B-19-732 - 0120 BOSTON STREET - Building Permit The Commonwealth of Massachusetts
eC OF
Board of Building Regulations and Standards t SAtiEM
Massachusetts State Building Code,780 CMR
c
l � Mar 2011
Building Permit Application To Construct,Repair,Renovate lye o a
One-or Two-Fwnily Dwelling
_nv This Section For Qfficial Use Only;
J Bu>Idmg Pernut Number Date Applied
Building Official rmt Name) y� '. Si tore Date
t ..
SECTION 1:SITE INFORMATION
1.1 Property Address: O 1C� .2 Assessors Map&Parcel Numbers
1a0�l�S Mn �a . i
1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
13 Zoning Information: 1.4 Pror�pre�rty Dimensions:
Zoning District Propos Use i Lot Area q ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided'
I ,;Wat Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage, isposal System:
Public r Private❑ Zone: _ Outside Flood Zone? Municipal�On site disposal system ❑
Check if yes❑
SECTION 2 ;:PROPERTY ONVNERSHIPI
2.1 Owner'of Record.
30CAPS, tab Bdskn a. 3aeon l46_ oio
Name(Print) City,State,ZIP
I saS �SR01 Nero (t- 6 Iek)),
No.and Street T Telephone Email Address
SECTION 3 DESCRIETI OF PROPOSEDVVORKZ(check all thaf:appty)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) d1l Addition ❑
Demolition ❑ Accessory Bldg.El Number of Units I Other -VSpeci1y:7,d.1Rbbr yy1
Brief Description of Proposed Work2:
SECTION 4 ESTIMATED CONSTRUCITON COSTS
Estimated Costs:
Item Official.Use Only
(Labor and Materials
i.Building $ 1 Building Permtt Fee:$ Indicate how:'fee is determined:
2.Electrical $
❑Standard,CitylT. Application Fee
❑Total Project Costa Item 6).X;mul her x
J ( .. trP
3.Plumbing $ 2 Other Fees
4.Mechanical (HVAC)
5.Mechanical (Fire $Suppression) Total All Fees:
CheckNo Check Amount: Cash Amount:
6.Total Project Cost: Old ❑Patd in Fuil ❑Outstanding Balance I)ue.
ro C, se ,
SECTION 5: CONSTRUCTION SERVICES
5A Construction Supervisor License(CSL) o
O 7,okq
A r 1 � Licen mi Expber cation Date
h ob SL I-o l�'�rn� se
List CSL Type(see below)
No.and Street Description
, 41 UUnrest Restricted 1 (Buildings el 35,000 cu.ft.)
_� w R Restricted 1&2 Family Dwelling
(.i y/Town,'State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
U l-3Q I Insulation
Telephone Email addresloec" D Demolition
5.2 Registered Home Improvement Contractor(HIC)
3 2dZ�
HIC Registration umber Expiration Date
C Co m any Name or C Registrant Rame
i'l- ly(P:C-� �ii 1bG\I('��cIsdn
No.and treet Email address mQ l( (°,oly)
City/Town,State,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
1,as Owner of the subject property,hereby authorize ✓
' to act pn my behalf,in all ers relative to work authorized by this building permit applica n.
f _ - ? E2"/
Pn'ht Owner's Name nic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under theYpains 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 choreic Signature) Date
NOTES:
1. An Owner who obtainuilding permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered a Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or,.gnaranty fiord under MG.L.c.142A_Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.yov/dpss
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" .
i
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The Commonwealth of Massachusetts
Department.of Industrial Accidents
m 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/Organization/Individual): [�(� +-} �
Address: n� P.C��'S�-• �f Q WOro
City/S-tate/Zip: btQ Phone#: �
Are you a4n employer:'Cheek the appropriate box: Type of project(required):
I.[?/[am a employer with , employees(full and/or ; e).* 7. [l New construction
2.❑I ant a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp_insurance required.] .
9_ El Demolition
3.❑ m I a a homeowner doing all work myself.[No workers'comp.insurance required.]r
10 0 Building addition
4.❑I an i a homeowner and wilt 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 LE]Electrical repairs or additions
pr%)rietors with no employees. 12.❑Plumbing repairs or additions
5. Ian 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.M we area corporation and its officers have exercised their right of exemption per MGL c_ i 4.v[�Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.] AA 3Y-1 I boy
"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 sub-contractors and state whether or not those entities have
employees. If the subcontractors 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.
Insurancf Company Name:, 1
Policy#or Self-ins.Lic.#: C` �bad 3aExpiration Date:
Job Site Address:u b City/State/Zip: I 1�� � �`Ci
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 un a ain and penalties of perjury that the information provided above is true and correct;
Signature: �q Date:
Phone#: ll�
Official use only. Do not write in this area,to be completed by city or town:official.
