B-19-611 - 0044 VALLEY 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
This Section For official Use Only
Building Permit Number: Date Applied.
Buildinggfficial t Name Si afore _
) gn ;
I SECTION.I:.SITE INFORMATION
1.1 P r_operty Address: L 1.2 Assessors Map&Parcel Numbers
L I a Is this an accepted street?Yes no Map Number Parcel Number
P ••r
1.3 Zoning Information: 1.4 Property yDimensions:
a'
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yazd 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
2.l�neri of Reco�y '
Naine(Print) City,State,ZIP
t-j Vr��)ev S�T� '- 17V-210-0001 S�anca�weU; �`Itil.ov:� dui
No.and Street Telephone Email Ad ess
SECTION.3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed World:
SECTION 4:;:ESTIMATED'CONS.TRUCTION
Estimated Costs:
Item Official Use Only.
(Labor and Materials
1.Building $ /yo k 1. Building Permit Fee $ Indicate how fee is determined:
❑Staridazd City/Town Application Fee
2.Electrical $ /,S
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ AllQ 2 Other Fees::.$
4.Mechanical (HVAC) $ List (✓
5.Mechanical (Fire $
Su ression Total All Fees::$
:Check No. Check Amount Cash Amount
6.'Total Project Cost: $ 20 fX-b4 ❑paidin Full ❑Outstanding Balance Due
SECTION 5: C.ONSTRUCTIONs E§
5.1 Construction Supervisor License(CSL) o T n 0�
` o Yl. y r�w (� License Number Expiration Date
Name;of CSL Holder y�
List CSL Type(see below).2 mRPI� C%Ac/�
No.and Street Type Description
c�S— U Unrestricted(Buildings up to 35,000 cu.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) 14
HIC any e o)LHIC R gistrant Name HIC Registration Number Expiraf on Date
No.and Street Email address
1Nle6ej4r4 Au z:�,d� 207/cf2?&
Ci /Town,State,ZIP T 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 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.
1C I,
Print Owner's Name(Electronic SfpaVo 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 acc th est of my knowledge and understanding.
Print Owner's or Authorized Agent's NamefikeWonic 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,,ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/des
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,fmished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Ntunber 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"
------------
P
The Commonwealth of Massachusetts
Z Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
-y www.mass.gov/dia
Z orkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED)AgTH THE PERMITTING AUTHORITY.
AppIicantlnformstion Please Print LeZibly
Name (Business/Organization/Individual): �J D�A) I. OA)4- Q
Address: 9I�wle Gi'i e
City/State/Zip:12NAW Ci: � AM, D fl�Y,SPhone#: f
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.�J I am a sole proprietor or partnership and have no employees working for me in g. ®Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.F-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 E]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.❑Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
14.E]Other
6.E.1 we are a corporation and its officers have exercised their right of exemption per MGL c.
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.
%Cont:ractors 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.
I P1
Insurance Company Name: I&A4Y20
Policy#or Self-ins.Lic.#: w S/(J 7�� Expiration Date: t/
Job'Site Address: / q V 4116 7"a City/State/Zip:L�
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.
I do hereby ce 'y nder a ns and penalties of perjury that the information provided above is true and correct.
Si nature: Date: 0
Phone#• 2 �,-1 -7 21 9
bfficial use only. Do not write in this area,to be completed by city or town official
City or Town: PermitlLicense#
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#'
S
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 onlysubmit 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.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
i
r
Office of Consumer Affairs/&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE: Individual before the expiration date, If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
161602 10/28/2020 1000 Washington Street-Suite 710
JOHN COUNTIE Boston.M 'f 0 118
/ f
JOHN COUNTIE
7 MAPLE CIRCLE
MARBLEHEAD,MA 01945 Not valid without signature
Undersecretary 9
t Commonwealth of Massachusetts
Divi;ion of Professional Licensure
Board of 3uilding Regulations and Standards
Construction,SboervIll"r,1 & 2 Family
CSFA-080905 Eacpires: 05/28/2021
JOHN F COURPM 0
7 MAPLE CIRCLE
MAR13LEHEAO MA 0194.
Commissioner _��.,��J
• ACC;)" CERTIFICATE
�— ATE OF LIABILITY INSURANCE EDATE(MMfDDIYYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS 06/10/2019
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED B Y THHOLDER.TH
E POLICIES IS
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTLINT: If the certifipte holder is an ADDITIONAL INSURED,the pAicy(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 endorsement(s).PRODUCER -
CONTA
Cleary Insurance Inc
NAME: Nancy Bums
PHONE (61 723-0700 FAX
226 Causeway Street A/C-M IL Ext: AIc,No: (617)723-7275
E-MAIL nbums c ry
Suite 302 ADDRESS, Cm lea insurance.com
Boston INSURER(S)AFFORDING COVERAGE
MA 02114-2155 Ohio Secur' Company NAIL
INSURED INSURER A: Security insurance 24082
John Countie INSURER B: Ohio Casualty Insurance Company 24074
dba J F Countie Building INSURER C:
7 Maple Circle INSURER D:
Marblehead MA 01945 INSURER E:
COVERAGES INSURER F:
CERTIFICATE NUMBER: 2019-2020 GL&WC
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOE EISORN NE MOBER: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
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP
COMMERCIAL GENERAL LIABILITY MWDD/YYYy MMVDDIYYYY LIMITS
CLAIMS-MADE ®OCCUR EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 300 000
_ PREMISES Ea occurrence $
BKS59891359 MED EXP(Any one person) $ 15,000
06/01/2019 06/01/2020 PERSONAL&ADVINJURY $ 1.000,000
GEN'L AGC::REGATE LIMIT APPLIES PER:
POLICY ❑JEa ❑LOC GENERAL AGGREGATE $ 2,000,000
OTHER: PRODUCTS-COMP/OPAGG $ 2,000,000
AUTOMOBILE LIABILITY Hired&Non Owned Aut $ 1,000,000
COMBINED SINGLE LIMIT
ANYAUTO Ea accident $
OWNED SCHEDULED BODILY INJURY(Per person) $
AUTOS ONLY AUTOS
HIRED NON-OWNED BODILY INJURY(Per accident) $
AUTOS ONLY HAUTOS ONLY PROPERTY DAMAGE
Per accident $
UMBRELLA LIAR $
OCCUR
EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $
DED RETENTION $ AGGREGATE $
WORKERS COMPENSATION
AND EMPLOYERS'`LIABIUTY $
ANY YIN X PER
FORTH
B OFFICER/ME BEREXCLUDED ECUTIVE 7 NIA XWO59891359
(Mandatory d ory be NH)and 06/01/2019 06/01/2020 E.L EACH ACCIDENT $ 100,000
If Yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-EA EMPLOYEE $ 100,000
E.L.DISEASE-POLICY LIMIT $ 500,OW
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Add Itional Remarks Schedule,maybe attached If more space Is required)
RE: 44 Valley SITeet,Salem MA
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Salem THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Salem City Hall ACCORDANCE WITH THE POLICY PROVISIONS.
93 Washington Street I AUTHORIZED REPRESENTATIVE
Salem MA 01970
it/�o+ccri A �C�.+...
ACORD 25(201WO3) The ACORD name and logo are registered marks of ACORD
15 ACORD CORPORATION. All rights reserved.
CITY OF SALEK AWSACHUSETI'S
BuaDING DEFAR' ENT
120 WASIIDJGWNSMMET,PFLOOR
'ILL.(978)745-9595
FAX(978)740-9846
KIMBERLEYDRISODIL
MAYOR THoMAs ST.PIERRE
DIRECTOR OF PUBLIC FROPERTY/BUELDING COMMISSIONER
Construction Debris Disposal Affidavit
(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 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:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
I
Sig re of applicant
V ffj-V/V� Z� /9-
(today's date)