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B-20-513 - 0078 BRIDGE STREET - Building Permit r The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF SALEM Massachusetts State Building Code, 780 CMR Revised Mar 2011 9 Building Permit Application To Construct,Repair,Renovate Or Demolish a . One-or Two-Family Dwelling This Section For-Official Use Only j J Buildi g Permit Number: ate Applied: Buil ing Official(Print Na e) Signature Date 1 SECTION 1: SITE INFORMAT N 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 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 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP.' 1 Owner'of Record: Name(Print) City,State,ZIP be 96� No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building e Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: I SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ Cod vl 1. Building Permit Fee: $A(a$.00Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project'Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ U 1 Check No. Check Amount: Cash Amount: 1 6.Total Project Cost: $X5)S53. LA ❑Paid in Full ❑Outstanding Balance Due: C)y oo 00.\ CJk - Ii C SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type' Description ' U Unrestricted(Buildings up to 35,000 cu.ft.) ft R Restricted 1&2 Family Dwelling City/Town,State,ZIP 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) H HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date No.and Street Email address 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...........0 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 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 contained in this ap ation is a and accurate to the best of my knowledge and understanding. Print o Agent's Na lectronic 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.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,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" ric %lurnnaurrrvruirrr vJ ulu��u�rsu�Ccr� Department of Industrial Accidents ' Office of Investigations r Lafayette City Center t 2 Avenue de Lafayette, Boston,MA 02111-1750 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): Addario, Inc. Address: 2 Gill Street, Suite J City/State/Zip: Woburn, MA 01801 Phone#: 877.233.2746 Are you an employer? Check the appropriate box: Type of project(required): 1.Q I am a employer with 12 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑■ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' ' 13.0 Other 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. *Contractors 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 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: Hefferan'Agency Policy#or Self-ins. Lic. M 2001 W8777 Expiration Date: 5/1/202 1 Job Site Address: City/State/Zip::�SCAPV,-,r Attach a copy of the workers' comp ation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 Aawains a&4penallies of perjury that the information provided above is true and correct. Signature: Date: U Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1❑Board of Health 211 Building Department 30City/Town Clerk 4.0 Electrical Inspector 501umbing Inspector 6.❑0ther Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who.resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you,have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Off ce of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Revised 7-2019 Fax (617) 727-7749 www.mass.gov/dia Fold,then Detach Along A11 Perforations m t a f s S �1• - aka ,� '� �' a14 DARTQ�BTVG a TiAA 0WIN 31 $ ;14250 -101M812.01 0 ! -,•_• �.�:-S.'&,. ...... ,yFiwAm+rfs.xa�� ...w.