Loading...
126 BAY VIEW AVENUE - BUILDING JACKET 12 (o rsupocr abb. i0><loplrlliO�Aw 9NIEAD® KEEPING YOU OR"NIIEO No. 10301 Y,o.pIW CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET, 3"D FLOOR TEL: 978-745-9595 FAX: 978-740-9846 HIMBERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER November 14, 2017 Cheryl Vickery 126 Bay View Avenue Salem Ma 01970 Dear Owner; We have received your affidavit stating that your basement space will only be used by you the owner of the property and not as a second unit. After a recent inspection to inspect your egress window in your basement bedroom. I have determined that the size of the egress window does meet state building code. I now consider this entire matter of the basement unit a closed matter pertaining to 126 Bay View Avenue Salem Massachusetts. Stephen Cummings Assistant Building Inspector CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET,31D FLOOR TEL. (978) 745-9595.- FAX(978) 740-9846 KIMBERLEY DRISCOLL MAYOR THomAs ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Violation Notice/Required Inspection Notice 126 Bay View Avenue October 23,2017 Cheryl Vickery 126 Bay View Avenue Salem,Massachusetts 01970 Cheryl Vickery, I We have received an affidavit stating that your basement space will only be uses as living space as you the owner and not to be used as a second unit. However since there was a bedroom created in the basement we will be looking to inspect the bedroom in the basement to make sure you have the proper sized egress window required by the state building code. Per Mass State Building Code 780 C.M.R. Section R 104.1 and under the provisions of 780 CMR, Section 104.6—Right of Entry, of the State Building Code,access to this property must be granted for the purposes of this inspection. If this property has rental units, these tenants must be notified in advance of this inspection, so that access to these spaces may also be accomplished. This inspection is scheduled for Tuesday, November 7th at 1:30 p.m. You are hereby directed to contact this office immediately upon receipt of this letter. Failure to respond to this notification will be construed as non-compliance,and as such an Administrative Search Warrant will be sought, so as to allow the lawful inspection of this property. If you feel you are aggrieved by my zoning interpretation,your Appeal is to the Salem Zoning Board of Appeals. If you feel you are aggrieved by the Building code sections,your Appeal is to the Board of Buildings,Regulations and Standards in Boston. Stephen Cummings Assistant Building Inspector r SERAFINI , DARLING & CORRENTI , LLP ATTORNEYS AT LAW 63 FEDERAL STREET SALEM, MASSACHUSETTS 01970 JOHN R. SERAFINI, SR. TELEPHONE JOHN E. DARLING 978-744-0212 JOSEPH C. CORRENTI FACSIMILE KRISTIN E. KOLICK 978-741-4683 October 19, 2017 Thomas St. Pierre, Building Commissioner Stephen Cummings, Assistant Building Inspector City of Salem Building Department 120 Washington Street, 3'd Floor Salem, Massachusetts 01970 Re: 126 Bay View Avenue, Violation Notice Gentlemen: Please be advised that this office represents Cheryl A. Vickery, owner of 126 Bay View Avenue, regarding her receipt of a Violation Notice from your office alleging the creation of an illegal dwelling unit in the basement level of the property. Ms. Vickery denies creating a basement dwelling unit in her home, rather she simply remodeled the outdated kitchen and bath that have been located in the basement level since she purchased her home. The basement level is ground level to the oceanfront yard in the rear of the property, and the kitchen/bath have been in place for at least 20 years or more. At no time has Ms. Vickery ever rented out space in her home, either in the basement or anywhere else in the structure, nor does she intend to. Her property has never been listed on AirBnB or any other website as being for rent, in whole or in part (see attached Affidavit of Ms. Vickery). The renovated kitchen and bath are for the convenience of entertaining in the yard and oceanfront patio, and have not and will not be used at any time as a separate unit from the rest of the house. Ms. Vickery purchased her home as a single-family dwelling and