B-20-801 - 0023 UNION STREET - Building Permit I
' The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY dF
1 Massachusetts State Building Code, 780 CMR SALEM
i Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
�— This Section For Official Use Only
Building Permit Number: Date Applied:
i
'Zd
f Buildi fficial(Print Name) Signature
Date
SECTION 1:SITE INFORM TION_
1 operty Address: 1.2 Assessors Map&Parcel Numbers
u Niorl S 1
^ ^ 1.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 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2 V
wner of Record:
Name(Print) City,State,ZIP f
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg.p Number of Units Other ❑ Specify:
Brief Description of Proposed WorkZ:
—
v
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.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: �,o ��i'CA L
5.Mechanical (Fire
Suppression) $ Total All Fees:$
6.Total ProJ'ect Cost: $ �` r Check No. Check Amount: Cash Amount:
❑Paid in Full ❑Outstanding Balance Due:
Pf�+•
AUG
r
SECTION 5: CONSTRUCTION SERVICES
5t1 Construction Supervisor License(CSL) CS _ 441 C&g o/ CO Cb a
1,C ® 3, License Number Expiration Date J-
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
`Q®� U Unrestricted(Buildings u to 35,000 cu.ft.)
l R Restricted l&2 Family Dwelling
City/To",State,ZIP M Masonry
RC Roofing'Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
310 ( �i��1�111 pl�(��I�o14�YL I Insulation
Telephone Email address D Demolition
5.2 Registered Home Immprovement Contractor(HIC) ( ® '
l' r,� \e< C HIC Registration Number Expiration ate
H C Company Name or HIC Registrant�vame _
Sa y S C OTT< , Yet 1\ C'
No'.and Street Email address
�*-U6.0 � 6
I �D Q o
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
I,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.
C"'A-P� ,� _ tO P rVI4-,N b,
Print Owners 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.gov/oca v�Information on the Construction Supervisor License can be found at www.mass.gov/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 halfibaths
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
The Commonwealth of Massachusetts
Department,of Industrial Accidents
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.
Apulicant Information Please Print Ledbly
t
Name (Business/Organization/Individual): (J,I Ch'l- l 1(VJ 4 fMT', '(—(—C.-
Address: lf i VY") SI 3_kIF gb�(
City/State/Zip: 05 10(\) VV\P 'z;Qm Phone#: —777- -
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I 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 $. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑i am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. .2[Demolition
4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. [will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole I IQ Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6. We are a corporation and its officers have exercised their 14.❑Other.
❑ tpo right of per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 roust 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 subcontractors 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: V tt \ti u A114 Ce
Policy#or Self-ins.Lic.#: 30 Expiration Date: Z 7 C n
i
Job Site Address: 3 Q N t�l7Nl ST City/State/Zip: SI AL,-Vy\ m 10a O
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.
.J: . I do hereby cerd under the pain andenaldes of perjury that the information provided above is true and correct
Si nature• Date: I
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(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person Phone#:
/4CO DATE(MMIDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE F06/15/20
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.
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 endorsement(s).
PRODUCER
NAME: Anthony
Robert M.D®Gregorio Insurance Agency Inc. PHONE . 617-846-3313 a/c No): 617-846-3317
34 Woodside Avenue ADDRESS:MA 02152 Anthon .RMDlnsurance mail.com
Winthrop,W
INSURERS AFFORDING COVERAGE NAIC#
INSURERA: HIScoX Insurance
INSURED INSURER B: US Liability Insurance Co
Lighthouse Realty Mgmt LLC INSURERC: Mount Vernon Ins Co
Harrison Levitsky 581 Boylston Street Ste 604 INSURERRER D: Travelers Insurance
Boston,MA 02116 INSURER E: Safety Insurance
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.
I SUBM
LTR TYPE OF INSURANCEIR POLICY NUMBER POLICY EFF POLICY-OUP
MMIDD MMIDD LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE OCCUR DAMAGE TO RENTEU_
REMISES Ea occurrence $ 100,000
MED EXP(Any oneperson) $ 5,000
B CLI616485F 08/02/19 08/02/20 PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY❑PRO-
JECT LOC PRODUCTS-COMP/OP AGG $
OTHER:
AUTOMOBILE LIABILITY Ea aced ED SINGLE LIMIT $ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
E X OWNED SCHEDULED AUTOS ONLY AUTOS 5911736 12/03/19 12/03/20 BODILY INJURY(Per accident) $
X HIRED X NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident $
$
X UMBRELLA LIAR X OCCUR
EACH OCCURRENCE $ 1,000,000
C EXCESS LIAR CLAIMS-MADE XL255543SE 01/02/20 01/02/21 AGGREGATE $ 1,000,000
DEC) I I RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY D OFFICER/MEMBER EXCLUDED ECUTIVE❑ N/A 9F46302 02/04/20 02/04/21 E.L.EACH ACCIDENT $ 1,000,000
I Mandatory In and E.L.DISEASE-EA EMPLOYE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
Professional Liability Liability Coverage 1,000,000
A MPL160132916 08/20/19 08/20/20 Deductible 1,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Property Management
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
LH Capital Development LLC ACCORDANCE WITH THE POLICY PROVISIONS.
23 Union St
Salem,MA 01970 AUTHORIZED REPRESENTATIVE
Anthony M.DeGregorlo
O 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD
CITY OF SALEM MASSACHUSETTS
BUILDING DEPARTMENT
98 WASHINGTON STREET,2ND FLOOR
TEL: 978-745-9595
KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER
I
Construction Debris ff
Disposal Affidavit
p
(required-for 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 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:
pu MP(m
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
i ature of pplicant
913
(today's date)
Commonwealth of.Massachusetts
Division of Professional Licensure
Board of Building Regulations,.and Standards
Const�rt�ctor ' r5 ruisor s
C5-111689 � 06110120,21e
fires:. '
RICHARD B KUMPEL
4527 SCOTTS MILL CT I .
CA
Commissioner M`
r
. 4
t .. . • - - ter. • ` i.
Your Confirmation number is 20200803187403
Date of Confirmation:8/3/2020
NOTE:When paying by ACH(Checking)it will take two business days for the payment to be debited from your bank account.Your
account number is not verified until this payment is presented to your bank.They have the right to return this payment if unable to
process this transaction against your account.
Your request for payment(s)of$52.50 has been received and is subject to approval by your financial institution. No email was entered
so a confirmation was not sent.
Account Information Payment Information
Name: LEN KARAN Payment Type: Credit Card
Note: QUICK PAY TRANSACTION Payer Name: LEN KARAN
Card Number: **************1388
Transaction Information
Transaction Quantity Amount Fee Payment Type
City of Salem-Inspectional Services 1 $50.00 $2.50 Credit Card
Building Permit
First Name:ALEX
Last Name:DA SILVA
DBA/Company Name,if applicable:
LIGHT HOUSE REALTY
Name of permitted/inspected property:
23 UNION ST
Address of permitted/inspected
property:23 UNION ST
Phone#:508-364-6122
Contact Email Address:
smurtagh@salem.com
Total:$52.50