�ui;�Ta"m-+...x....n. -.w.,.,..r,.i.Mcxr:,.�,.::>.,.•y c:....a.asi -?>.+s.a+tw,a:.+�n+..;...e�vw«z•�mc.rc�m;.,Wa-.u.�.,un.a.:,,�C�+ri�v:.w.+eNwv�>.�v'..as.h..�:aat _a�r-fA.�+c:..:. i ' •`p I t zw , .. -.:• • ( J o.� l� � ,,�� a � r "rt> 4 yr tH, NF CHiI fl 'r' i�X' k; r � ' �4 _' *Y ', r � r I j •, �•n (Y ";7.f�'k Y' t SfIEE 'Al:WOR 11 ISSU&S4T E FOL'LOW7NWLICCEJ i aYSII „TEVEWJ AID, DARf�5 ,��� .a �:. 4 •�� r��.. - 'ata�.• to- !�,?,,. f 5', j WOBURN,MA101801 47�4 _ .. ._.. _, y.,..�.A.�:•$'=ti+:..v-+.Fax.- .. ..�+�«w�e,? ,....._._,.L.�. ' +j �t`r M.�1t .`��Ap ���`+� r^'v�:t•�.�.�...�-.�.e...,_���..�.�w.._..r.•.�-+�iSi Y\`Il.n.,...��..w.a . 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P l r/ I/P 1 r {€ +f..� t,P ¢�'s p ,B a..- '+ r +* dr. ✓'� +l.,e',� f t,' af3 > -• 3 xjf J �s y €_",� •'"£ 'f Pa w'd> � {�:° � d.. dr files si'f s$ Ay r �-: {A p ,+� 1« !t s. f `6 x= ! ° a +� + d �r r� r"�� {' _ s i f 1,f, ar td '� Y'F ,a S.' ,.f t rd¢g t n✓i g� '` r. '�'✓ ''s s .✓' s ! � s� !: $� �n+•:,1F r dA t g.y.-r �;"u,. ��1�' Yf e• � r. l IT ">•9 Y ♦»rc • � � f F r r d v 't ' •[ ,, a is i ^ ^.•, <!,•t yet . }• .«r A f _ ..ski + k - n i i DATE(INM/OD/YYYY) AC-40 CERTIFICATE OF LIABILITY INSURANCE 05104=20 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(les)must have ADDITIONAL INSURED provisions or be endorsed, K SUBROGATION IS WAIVED,sub)ect 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 endorsements. PRODUCER HEFFERAN AGENCY CONTACT KRISSY ALESSANDRA _.. _. ._._.__ ,._____ _�_ .._...._ 5 Walter E.Foran Boulevard PHONE_ ,908-782-4028 EXT 131 1 IAIC._.._.908-782-5203 Suite 2010 uc No E .KRISSY.ALESSANDRA@AMERICAN-NATIONAL.CAM Flemington NJ 08822 _ WSURER(Sjj FORDING QOVERAGE INSURER A.FARM FAMILY CASUALTY COMPANY INSURED ADDARIO INCORPORATED INSURER B: 2 GILL STREET,SUITE J WOBURN MA 01801-1721 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 g TYPE OF INSURANCE ADDL�SUBii` ` !'POLICY EFF' POLICY EXP LTR f I POLICYNUMBER MMIDD MM D I LIMITS A ✓ COMMERCIAL GENERALLIABILIrY 20OIX2292 �0111212020 01/1212021 �EACHOCCURRENCE $2,000,000 AGETO RENTED 3OD,000 CLAIMS-MADE a OCCUR I ,PREMISES(Ea oocutrenoe) $ _. ....�.. _.. _....__. .._ ___.. .._ MED EXP(f, one person) _ $5,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERA4 AGGREGATE $4,000,000 ✓ POLICY JPRO-ECT Loc I PRooucrs COMP/0P AGG $4,000,000 OTHER I C $ A AUTOMOBILELIABILrrY 200lC6814 l01/12/2020 01/12/2021 1,(4rINED itSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $1,000,000 OWNED SCHEDULED _ AUTOS ONLY ✓ AUTOS ` BODILY INJURY(per exklent) $I,000,000 HIRED NON-OWNED PROPERTY DAMAGE ... .._..__, _...,. ...._. ✓ AUTOS ONLY ✓ AUTOS ONLY „(Per eCciderrt),_�_._. ........... .. $a,000,OOO— I I $ A o/ UMBRELLA LIAB ✓ OCCUR j 2001 E1 S69 1/12/2020 01/12/2021 EACH OCCURRENCE $5,000,000 EXCESS LIABI t CLAIMS-MADE AGGREGATE $S,OOO,000 DEO ✓ RETENTION$10,000 I l $ A WORKERS COMPENSATION 2001 W8777 05101/2020 05/01/2021 ' ✓ 7ER ER AND EMPLOYERS'LIABILITY _._.._....__.... IANYPROPRIETOR/PARTNER/EXECUTIVE YIN I I E.L.EACHACGDEN7 $1,00®,O®® zOFFICEWMEMBEREXCLUDED? NIA, L_. ... ._, ...._._ ._..__._.__..___. _.........__.._._.__ .. (Mandatory In NH) d i E L DISEASE EA EMPLOYEE $rc 1,000,000 under descnbe -. _.._ _ yes __- --• DESCRIPTION OF OPERATIONS below E L DISEASE POLICY LIMIT $19000,000 L f i I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES IACORD 101.Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION ADDARIO INCORPORATED 2 GILL STREET,SUITE J SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE WOBURN,MA 01801 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE VRTH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD