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B-19-675 - 0007 BURNSIDE STREET - Building Permit The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 S One-or Two Family Dwelling This.Section For Official Use Only t� Building Permit Number. Date Applied: 1 ' Building Official(Print Name) IV Signature Date SECTION 1:SITE INFORMATION . 1.1 Property Add t 1.2 Assessors Map&Parcel Numbers - 1.1a Is this an accepted street?yes C nc Map Number Parcel Number 1 1.3 Zoning Information: 1.4 Property Dimensions: ( x x Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) )a(i 1.5 Building Setbacks(ft) 3 Y Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Infoi oration: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if MO Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 wner'of Record: J awe WJ _J S' l C'''N- m �U Nae( rint) City State,ZIP �'® `6'G�t WL jf I r�rJ4,F, —16 3 8 ��oy► air No.and Street Telephone Email A SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: e— �Me SECTION 4: ESTIMATED CONSTRUICTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials L Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ S sion Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $02� ❑Paid in Full ❑Outstanding Balance Due: 11 - :S 1 S (v 2 R�-2 '-P U?-UAf st 0b , D 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 to 35,000 cu.ft. R Restricted 1&2 Famil Dwellin City/Town,State,ZIP M Masonry. RC Roofina Covering WS Window and Siding SF Solid Fuel Burning Appliances •' I Insulation Telephone Email address D Demolition 5.2,Registered Home Improvement Contractor(HIC) :J HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,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 .......... 0 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 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 application is true and accurate to the best of my knowledge and understanding. 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.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.Qov/dns 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" ;4 SECTION 5: CONSTRUCTION SERVICES 5.1 nstruction S pervisor License(CSL) ///M YG License Number Expfraticpf Date Name of C:iL Holder / 1 List CSL Type(see below) !� ��OLd► /• Type Description No.and Street U Unrestricted(Buildings to 35.000 cu.ft s'—tC., MAd d R Restricted 1&2 Family Dwellin City/Town,Stat ZIP M Masonry RC Roofin Covering WS Window and Siding SF Solid Fuel Burning Appliances (f:.>'•'_ tdAS'f�C d Q►/1 .@A^ 1 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improveme Contractor(HIC) Z 72! ?e ! �! Ql �� HIC Registration Number pi tion Date HIC Company ame o HIC Ree��'strant Name PG� C -gz t ,J .1T, Q1Cfi ' �&A- No. d Street � Q• d / 9 � -,t"ir Email address . /, Ci /Towri,State,21P 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 CONTRAC(T�OR APPLIES FOR BUILDING PERMIT I" I,as Owner of the subject property,hereby authorize ��Q� k9"P 01j-� to act on tiny 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 enterutg my name below,I hereby attest under the pains. d penalties of perjury that all of the information con ' ed in this application is tru and accurate to the of my knowledge and unders7&7g/ . �l Print Owner's or Auth nzed Agent's Name(Ele i ignature) ate 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.mgE&gov/oca information on the Construction Supervisor License can be found at www.mass.gov/dus 2. When substantial work is planned,provide the information below. Total floor area(sq.ft.) (including garage,finished basementlattics,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" CITY OF SALEK AWSAC USE'I'ISS BU[LDnVG DEPARn&NT 120 WASfIDnWNSTREET,3P0FL0OR ItL(978)745-9595 KRZERLEYDIUSOOLL FAX(978)740-984fi MAYOR THIoAs ST.PjERRE DIRECTOR OF PUBLICPROPERTY/BLS DING mNIIvIlSS om Construction Debris Disposal Affidavit N (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 00, 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: (name of hauler) The debris will be disposed of in: (name of facility) I (address of facility) Signature f app' ant (toda s da ) 4 —••� .....w..r.�ws�i�v) [II KJJKf./iKJCffJ' Deparhment oflndMhWAccidents Offlee oflnvestigations ' 600 Washington Sftet Boston,MA 02111 r "W mamgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianMumbers Applicant Information Please Print Le ' 1 Name(Buskesdorganizatim4ndividual): 1'/hi /Z Address: Q.