compensation policy infomtation. - t Horneownas who submit this affidavit indicating they are doing all work and then hireit outside contractors must subm a mew a rWavitindicating such tcontractors 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 mast provide their workers'tromp.policy number. I am an employer that isproviding workers compensation insurance for my employees Below is the policy and job site information. Insurance Company Name. A& 7fa'Vel1 vlSltt ra n et Policy#or Self-ins.Lic.#:__f'LP J8, 9 ?3 Expiration Date:. /7-'C» 4 •20 Job Site Address: 1 WM b- S4 City/State/Zip Tat le ot- M 14 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 under the pains and penalties of perjury that the information provided above is true and correct Signature: . _-. Date Tu& Ito Jep rs Phone#: GJ 7 57 J d kr t Official use only. Do not write in this area,to be completed 0 city or town offlcw 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#: