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B-19-933 - 0026 BRADFORD STREET - Building Permit ti�if ,t The Commonwealth of Massachusetts Y .r ;=3 fa pij Board of Building Regulations and Standards '} CITY Massachusetts State Building Code 780 CMR SALEM ZJ 1 AUG 2 3 iAviRd W 2011 [" Building Permit Application To Construct,Repair,Renovate Or Demolish a ( f One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print—Name) ignature. Date SECTION 1:SITE INFORMATION ' l.V esr,�f, `-rtx Adds1'�t� 5{" 1.2 Assessors Map&Parcel Numbers L l a 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 Watpr 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 OWNERSHIP'' 2.1Kab Owgr'of. ecord: � 11 ,� 6 A i-A sc f .`9 j 019 Name(Print) 0City,State,ZIP ?L-a1 (CVA cA Q 7-'t�,y7-QSZ7 /�,oler .kv► e��'�dvla f.0 No.and Street Telephone Email Ad ess SECTION 3:DESCRIPTION OF PROPOSED WORK Z(check all that apply) New Construction❑ Existing Building❑ i, Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: 041/ Cr 1 l a.v► r5. r . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ 0® 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ 01 ❑Total Project.Cose(Item 6)x multiplier x 3.Plumbing $ 2. Other Feesa $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression JC/ Total All Fees:$ O6 Check No. Check Amount: Cash Amount: 6.Tot<id Project Cost: $2 e 7oa , ❑Paid in Full ❑Outstanding Balance Due: 12— (.o M Pal LSD SECTION 5 CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) (q,3`1 01!S GCGA(NC/- License Number Expiration Date Name of CSL Holder List CSL Type(see below) 1-10 C-Li-st-n"A 5} No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) c,,- �t(4n ,W 0 01970 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding �y SF Solid Fuel Burning Appliances I Insulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(RIC) 12357S 3 G5/2 0/2 07 , —1-4r- i�, Re�ye GfC,/,CeS HlC Registration Number Expiration Date HISany Name or HIC Registrant Name ��1,•vN C.rl Ng.an Street A Email address Ci /Tov�m,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 Issuannce of the building permit. Signed Affidavit Attached? Yes..........9K 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 13coyin(Y - to act oon�m�y�behalf 'n all matters relative to work authorized by this building permit application. Prmt Owner's N e(Electr c Signature) Date SECTION 7bs 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. S 22�t 1 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(MC)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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dyss 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" tt The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia «rockers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Anplicant Information Please Print Le 'bl Name(Bgsiness/Organization/Individual): 9ytC11 �✓►C 'J�� r� �C��/� 1 r CQ 5 Address: 26`S WQ t► : G\ S City/State/Zip: $tt(Am HA )C07O Phone#: c0r6 7`1S S 7y,S Are you an employer?Check the appropriate box: Type of project(required): I.E21-am a employer with employees(full and/or part-time).' 7. ❑New Construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.[]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] - *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 0 tat check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site S information. Insurance Company Name:Z-,_ /►$w—&`C — Policy#or Self-ins.Lic.