has used it and will continue to use it as such. Both the architect and contractor on the renovation project understand that all proper permits and city inspections were conducted in a thorough and timely manner, and that all proper procedure for the renovation was followed. October 19, 2017 Page 2 We regret any misunderstandings as to the project or Ms. Vickery's intentions, but it is completely understood that no additional unit would be allowed within the property and the use shall remain a single-family home. Cheryl A. VickeryP , her Att n , Joseph C. orrenti JCC:dl Attachment: Affidavit of Cheryl A. Vickery AFFIDAVIT OF CHERYL A. VICKERY I, CHERYL A. VICKERY, hereby depose and say as follows: 1. That I am the sole owner of the property known as 126 Bay View Avenue in Salem, Massachusetts (the 'Property"). 2. That I purchased the Property by Deed dated July 19, 2011 and that I have lived at the Property since that time. 3. That when I purchased the Property, I understood that it was a single-family home consisting of multiple bedrooms, 2 bathrooms, 2 kitchens, including a full kitchen and bath in the lower level, a living room, a dining room, a three-season sunroom, and a garage. 5. That recently I hired a contractor and architect to do needed renovations at the Property, including remodeling of the basement kitchen and bath area, which I use when entertaining at my oceanfront rear yard. 6. That during the remodeling process, all necessary permits were obtained and several inspections were made by the City of Salem Building Department. 7. That at or around the time of the final inspection, the City of Salem Building Department asserted that an illegal dwelling unit had been created in the basement. 8. That I have never leased any portion of the house, including the basement, nor have I advertised any portion of the house, including the basement for lease, on any website such as AirBnB or otherwise. 9. That I have never, nor do I intend to rent the basement area or use it as a separate dwelling unit. 10. That I intend to continue to use the home as my single-family dwelling, as I have done since I purchased the Property in 2011. Executed under the pains and penalties of perjury this �day of October, 2017. I V Cheryl A. Vick ry 1 COMMONWEALTH OF MASSACHUSETTS Essex, ss. On this 0 day of October, 2017, before me, the undersigned notary public, personally appeared Cheryl, A. Vickery, proved to me through satisfactory evidence of identification, being Ma buzlu , to be the person whose name is signed on the preceding or attached document, and swore or affirmed to me that the contents of the document are truthful and accurate to the best of her knowledge and belief. (SEAL) ftlota4y blic My commission expires:' 2 f" CITY OF SALEM, MASSACHUSETTS " BUILDING DEPARTMENT 120 WASHINGTON STREET,3""FLOOR TEL. (978) 745-9595. Fax(978) 740-9846 KIMBERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Violation Notice/Required Inspection Notice 126 Bay View Avenue September 1,2017 Cheryl Vickery 126 Bay View Avenue Salem,Massachusetts 01970 Cheryl Vickery, During a recent inspection requested by your contractor to inspect a kitchen remodel at 126 Bay View Avenue. We observed that an illegal dwelling unit has been created in the basement of the above referenced property. Per Mass State Building Code 780 C.M.R. Section R 104.1 and under the provisions of 780 CMR, Section 104.6—Right of Entry, of the State Building Code,access to this property must be granted for the purposes of this inspection. If this property has rental units, these tenants must be notified in advance of this inspection, so that access to these spaces may also be accomplished. This inspection is scheduled for Tuesday,September 19th at 1:30 p.m. You are hereby directed to contact this office immediately upon receipt of this letter. Failure to respond to this notification will be construed as non-compliance, and as such an Administrative Search Warrant will be sought, so as to allow the lawful inspection of this property. If you feel you are aggrieved by my zoning interpretation, your Appeal is to the Salem Zoning Board of Appeals. If you feel you are aggrieved by the Building code