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B-19-1121 - 0028 BRIGGS STREET - Building Permit The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar.2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a _ One-or Two-Family Dwelling rVI This Secrion For;Official Use Only lw Building Permit Number. Date Apphed t k { Building Official(Print Name) Signature ate ! �. SE:CTION.:1:SITE INFORMATION 1.1 Pro e A ress 1.2 Assessors Map&Parcel Numbers _T \S r 1.1a Is this an accepte et?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) t 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 ZDne Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2:'PROPERTY<OWNERSHIl'1 2.1 Owner'of Record: iSFpire�� , (AhI{ifW" -0,6con M ObA,MA / Name(Print) City,State,.ZIP S+- No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED MOW(check It-that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) tf Addition 0 Demolition 0 Accessory Bldg.❑ Number of Units._- Other 0 Specify:-___._________.........___-_...............__. . Brief Description of Proposed Work2: orl a W h t/� 1 e SECTION 4 ESTIMATED CONST CTION COSTS' Estimated Costs: Item Official Uses Only (Labor and Materials I.Building $ 1 Building Permtt Fee $ Indtcate how fee is determined 2.Electrical ❑Standard Cttytr Application Fee 3: ❑Total Project Cost :(Item 6)x mulripher x Ono 3:Plumbing $ nC7 2. Other Fees: $ 4.Mechanical (HVAC) 5.Mechanical (Fire Suppression $) Total All Fees:$ CheckNo Check Amount Cash Amount 6.Total Project Cost: $ a-j j OC7 / ❑Paid in Full` �.Outstanding Balance Due.: ........... Gam.-`- -1 �?• u . SECTION 5 CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS - y-1y i V an ae C n L License Number Expiration D to Name Holder Holder List CSL Type(see below) Lee Type: Descnphon No:and.Street SU Unrestricted(Buildings up to 35,000 cu.ft. QACyn MA M91 R Restricted l&2 Family.Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Bunting Appliances 7 �1� 3( ) 5l aa- C mc.uOne �no4Md�� , I, Insulation.. Telephone Email address , GoM D Demolition 5.2 Registered Home Improvement Contractor(HIC) ' q I 1 a a 3 to(o la m 01 '�U\"t� HIC Registration Number Expiration Date HIC Company ame or HIC Registrant Name Q No.and treet Email address a(em 9Q19"70 '9-79 1C) �D a. City/Town,State,ZIP Telephone SECTION 6 _::WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG L c152 § 25C(�j 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 U.OWNER AUTHORIZATION TO BE COMI'LETEp WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILPIN PERMIT 1,as Owner of the subject property,hereby authorize C 'e to act on my behal 'n al re tive to work authorized Ay this building permit application. /0 - � Print er's Name(Electronic Signatu ) Date SECTION 7tic OWNERt O,R AUTHORIZED AGENT DECLARATION By entering my name below,I here ttest under the pains and penalties of perjury that all of the information co ta' ed in thin on is an accurate to the best of my knowledge and understanding. Print wner's or Authorized Agent's ame(Electronic Signature) Date NQTES 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. ov/_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"may be substituted for"Total PtojectCost' r . CITY OF SMXUNN 1►Lkss.,-kCHusETrs BUBMMG DEPARTUIUNT ' 120 W ASHINGTON STREET,31D FLOOR •I1.. (978)745-9595 FAX(978)740-9846 KIMBERMY DRISCOLL T MAYOR �iolllAS ST.PIERR6 DIRECTOR OF PUBLIC PROPERTY/BUILDIING COMNOSSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbera Anplicant Information Please Print L,egiblx Name(BuskmsiOrganization/individual): Hral rx� !�,e ti'V t ce L L CV Address: Ca Lee- S-I— City./State/Zip: M.., AAA- 14._7 c9 Phone#:. Gl -7 Are you an employer?Check the appropriate box: Type of project(required): 4. ❑ 1 am a contractor and i 1.® I am a employer with general 6: 0-New construction employees(full and/or part-time).* have hired the sub-contractors 2,❑ 1.am.a-sate proprietor or partner- listed on the attached sheet.+ ?• Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp:insurance. 9. ❑Building addition [No workers'comp. insurance S. ❑ 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 11.❑Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees.(No workers' 13.0 Other comp.insurance required.] •Any applicant that checks box#1 must also fil]out the section below showing their workers'compensation policy information. p I lnmeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating.such. =Contmtors that check this box must auachod an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees- Below is the policy and job site information. �n Insurance Company dame:__ L ine/(nV /►'t L/t /e Policy#or Self ins.Lie.#: 1Ct.� —3l —(�R l7"74•l ei p _S ` Expiration Date: Job Site Address: Ogg \-S.I't*eC< S fi City/State/Zip: � to g!aTAAA o r 474V aa Attach a copy of the workers'compensation 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 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 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 cerrJfy ur r the pai s and penalties of perjury that the information provided above is true and correct. *n t ire Date:. "l o� 7 9 J Phone#: -7 Ojfcial use only. Do not write in this area,to be completed by city or town offixiaL City or Town: PermidUcense# 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#• CITY OF SM ENI I$ 1��SSIICHLTSETTS •s BuHML IG DEP.AR'IINIENT ' 120 WASHIINGTON STREET,r FLOOR TEt_ (978)745-9595 Fax(978) 740-9846 KI ILBERL EY DRISCOL•L MAYOR T HomAs ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUHMING CONLUISSIONER 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: T)6jvv,�t� f s U S (name of hauler) The debris will be disposed of in Ovid 0 u (name of facility) � I J"V C-4-r-c� (address of facility) signature of permit applicant date dcbriwiT.doc w 9HALY02 ,a►�CORO® CERTIFICATE OF LIABILITY INSURANCE DA0 911 3120 1f9 � 09H 312019 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 endorsemen s`. PRODUCER 978-745-3300 CONTACT John J.Walsh Ins Agcy.,Inc. John J Walsh Ins Agency,IncNAME: - _..... 9 y. PHONE 978-745-3300 FAX 978-745 9557 P O Box 4407 A/c No Ext►: ac,No): Salem,.MA.01970-6407 AdPMkss.johnjw@waishinsurance.com. John J.Walsh Ins.Agcy.,Inc. INSURERS AFFORDING COVERAGE NAIC# INSURER A:The Concord Group InS.Cmpnies INSURED Halyard Services LLC INSURER B:Mass Wkrs Comp Assign Risk Ryan Marione 2 Lee Street INSURER C: Salem,.MA.01970 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. NSR TYPE OF INSURANCE' DDL UBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR 20023772 04/06/2019 04/06/2020 DAMAGE TO RENTED 50,��0 PREMISE Ea occurrence $ X Business Owners MED EXP oneperson) $ 6,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY F jpeT F-1.LOC PRODUCTS'COMP/OP'AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY Ea aentSINGLEUMIT $ ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY BOODILY INJURY Per accident $ AUTOS ONLY AUTO ONLDY pPeOr a�Id DAMAGE $_ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE. $. DED I I RETENTION$ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N TA TE E _ ANY PROPRIETOR/PARTNER/EXECUTIVE C2-31S-618679-02 09/11/2019 09/11/2020 100,000 WFICE WM MBER EXCLUDED? El N/A 00� •. E.L.EACH ACCIDENT $ andalory in NH) E.L.DISEASE-EA EMPLOYE $ 1�0, If describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/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 For record purposes ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE John J.Walsh Ins.Agey:,Inc: ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I "Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards, Cons;r, �:tt �iip�rvisor CS-101474pires: 12/0812 19 xegis RYAN M=MACfONE� j 2 LEE STREE[%j +, ;. SALEM MA 019 Commissioner