#:C,S(to(A IS C)S 23 N Expiration Date:�Q�7G Job Site Address: 2LarorA tack City/State/Zip:ySQ JeA't b iq )G Attach a copy of the workers'compensation policy declaration page(showing the policy number and exptration 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 penalti jury that the information provided above is true and correct. Signature: Date: 2 Phone#: 9 76-S a G17 Official use only. Do not write in this area,to be completed by city or town official. i City or Town: Permit/License# i 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#: i I CITY OF Smy-., , WsACUsT`rs BumDLNG DEPsRT1m,%-r 130 W.AsHLNGTON STREET,3M0 FLOOR TEL (978)745-9595 Fax(978) 740-9846 KI�[BERLEY DRISCOLL MAYOR Tkows ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUUMING COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris,and the provisions of MGL c 40,S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of facility) r 2®3 F ,MG . Y\ - Gey- (address of facility) signature of permit applicant date dcbris►ffdu cmmewWm¥Massachusetts . Division of&o s¥n Licemure, a Of Suit ding Regulations andStmdards � s-0m¥o3 4i�\ y»a\ » % I : » p es- 12/31,12019L . SEAM ONNbR a £■C HEST■�sr SAL■M MA Hsg! . 6mms bn r < Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration x Type: Corporation I41 Registration: 123553 KYRON INC t Expiration: 03/05/202.1 D/B/A PRESERVE SERVICES 203 WASHINGTON ST.#2561 "l. SALEM, MA 01970 M p" 4, t� Update Address and Return Card. $CA 1 Q 2OM-05/17 t Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corooration before the expiration date. If found return to: Renistri tion Expiration Office of Consumer Affairs and Business Regulation $1.2355.3 03/05/2021 1000 Washington Street-Suite 710 KYRON INC Boston,MA 02118 D/B/A PRESERVE SERVICES SEAN P.O'CONNOR \;Q 203 WASHINGTON ST.#256 (_} SALEM.MA 01970 Undersecretary Not valid without signature i . r '''A 07/09/2019 D. CERTIFICATE OF LIABILITY INSURANCE DATE9/2019 PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION I Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE t HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenu_ ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 {1 Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:WESTERN WORLD INSURANCE C Kyron Inc. dba Preserve Services INSURER B:Hartford 203 Washington Street #256 INSURER C:Pilgrim i INSURER D:Great American Salem MA 01970- INSURER e I COVERAGES THE POLICIES OF INSUPJkNCE 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 WITHIRESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, P THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. f AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ( i INSR ADD'L POLICYiEFI°ECTIVE POLICY EXPIRATION k LTR INSRD TYPE OF.INSURANCE POLICY NUMBER DATE(MWDDNY) DATE(MWDDNY) LIMITS I A GENERAL LIABILITY NPP8478507 05/22/2019 05/23/2020 EACH OCCURRENCE s 1000000 DCOM MERCIALGENERALUABILITY DAMAGE TO RENTED 100000 PREMISES a occurrence $ CLAIMS MADE OCCUR I I I I MED EXP(An one person) $ 5000 1 i PERSONAL&ADV INJURY S 1000000 I I I I GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: �. PRODUCTS-COMP/OP AGG $ { 2000000 X POUCY JECCT LOC I `: I I I [ C AUTOMOBILE LIABILITY CSC00001002405 06/65/2019 06/05/2020 COM13INED SINGLE LIMIT } II=ANY AUTO (Ea acciderd) $ 1000000 1 T ALL OWNED AUTOS / / / / BODILY INJURY R SCHEDULED AUTOS (Per person) X HIRED AUTOS I ` / / / BODILY INJURY I 1 X NON-OWNED AUTOS j (Per accident) S PROPERTY DAMAGE S f (Per accident) GARAGE LIABILITY ' AUTO ONLY-EA ACCIDENT $ ANY AUTO I { I I I OTHER THAN EA ACC $ t AUTO ONLY: AGG $ i D EXCESSIUMBRELLA LIABILITY AN067911 05/30/2019 05/30/2020 EACH OCCURRENCE $ ) 2000000 X1 OCCUR CLAIMSMADE E AGGREGATE $ i 2000000 S ' DEDUCTIBLE I I I I g RETENTION S { $ B WORKERS COMPENSATION AND 6S601'JB0523NO09 05/20/2019 05/20/2020 X WC STATU- I 0TH- EMPLOYERS LIABILITY TORY LIMITS ER 41 500000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S ` OFFICER/MEMBER EXCLUDED? / / I / E.L.DISEASE-FA EMPLOYE $ 500000 If yes,describe under f SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 i OTHER I I I I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS s Y CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE g 1; EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 Y 301s DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT t For Insyxred's records only FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE i INSURER,ITS AGENTS OR REPRESENTATIVES. AUTIAORI nEAEPRESENTATFVE ACORD 25(2001/08) r' ©ACORD CORPORATION 1988 INS026(olos)m Page I of 2 - r