sections, your Appeal is to the Board of Buildings, Regulations and Standards in Boston. Stephen Cummings Salem Building Department SENDEM COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3. A. Si nat ■ Print your name and address on the reverse X ❑Agent so that we can return the card to you. 4"4 ❑Addressee ■ Attach this card to the back of the Tailpiece, 5. Received by(Printed Name) t elivery or on the front if space permits. EN 1. Article Addressed to: D. Is delivery address different from item es vt GK�I l If YES,enter delivery address below: I-L IP &"f ' \415-w A'VE S P t.rS" f M r� O I,g"'1 O 3. Service Type ❑Priority Mail Express® 0 Adult II IIIIII I'll III l II I II II II I I I II II i II I III III ❑Adult Corti ed Mailr Restr cted Delivery ❑ER re 0 $istt�d MailtRestnctei 9590 9402 1868 6104 8484 40 ❑Certified Mail Restricted Delivery ❑Return Receipt for ❑Collect on Delivery Merchandise ❑Collect on Delivery Restricted Delivery ❑Signature Confirmation*'^ 7012 164D 0002 3313/ ElInsured Mail ClSignature Confirmation ❑Insured Olil Restricted Delivery Restricted Delivery ,,PS Form 3811,July2015 PSN 753,r� c..'453 Domestic Return Receipt usP i}t��}�s' -u I�ln#I�q First-Class Mail II1II III III�YIfI� l�ItII IIII US S9e8Feesr'mid Permit No.Gd0 9590 9402 1868 6104 8484 40 United States •Sender:Please print your name,address,and ZIP+q®in this box- Postal Service «t City Of Sa rn Buil_ ng Der ent 120 ashIngto Street Salem, M! 1970 Commonwealth of Massachusetts SON➢12,1 City of Salem 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 t PERMIT REPORT BY ADDRESS `- Address: 126 BAY VIEW AVENUE PIN Permit For Parcel ID Occupancy Type Building Type Work Description Construct. Fee Paid Cost B-17-214 Repair/Replace 44-0118 Residential Single Family REMODEL KITCHEN&BATH 39000 273 B-2003-0662 434 Residential:additions,alterations,conv. 44-0118 Residential Single Family 664-2008 REMOVE 2 EXISTING 20000 125 DECKS AND REPLACE W/NEW, GLASS SUNROOM BUILT ON NEW-FRAMED STRUCTURE. PER BOA DECISION. TJS B-2012-0501 REPAIR/REPLACE 44-0118 Residential Single Family REPLACE SIDING AND(2) 5800 43 W INDOWS jbh E-17-268 Other 44-0118 Residential Single Family BATH AND IST FLOOR REWIRE. 0 120 8 SW ITHCES,INSTALL 2 ISLAND OUTLETS AND REPLACE BATH FAN G-17-152 Boiler 44-0118 Residential Single Family BSMT:1 BOILER 0 30 P-15-428 Remodel Kitchen or Bath 44-0118 Residential Single Family 2ND FL: 1 BATHTUB, 1 0 25 LAVATORY, I TOILET P-17-171 1 Plumbing Fildure 44-0118 Residential Single Family BSMT: 1 CROSS CONNECTION 0 10 DEVICE P-17-240 Remodel Kitchen or Bath 44-0118 Residential Single Family BSMT: 1 BATHTUB, 1 0 50 DISHWASHER, 1 FOOD DISPOSER, 1 KITCHEN SINK,1 LAVATORY,1 TOILET Total Permits: 8 64800 676 1oft ' OOWNCITY OF SALEM9 MASSACHUSF£MjSF SALEM..MA k, e � BOARD OF APPEAL CLERK'S OFFICE j 3 120 WASHINGTON STREET, 3RD FLOOR SALEM, MA 01970 �s ,t TEL. (978) 745-9595 9g0�MmeW� FAX (978) 740-9846 1000 DEC 30 P 3: 13 STANLEY J. USOVICZ, JR. L L MAYOR DECISION OF THE PETITION OF NATAL & DELEILA BETTENCOURT REQUESTING A VARIANCE FOR THE PROPERTY LOCATED AT 126 BAY VIEW AVENUE R-1 A hearing on this petition was held December 18, 2002 with the following Board Members present: Nina Cohen, Bonnie Belair, Stephen Harris, Nicholas Helides and Richard Dionne. Notice of the hearing was sent to abutters and others and notices of the hearing were properly published in the Salem Evening News in accordance with Massachusetts General Laws Chapter 40A. The petitioner is requesting a Variance from relief from side setback to construct a 3- season sunroom for the property located at 126 Bay View Avenue located in an R-1 zone. The Variances, which have been requested, may be granted upon a finding by this Board that: a. Special conditions and circumstances exist which especially affect the land, building or structure involved and which are not generally affecting other lands, buildings and structure involve. b. Literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship, financial or otherwise, to the petitioners. c. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent of the district of the purpose of the Ordinance. The Board of Appeal, after careful consideration of the evidence presented at the hearing, and after viewing the plans, makes the following findings of fact: 1. Petitioner appeared and represented herself at the hearing. 2. Plans were submitted showing the proposed sunroom. 3. Two letters from neighbors were submitted in support of the petition. 4. There was no opposition to this petition. CITY OF SALEM. MA i CLERK'S OM E DECISION OF THE PETITION OF NATAL & DELIELA BETTENCOURT REQUESTING VARIANCE FOR THE PROPERTY LOCATED AT 126 BAY VIEW AVENUE R-1 page two 1001 DEC 30 P 3:13 On the basis of the above findings of fact, and on, the evidence presented at the hearing, the Zoning Board of Appeal concludes as follows 1. Special conditions exist which especially affect the subject property but not the district in general. 2. Literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship to the petitioner. 3. Desirable relief can be granted without substantial detriment to the public good and Without nullifying or substantially derogating from the intent of the district or the purpose of the Ordinance. Therefore, the Zoning Board of Appeal voted 5-0 to grant the Variances requested, subject to the following conditions; 1. Petitioner shall comply with all city and state statutes, ordinances, codes and regulations. 2. All construction shall be done as per plans and dimension submitted and approved by the Building Commissioner. 3. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 4. Petitioner shall obtain a building permit prior to beginning any construction. 5. Exterior finishes of the new construction shall be in harmony with the existing structure. VARIANCE GRANTED DECEMBER 3 DECEMBER 18, 2002 Bonnie Belair sC � Board of Appeal 1 MY OF SALEM- A t CLERK'S OFP- A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CIITY CLERK 1001 UEC.30 P 3: 13 , Appeal from this decision, if any, shall be made pursuant to Section 17 of the Massachusetts General Laws Chapter 40A, and shall be filed within 20 day date of filing of this decision in the office of the City Clerk. Pursuant to Massachusetts General Laws Chapter 40A, Section 11. The Variance or Special Permit granted herein shall not take effect until a copy of the decision bearing the certificate of the City Clerk that 20 days have elapsed and no appeal has been filed, or that, if such appeal has been filed, that is has been dismissed or denied is recorded in the South Essex Registry of Deeds and indexed under the name of the owner of record or is recorded and noted on the owner's Certificate of Title. Board of Appeal 4 , (City of .aWVM' � ttsstttljusetts io4. s �Buttra of '�"' �j i8 �fC 13 `� 85 ii ',,6 CI1Y Of ;ALEM, kASS CLURK'S OiVICE DECISION OF THE PETITION OF_NATAL_BETTENCOURT_ REQUESTING A VARIANCE FOR THE PROPERTY LOCATED AT 126 BAYVIEW AVENUE, (R-1) A hearing on this petition was held December 11, 1996 with the following Board members present: Gary Barrett; Chairman, Nina Cohen, Richard Dionne, Albert Hill and Paul Valaskatgis. Notice of the hearing was sent to abutters and others and notices of the hearing were properly published in the Salem Evening News in accordance with Massachusetts General Laws Chapter 40A. Petitioner, requests a Variance from sideyard setback to construct a garage for the property located at 126 Bayview Avenue, Salem. The Variance which has been requested may be granted upon a finding of this Board that: 1 . Special conditions and circumstances exist which especially affect the land, building or structure involved and which are not generally affecting other land, buildings, or structures in the same district. 2. Literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship, financial or otherwise, to the petitioner. 3. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogation from the intent of the district or the purpose of the Ordinance. The Board of Appeal, after careful considerations the evidence presented at the hearing, makes the following findings of fact: 1. The petition was presented by John Nicosia, a licensed contractor. 2. There will be no structural change to the building. There will be no extension off the footprint of the building. 3. A letter from the Historical Commission asking to conform to surrounding properties. 4. A letter was in submitted in support of this petition by Everett Dawtskins, of 122 Bayview Avenue. On the basis of the above findings of fact, and on the evidence presented at the hearings, the Board of Appeal concludes as follows: 1. Special conditions exist which especially affect the subject property and not the district in general. 2. Literal enforcement of the provisions of the Zoning Ordinance would involve substation hardship to the petitioner. 3. Desirable relief can be granted without substantial detriment to public good and without nullifying and substantially derogating from the intent of the district or purpose of the Ordinance. DECISION OF THE PETITION OF NATAL BETTENCOURT REQUESTING A VARIANCE FOR THE PROPERTY LOCATED AT 126 BAYVIEW AVENUE (R-1) page two On the basis of the above findings of fact, and on the evidence presented at the hearing, the Zoning Board of Appeal voted unanimously, 5-0 to grant the variance requested, subject to the following conditions: 1. Petitioner shall comply with all city and state statures, ordinances, codes and regulations. 2. All construction shall be done as per plans and dimensions submitted to and approved per the Building Inspector. 3. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 4. Petitioner shall obtain a building permit prior to beginning any construction. 5. Exterior finishes of the new construction shall be in harmony with the existing structure. 6. A Certificate of Occupancy is to be obtained. Variance Granted December 11, 1996 Paul Valaskagis, Member Board of Appeal A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK Appeal from this decision, if any, shall be made pursuant to Section 17 of the Massachusetts General Laws Chapter 40A, and shall be filed within 20 days after the date of filing of this decision in the office of the City Clerk. Pursuant to Massachusetts General Laws Chapter 40A, Section 11, the Variance or Special Permit granted herein shall not take effect until a copy of the decision bearing the certification of the City Clerk that 20 days have elapsed and no appeal has been filed, or that, if such appeal has been filed, that it has been dismissed or denied is recorded in the South Essex Registry of Deeds and indexed under the name of the owner of record or is recorded and noted on the owner's Certificate of Title. Board of Appeal The Commonwealth of Massachusetts CffY Board of Building Regulations and Standards Massachusetts State Building Code,780 CMR,7 b edi ' n OF SALEM I - Revised Jw u uy Building Permit Application To Co Repair,RenoY Or Demolish a I,2008 One-or T Farm Ming This on r U Only Building Permit Number: .. pplied: Signature: �Z/fin A Budding.Commissioner/ of B 'dings _ Nate SECCI N9 1TE INFORMATION 11 Property Address: 1.2 Assessors Map&Parcel Numbers l.la Is this an accepted street?yes no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use, U 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:(IvLG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone-- Outside Flood Zone? - Public El Private❑ — Check if yes❑ Municipal❑ On site disposal system ❑ . SECTION 2: PROPERTY OWNERSHIP' - 2.1 Owners of Record: Name(Print) ' 'T Address for Service: Signature _. - Telephone SECTION 3E DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ 'Existing Building Ill- I Owner-Occupied it Repairs(s) ❑ I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ - Number of Units I Other ❑ Specify: Brief Description of Proposed Work?:`REp\g Si�S�ng [t,..na -two wthdow5 a SECTION.4:.ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only . (Labor and Materials 1.Building $ 5.�00 1. Building Permit Fee:$ - Indicate how fee is determined: ❑Standard Cityll'own Application Fee - - 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ - 4.Mechanical (HVAC) $ Ltst: 5.Mechanical (Fire $ , S ion Total All Fees:$ Check No. Check Amount Cash Amount 6.Total Project Cost: $ 5-�®O.oo ❑Paid in Full ❑Outstanding Balance Due: c t SECTION 5: CONSTRUCTION SERVICES 5.-1}Liicensed Construction Supervisor(CSL) C*6 603 5--9- l3 �J 0.W�Q5 � ODd License Nwnber Expiration Date Name of CSL.Holder G tb SS - AJP Ste(��' MAA List CSL Type(see below) •� ` Address ` Type Description ? U Umesnicxed(up to 35,000 Cu.Ft. . . ;Si R Restricted l&2 FamilyDwelling 978. 