� City/Statemp:_�� d f 70 Phone M I7-�,T Are you an employer?Check the priate box: 4. I am a general contractor and I �'Pe of project(required): 1�I am a employer with ❑ g 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 Tbese sub-contractors have S. ❑Demolition working forme in any capacity. employees and have workers' 9 Budding addition [No workers'comp.insurance comp.insurance.t ❑ g 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.❑Roof repairs insurance required,]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other Comp.insurance requited.] `My applicant that checks box aYl most also fill out the section below showing their workers'compensation policy information. t Homeowner who submit this affidavit indicating they are doing all work and than hire outside contractor;must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-ontractors and state whether or not those entities have employees. If the sub-contractors have employees,they most provide their workers'comp policy number. I ran an employer that is providing woorkenI compensation insurance for my employees: Below is thepolicy and job site information. pray Name: ..�• /" �vr, Insurance Coro Policy#or Self-ins.Lic.M J''A _,� 74- 2d Expiration Date: Job Site Address: �i/�C/1li7�►ri .�` l.P City/State/Zip:.� 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$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 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 cerai� the pacts and" ofperjury that the rnfornratiort provided abov is and correct Si atuue: Date: b l9 Phone#: 2 rcial use only. Do not write ur this area,to be completed by city or town o,�wal City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Buihling Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M 9AFF101 OP ID:D ACORa►° CERTIFICATE OF LIABILITY INSURANCE DA06117120 9 THIS CERTIFICATE 18 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 978-745-3300MEACT Mark W.Bettencourt John J Walsh Ins Agency,Inc PHONE 978-745-3300 FAX 978-745-9567 P 0 Box 4407 (A/C,No,Ext): (Arc,No Salem,MA 01970-6407 E-MAIL Mark W.Bettencourt ADDR INSURE S AFFORDING COVERAGE NAIC# Affinity Construction,Inc. INSURER A:`lames River Group INSURED tY 25 Osgood St INSURER B:A.I-M-Mutual Ins.Companies Salem,MA 01970 INSURER C:Commerce Insurance Company p Y 34754 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. ILTR NSR TYPE OF IN7URANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADI_ �X OCCUR 00749622 12/01/2018 12/01/2019 P EMGET Ea.TErrence $ 50,000 MEDEXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: C AUTOMOBILE LIABILJT! COMBINED SINGLE LIMIT 00Ed.nt, $ , ,0 ANY AUTO RXQ160 11/26/2018 11/26/2019 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY Per accident $ X AUTOS ONLY AUOTO ONLDY Per acadentDAMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LJAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ B WORKERS COMPENSAIIION PER OTH- AND EMPLOYERS'LIAE ILITY STA E E ANY PROPRIETOR/PAR-NER/EXECUTIVE YIN WCC-500-5015376-2018A 12I20/2018 12/20/2019 E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXC!.UDED? N/A (Mandatory in NH) E.L.DISEASE SOO,000 -EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 500,000 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 Graham Hines THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 7 Burnside Street ACCORDANCE WITH THE POLICY PROVISIONS. Salem,!'NA 01970 AUTHORIZED REPRESENTATIVE Mark W.Bettencourt ACORD 25(2016/03;, ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Assessor's Map 36 Lot 149 50.00' Shed 4.9' LOT IV 5,622 S.F.f Ln Assessor's Map 36 (A Lot 158 N Assessor's Map 36 N Lot 156 0) 1 .9' a 0 N o.7 0 2 1/2 Story Assessor's Map 36 Vinyl Lot 494 Dwelling 23.3' 50.00' B U R N S l D E S T R E E T OF ygss�c yG PLAN Off' LAND c DAVID PHIUP s �i HPLOT No. 38720ERE JM720 y SALEM, MA. �Nt)Ess�o` PREPARED POR: GRAHAM HINES 7 BURNSIDE STREET Zoning District: R2 SCALE:1"=20' DATE: MAY 25, 2019 Deed Reference: Book Page 5$7 DAVID P. TERENZONI, P.L.S. Assessor's Map 36, Lott 157 157 Existing Lot Coverage = 20.7% t 4 ALLEN ROAD, PEABODY, MA. 01960 P19-053 << �J/p C�crtrnzcv�rccec�l!/a�'�j�ccrluc�ute(ls Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation ! I Registration Expiration 177436 . 01/11/2020 AFFINITY CONSTRUCTION INC., } PETER SHEPPARD JR. : f 25 OSGOOD ST SALEM,MA 01970 Undersecretary Commonwealth of-Alassachusetts Division of Professional Licensure Board-of Building Regulations and Standards Constr, ction Supervisor CS-064786 Expires: 10/01/2020 PETER A SHEPPARD " ` 25 OSGOOD STREET SALEM MA 01970. Commissioner m