City or Town: PermitlLicense#
Issuipa 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#:
f '
w r
r CITY OF SALEM, MASSAaR SE f {. TTS
BUILDING DEPARTNIENT
120 WASHINGTONSTREET,3-FLOOR
'AL.(978)745-9595
KMERLEYDRISCUji- FAX(978)740-9846
MAYOR THOMM STTIERRE
DIRECTOR OF PUBIICPROPERTY/BUILDING OpAWSSIONER
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,
find 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:
1
(name of hauler)
The debris will be disposed of in:
(name of facility)
(addr of facility)
Signature lof a I cant
(today's date)
i
COMMERCIAL GENERAL LIABILITY COVERAGE PART
POLICY NUMBER:CL00271232 DECLARATIONS
❑Extension of Declarations is attached. Effective Date:01/17/2019 12D1 A.M. Standard Time
LIMITS OF INSURANCE
General Aggregate Limit(Other Than Products/Completed Operations) $ 2,000,000
Products/Completed Operations Aggregate Limit $ 2,000,000
Personal and Advertising Injury Limit $ 1,000,000 Any one person or organization
Each Occurrence Limit $_1,000,000
Damage To Premises Rented To You Limit $- 100,000 Anyone premises
Medical Expense Limit $ 5,000 Any one person
RETROACTIVE DATE CG 00 02 only)
This insurance does not apply to"bodily injury", °property damage"or"personal and advertising injury"which occurs
before the retroactive date, if any, shown here: (Enter Date or"None"if no Retroactive Date applies)
BUSINESS DESCRIPTION AND LOCATION OF PREMISES
Form of Business: ❑X Individual ❑Partnership ❑Joint Venture ❑Trust ❑Limited Liability Company(LLC)
❑Organization, including a Corporation(but not including a Partnership,Joint Venture or LLC)
Business Description: Contractor
Location of Primary Premises You Own, Rent or Occupy:
352 Andover Street
Dangers MA 01923
CLASSIFICATION AND PREMIUM
Code No. Classification * Premium Basis Prem/O Rate
Pr/Co Advance Premium
95625 Remodeler/Handyperson p 32,000 22-408 717
7.047 226
Total Coverage Part Advance Premium $ 943
FORMS AND ENDORSEMENTS other than applicable Forms and Endorsements shown elsewhere in thepolicy)
Forms and Endorsements applying to this Coverage Part and made part of this policy at time of issue:
See SCHEDULE OF FORMS AND ENDORSEMENTS-CO 1010
* PREMIUM BASIS TYPE LEGEND
a =Area (per 1,000 sq.ft.of area) c=Total Cost (per$1,000 of Total Cost) m=Admissions (per 1,000 Admissions)
p =Payroll (per$1,000 of Payroll) s=Gross Sales (per$1,000 of Cross Sales) It =See Classification u =Units (per unit)
+=Products/Completed Operations are subject to the General Aggregate Limit
THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.
Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Copyright,ISO Properties,Ina,2000
AL 00 01 09 08
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INSURANCE ACCEPTANCE INDEMNITY INSURANCE COMPANY
•� 1 GROUP 1314 Douglas Street,Suite 1600 Omaha,NE 68102 (888)389-0598
COMMON POLICY DECLARATIONS
Policy Number' CL00271232 Renewal of Number: CL00270963
This policy is insured by a company which is not
Named Insured and Mailing Address admitted to transact insurance in the
Great Rock Church commonwealth, is not supervised by the
commissioner of insurance and, in the event of an
352 Andover Street insolvency of such company, a loss shall hot be
paid by the Massachusetts Insurers Insolvency
Danvers MA 01923 Fund under chapter 175D.
Agency and Mailing Address Agency Code: 00244
NIF Group, Inc.
183 Davis Street P.O. Box 1139
Douglas MA 01516
Policy period: From 01/17/2019 to 01/17/2020
'12:01 A.M.Standard Time at your mailing address shown above.
Business Description: Contractor Tax State: MA
IN RETURN FOR PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY,WE
AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM
Commercial General Liability Coverage Part $ 943.00
Other Charges:
Surplus Lines Tax $ 38-08 TOTAL ADVANCE PREMIUM $ 943.00
TOTAL OTHER CHARGES $ 38.08
TOTAL $ 981.08
Forrrl(s)and Endorsement(s)made a part of this policy at time of issue:
See SCHEDULE OF FORMS AND ENDORSEMENTS-CO 1010
`Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations.
NO FLAT CANCELLATION
25 % MINIMUM EARNED PREMIUM
Countersigned: Douglas, MA
02/04/2019 JS-MLG Countersigned By Authorized Representative
THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS,COVERAGE PART DECLARATIONS,COVERAGE PART-COVERAGE FORM(S)
AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY.
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MIDDLETON MAr 01949
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MEN OF VALOR CONST Partnership
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MATHEW NADWORNY
67 FOREST ST
MIDDLETON,MA 01949
Undersecretary