735—b35T :R ResidentistRoo ; c . Telephone , . . VVS" Residential Window and Sidin SF RecidentiahSotid Fuel Burning-Appliance Installation - - D Residential Demolition 5.2 R red Home I�Provemeut Contractor(RIC) - '(7�7 a - `moo. 2r5 TAG HIC Comparry Name or C Registrant Name Registration Number H Gross r}oe Sc�,e. (VGA 01970 Address -7%97/901s q79-'735-0357 Expiration Date Signanue 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 fo provide this affidavit will result in the denial of the Issuance of the building permit. ` Signed Affidavit Attached? Yes..........K No...........❑ SECTION 7ar0WNER AUTHORIZATION TO BE COMPLETED WHEN . OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject propery hereby authorize - to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION I - 0.vWw-s HTt a 0 as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and bebal . _ r( Print Name Signatureof Owner orAutbonzed t Date - (Siened under the vains and penalties of ' 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(MC)Program),will not have access to the arbitration program or guaranty fund under M.G-L-c.142A.Other important information on the MC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I I0.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors 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 beating system Number of decks/pores Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" i f/ it CITY OF S.U.&N4 NLAss kaiUsETTS • BI:UM=DEPART�w`r 120 W ASH NGTON STREET,YD MOOR TEL (WS)745-9595 FAX(978)740-98" KiJ'BERI.BY DRLTCOLL " ;MAYOR_ _'THOMAs ST.PmM DIREI;rOROF Punic PROPERTY/IlUn DLKG COMOSSIONER Workers'_Compensationlninranci;Affidavit: Build/Contractors/Electrici=WPIumbers Anplicant Information _:-" =- \\ Please Print l edkly Vatne(Bttsitt6s,orgauimlioMtntivitltd): T°�Z3 "'�'h7:\OpR-5 Zr\� Address: L' G r o 5 S . Vol cityistarrizip Sa\e,n• (YIN o troo Phone n: 4 -7 S 73 S ,0 3 6-1 Are oo an employer?Check the appropriate box: Type of project(►egaireM; 1.�1 am a_anptoyer with 4. ❑ 1 am a genera!conhactor and I 6. ❑New construction Ea (fnll and/or prat titne).s have hired tla sub�ttracrors 2.❑ 1 am a sde proprietor or parhter listed on whe attached Meet 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for the in any capacity. workers'comp.imumom 9. ❑Budding addition [No worker'comp.insoraaee S. ❑ We are a corporation and its required.] offikers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of ousalption per MGL I I_Q Plumbing repairs or additions myself,fro workers'comp. c. 152,§1(41 and we have no 12❑Roof repairs insti mice required.]t crnployees.lNo workers' 13.©Other - comp,insurance required.) 'Aoy appliool that dtpdu troy 91 must alw GII uul We seetiao hebtr�oaiug theuwotlats' Dutxp idomtatioa t rtotucotvtamwhostbffdlltisaaldavu inlicaing aayatedomgell u kond then hue ottaideeanttazbta must mhmh anewandav"e Wicaing such. {mumams tha sheet this hoer mmt anached an adchuccai sheet showwa Metmmeof ate VA4voruOum and their wmkaa'pump-policy infa®tiow I am an employer that it providing workers'compenratlon insaroncefor my employees, Below is the policy and Job site information. Insurance Company dame: ]— !�4AA� t rir\,>V 0 �A _ Policy N or Self--ins.Lic.Al: y=/1/G rJ.— `S 377 9�5,5"OZ.NExpimtion Date:' 3 O —1 '2 Job Site Address: 17..s-{ Q a_ /�7T i P,..J Jy - City/stew izip:5t(e m rx A OLI 97d Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration daft). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fate up to S1,560_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 lovestigatiuns of the DIA for insurance coverage verification. I do hereby certify rattler the pains aannd�p.eenaUhs ofperjwyL4 t the information provided abo v e cr aae aad correct Signalttr yt1liG. li - !g 1 ,r , Dom. Phona# -735 - . 0357 - Official use only: Do not write Ji this area,to be completed by try or Iowa official City or Town: Pertnitlllecare d Issuing Authority(circle one): 1.Board of Ifealth 2.Building Department 3.C•ityffowu Clerk 0.