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4 ADAMS ST - BUILDING INSPECTION (2)
33 -- 14- 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: D Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Ads: 1.2 Assessors Map&Parcel Numbers L la Is this an accepted street?yes 4/no Map Number Parcel Number 1.3 Zoning Information: ` "1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(11) 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? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) City,State,ZIP q 7 gl�o dX6 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) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Dp�scription of Propos World: Kf vw e dlld urn `Gi 4 w �i� iv ��.rov _Sea sir, �av raa �7f s Y e SECTION 4:ES IMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials (c/ I.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 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: $ �y 00 0 ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ,/ � (J EGG/ /D/7/�[3 S' U� A License Number Expiration Date Name of CSL Holder 7 List CSL Type(see below) a 3 q J e SO4 jiPJ No.and Street Type Description U - Unrestricted(Buildings up to 35,000 cu.ft. Sig l P Yn 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 Tile hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 6�" Cd �Q HIC Registration Number Expiration Date HIC Company Name or HLC Registrant Name - .TA 9 7e ersUn ve, S633 �l,' (�mCl� she No.and S ee .i Email address .- 7,o,44,f f/l 0197J �7�3/7 lIG:S City/ own,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...........❑ SECTION 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize v ez,4,4�10 to act on my behalf,in all murfte relative to wor,authorized by this budding permit application. //, kaf Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNERS 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: I. An Owner who obtains a building permit to do his/her own work,or an owner who titres 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 Information on the Construction Supervisor License can be found at www.mass.gov/c1ps 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" 1 The Commonwealth of Massachusetts Department of Industrial Accidents Of ceofInvestigations wi 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (�1 �{(((p (n/ l� Please Print Leeibly Name(Business/o rganization/Individual): J / �� /�L&&t G Address: c23 S O eti City/State/Zip: J� 1` eyl `y/it Oiq Phone#: Ed— 3/ 7 G Are an employer?Check gthe appropriate box: - Type of project(required): - l. I am a employer with .[� 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ m I a a sole proprietor or partner- listed on the attached sheet.I ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition waking for me in any capacity workers'comp.insurance. 9. ❑Building addition [No workers'comp,insurance 5. ❑ We are a corporation and its ME]Electrical repairs or additions required.] officers have exercised their 3.Q I am a homeowner doing a8 work right of exemption per MGL it. Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] "Any�pfi=,that checks box#1 must also fill out Me section blow slowing their workers'compensation policy information. t He.=rms who submit this affidavit indicating they are doing all work and then hire outside connactms Muir submit a new affidavit indicating such. iConnoo,cas that cheek this box most attached an additional sheet slowing the time ofde subcontmetvn and their workes comp.policy information. law an employer that is providing workers'compensa6an insurance for my employees. Below&the policy and job site information. /J/ / Insurance Company Name: L t J'G� i.� //1/V " Policy#or Self-ins.Lic.#: ////'- '�� C 3�,7 0 G y�3 Expiration Date:_� , Job Site Address: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pairs and penalties of perjury that the information provided above is true and correct. Suture: Date' Phone# Official we only. Do not write in this area,to be completed by city or taws ojykiaL City or Town: Permit/License# Issuing Authority(circle am): 1.Board of Health 2.Building Department 3.City(Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACORV OATB tMMIDD'YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/23/13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED 'REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: H the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. M SUBROGA710N 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 tD the certificate holder in lieu of such endorsemen a). PRODUCER p M.P. Roberts Insurance Agency rye FAX N 1060 Osgood Street atnaijAg North Andover, MA 01845 ADDRESS: INSUREINSIAFFORDING COVERAGE NAIC0 ------ _____ INSURER A:Atlantic casualty Insurance Co INSURED SIEVE BARLEY INSURER e:Merchants Mutual Insurance Co INSURBRc:Libert Mutual DBA STET/E HADLEY CONTRACTING INsuRERo: 239 JEFFERSON AVENUE SALEM, MA 01970 INSURER E: INSURER F: COVERAGES CERTIFICATE-N UMBER: - - 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. INSR-.._--_-- AOOL SUBR ----__— POLICY EFF POLICY EXP — LTR TYRE OF INSURANCE POUCYNUMER MOWN MAIOdYYYV LMTS A OENERALLUIBIUN L143002666 7/8/12 7/8/13 EACH OCCURRENCE $ 1,000,000 X COMNIERCW.GEFIERALLIABLLITY DAMAGE TO RENTED_RREMISES $ lOO OOO CIAINS-MADE FXIOCCUR MEDEXP(Aryom Paem) $ 5 000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2.000.000 - GENTAGGREGATELMITAPPLESPER PRODUCTS-OOMPIOPAGO $ 2,000,000 POLICY PR0. LOC S B AUTOMOBILEUABNTY MCA7014084 10/28/12 10/28/13 (CE0awaM'Ni(E0ftS)`NoL L $ 300,000 ANYAUTO BODILY INJURY(Per person) S ALLOWAUTOS FEO X AUTOSSCHED BODILY BODILY INJURY(Per smidenU $ X HIREDAUTOS X NAOTOOVVNED PROPERTY DAIMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCE55UAS CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC531332906403 7/e/12 7/9/13 WC STATU- OTH- AND EMPLOYERS'LABILITY Y/N ANY PROPRIEMRIPARTNERIEXEOITME E.L.EACH ACd OEM 500,000 OFFICERMEMBER EXCLUDED? NIA (MeMabry in NH) E.L.DIS EASE-EA EMPLOYEE 500,000 N Yyes Ow ieewder DESCRIPTION00'PERATIONSt.b. E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IAU=h ACORD 101,Adll0onal Rernaft Srhe",Bmors Spam is mgdmdl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and.logo are registered marks of ACORD Phone: Fax: E-Mail: 4, ADAMS STREET 438-14 GB a: 3323 COMMONWEALTH OF MASSACHUSETTS �Map: 23 Elock: CITY OF SALEM Lot: 0168 Category: RENOVATIONS Pennit# . 438-14 BUILDING PERMIT Project# s JS-2014-000985 Est. Cost:W $14,000.00 Fee Charged: $103A " Balance Due: $.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: -Contractor: License: Expires: Use Group:.. STEVE HADLEY CONSTRUCTIO SUPERVISOR-99661 Lot Slze(sq &): 5800.014 Zcmn u _ Owner. Leo&Claire Pelletier RI Units Gained: Applicant: STEVE HADLEY Units Lost: AT. 4 A-DAMS STREET Dag Safe#: ilSSUED ON. 25-Nov-2013 AMENDED ON. EXPIRES ON: 25-May-2014 TO PERFORM THE FOLLOWING WORK. z REMOVE OLD AWNING WINDOWS IN THREE-SEASON ROOM. INSTALL NEW SLIDING WINDOWS AND SLIDING `D'OOR. INSTALL NEW PANELING. POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: Underground: Underground: Excavation: Service: Meter: Footings: Rough: Rough: Rough: Foundation: Final: Final: Final: Rough Frame: Fireplace/Chimney: D.P.W. Fire Health Insulation: Meter: Oil: Final: Plouse# Smoke: Treasury: TVater. Alarm: Assessor .'I..Y..i; Sewer: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount BUILDING REC-2014-000989 25-Nov-13 5113 $103.00 i ':GeoTMSm 2013 Des Lauriers Municipal Solutions,Inc. 'is