@tectrical Inspector S.Plumbing laspect" 6.Other Contact Person Phone g: WORKERS COMPENSATION AND EMPLOYERS LABILITY INSURANCE Liberty POLICY Mutual:r AR INFORMATION PAGE Liberty Mutual Group - 17s Berkeley street Boston,MA 02117 Issued by LIBERTY MUTUAL FIRE INSURANCE 16586 Policy Number WC2-31S-377255-021 Issuing Office 181 NEW BUSINESS NEW Issue Date 08-31-11 Account Number 1-377255 Sub Account 0000 1. Insured and Mailing Address FEIN 271976112 JRB BUILDERS INC 4 CROSS AVE SALEM MA 01970 RISK ID 859092 Status 03 - CORPORATION Other workplaces not shown above: SEE ITEM 4. PREMIUM-EXTENSION OF INFORMATION PAGE 2. Policy Period:The policy period is from 07-30-2011 to 07-30-2012 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the.policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100, 000 each accident Bodily Injury by Disease $ 500, 000 policy limit Bodily Injury by Disease $ 100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is.subject to verification and change by audit. Code Premium Basis Total Rate per$100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 2, 523 Premium will be billed ANNUAL Producer 0004-152882 GILBERT .INSURANCE AGENCY INC 137 MAIN STREET (RTE 28) READING MA 01867-3922 Sales Representative 3D00 Sales Office Name WESTON 01987 National Council on Compensation Insurance,lnc. WC 00 00 01 A All Rights Reserved Ed. 07/01/2011 Insured Copy CITY OF Sm E'm, iNLkss.VCHL'SETTS BLMDLNG DEP_� MWQ-T 120 WASHVIGTON STREET,Va FLOOB TrZ (978)745-4595 FAX(979)740-9846 (QgHWA FY DRISCOLL MAYOR THOMAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER 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: (name of hauler) The debris will be disposed of in TacnS�e,r �a�•o✓1 (name of facility) SWGrn�5coT1 lZ� , (address of facility) signature of pemtit applicant i 2-s- ►/ date dc6rivlr.duc L IE > ' The Commonwealth of Massachusetts Board of Building Regulations and Standarc}�' AR 28 A "QTY OF Massachusetts State Building Code, 780 C 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: Da pplied: 1 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION ti.l Property Ac dress: 1.2 Assessors Map&Parcel Numbers 11(otfliW Ove l.la 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 E3On site disposail system 13 SECTION 2: PROPERTY OWNERSHIP 2.1 Owner'of Record: Name(Print) City,State,ZIP —� I Z(- I5i)q ViCau fav Qj'g yY- ZZ2T C:lkd�jI v, 5vr No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction Cl Existing Building❑ Owner-Occupied ❑ I Repairs(s) 10 1 Alteration(s) Cl I Addition ❑ Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify: Brief Description of Proposed Work 2. , 9/1t)I yl SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ 3 a2 1. Building Permit Fee:$ Indicate how fee is determined: Li Standard City/Town Application Fee 2.Electrical $ ,_ ' ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ j 9 „ t ❑Paid in Full ❑Outstanding Balance Due: F0 R V C-X-6 A\,— SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) r / ii f C ( _�� 1 �V/U7/Z ,1 4C hur d� cYe Z C,° r f � �� License Number Expiration bate Name of CSL Holder 11vtt' List CSL Type(see below) No.and Street Type Description MNy � ` } Unrestricted(Buildings u 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 s.v` ill . a y�� � � r' i. i��_wrir�i � V�'i''1 I Insulation Telephone Email ad ess D Demolition 5.2 Registered Home Improvement Contractor(HIC) d HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name Z �vn}� Sind, t !fir No.and treet }� I Vq rt b( ��r 1 h 1 0'�41� Email address Cit /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 ..........1f No...........13 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 f t!�"`� n f4)U Y' --L to act on my behalf,in all matters relative to work authorized by this building permit application. / (11,w-- `Ad` I ('._ Print Owner's Mame(Electronic Signature)( Date SECTION 7b: OWNEW 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 " A--�vcv,e_-F accurate to the best of my knowledge and understanding. 2.114 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 wXiAv.mass.lov/oca Information on the Constniction Supervisor License can be found at w,,Nw.uiass.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 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"