67 AURORA LN - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
,,, , MUNICIPALI'I 1'
b Massachusetts State Building Code, 780 CMR, 7 edition
USE
Lr
Building Permit Application To Construct, Repair, Renovate Or Demolish a kr'i'i+co/luntell)'
One- or Tiro-Family Duelling
This Se• For Official Use Only
Building Permit umb — � Date Applied: 2 b�
Signature: 12,
\ \ Building Commissioned Inspector of Buildings Date
SECTION 1: SITE INFORMATION
LI Pro Add 1.2 Assessors Map & Parcel Numbers
�¢�l U/00/7
L Ia Is this an accepted street'? yes no Map Number Parcel Numher
- 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage tfo
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
i
1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'? stam
Public ❑ Private ❑ Check if yes❑ Municipal ❑ On site disposal
P y ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O}yn�{of Recor e c -.-Z A do f 4
Cti d
Name(Print) Address for Service:
47& 7LI f • 7060
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ 1 Number of Units Other ❑ Speedy:
Brief Description of Proposed Wo '^
Q�p tfl�t� ✓d 'le-0 -cc,
`i'C o..n7� r�oPr-� �' .t �t� � � � o c.n�:-Ft-�h✓�'�—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ 3. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
$ 'Dotal All Fees: $ yj2 rr
Suppression) �
Check No.404 Check Amount: 161 Cash Amount:
6. Total Project Cost: $ i ��, bC7 paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) a-« `7 7 5 0Cl
D 1/LIG e-- License Number Expiration Dute
Name of CiL- Holder 7 �
j(C6- 3 �, �, List CSL Type(see below)
Addre A6, Type Descri tion
�. U Unrestricted(tip to 35.000 Cu. Ft.)
R Restricted 1&2 Family Dwellin
Signature J�7 0 M Masonry Only
J RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Bunting Appliance Install:nion
D Residential Demolition
5.2 Registered Home Improvement Contractor(111C)
�, yvtcr� CpuS't/V c ��vt
HIC Compan Name or HIC Registrar,{ Nat e - _ Registration Number
t I $ ��I wR t tG v otS E 5
Addre-s
bLb�.rti 'Z,-I—6r"S -DV-(6 Expiration Date
Signature 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 ........... ❑ A4,C4 '
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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as..or Authorized Ai,ent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Na ._&-�-li oZ�la—1
Signature of wner or Authorized Agent Dan
(Signed under the pains and penalties of perjury)
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 Lind
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and t 10.R5, respectively.
?. When substantial work is planned, provide the information below:
Total floors 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"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTN[ENT
•.Vlsl{f' amyCIL
.%Wk\ Ix�.�Q)i: f�{�*• i fl.lta�Y::Y It 111•.�
To.10't 46'm •f.%*97a��6ltM
r-
Constru¢do. Debris Disp"af Affidavit
(Mluimd fm all.lanolitim and Mpvatim work)
In monwwA with dts 4z&ad doe of the State lluildles Cods6 730 C 11 sactim 111.3
Dario.ud dw provisiom of M. CL a 40.S 54
8uilaq!moil A _ is isou"with dw eondidom that dw debris mnd&s ftom
,his wort shall be disposed of in s properly llcensad waste disposal facility ss defined by WX e
111. S 15"
The debris will be =nsported by:
� g V'ac-e
-- Inonar of haJa)
rho debrs will be disposed of in :
t u.m.ul'fxlLq)
S-
pit
Information and Instructions
Massachusetts General Laws chapter l32 requires all employers sttop%vei a woe a another under compensation for heir Cue of lu�'
pursuant to this itatute.an sw�feyee is defined as"...every Pe
eaPtess or implied,oral or writtes.
aweiatiQ16 Corporation a outer kgsi entity,err any two or toont
An err�ny+r is engage N art is Pn�tP' the le representatives of a debeased employer.or the
of the it engaged in a joint parmrwe.and incht►tmg � eP o However the
essoeiation or other legal entity,employing ernpl Y�
receiver or trustee of an iudividual,partagtshhP. aparaneuts and who resides therein.or the occupant of the
owner of a dwelling botam having act to=tb,a three maintenance.
. , dweUirta house of another who employs Persons ro do of because,of conbIr
emp& or repair work a tube dwelling house
or on the grounds or building appurtenant
thereto shall not because of wee en+pbytamt be deemed to be an employer."
btGL chapter I52,42SC(6)also srsces that"wary state or beat lkaasfag attanay shad withhold the issuance or
so o raft a business or to eoastrud baddla0 la the commeaweslth for nay
reaewai of a e has a or permit Pa with the Insunme coverage required."
applies N wM has not produced accept"widths .f e commonwealth
Additionally.MGL chapter 132,423C(7)states"Neither the until
acceptable
evidence of compliance withinsurance
enter into any contract for the performance of public woe until acceptab
requirements of this chapt
er have been presented to the contacting authority."
Appdeanta
Please fill out the worker
s' compeasanon affidavit completely.by cheeping the boxes that apply go your situation sad if
necessary.supply cube°a rods)name(&),address(es)and phone number(s)along with their certificaes)of than the
Limited Liability Compsoies(LLC)or Limited Liability Partnerships(LLP)with no employt
insra unce errs not��to carry w�'compensation insurance. If an LLC or LLP does have
members or Partners. ens of Industrial
employees.a policy is required. Be advised that this affidavit may be submitted to the Departm
Accidents for Policy i is require
ion of insurance coverage. Ababa sure to saga and date the affidavit. The affidavit should
for the permit or license is being requested not the Department of
be returned to the city or town that the application
required as regarding the law or if you a
ladustriul Accidents. Should you have any questiorequired to obtain a worker'compensation policy.Please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the lam•
City or Towa Off c"
- Please he sure that the affidavit incomplete 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 applicanL
laloase he we to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that y in submit multiple necessary)
l aril neapplications Site Address"the applien year,need only submit one affidavit cantt should write"all locations in beating currently
or
policy information(if necessary)
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 ere.)said Person is NOT required to complete this affidavit.
(he ptji.c of Investigations would like to thank you in advance for your cooperation and should you havc any questions,
please do not hesitate to give us it call.
The Department's address,telephone and fax number
The Commonwealth of Massachusetts
DepaMent of Industrial Accidents
OAka of[awsotildefn
600 Washington Street
Boston, MA 02111
Tel. #617-7274900 ext 406 or 1-877-NIASSAFE
Fax N 617-727-7749
2cvi.cd 3-��-os www.nim.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:.tstnr-atFr utustxxi
Mvrfta 12C VAste.%e-_ MST1s9rr a$Abet,WAscncYnza:7-IN019M
'rt�9711.743.9595 a FAx:97e.74C."46
Workers' Compensation Insurance Afl)davlt: BaildenlContractors/Electridons/Plumbers
.Applicant Information Please Print Lee y
Name ilbnincss[OrgmizadoWInshvtdmi):
Address:
Are t you as employer?Check the appropriate cross FORenwdeling
ct(required):
1.tit 1 am a employer with 4. ❑ 1 am a gcn=W contractor and 1rnsfructi�
employees(full and/or part-tine).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or patina. listed on the attached shoat t ling
ship and have no employuets These have tionworking for rite in any capacity. workers' comp. insurance. Irklition
INo workers'comp. insurance S. ❑ We am a corporation and its 10. Electrical n quim L) officers have exercise!thew ❑ repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs;or additions
myself.(No workers'comp. c. 1 S2,41(4),and we have no 12.0 Roof rupaus
insurance required.) t employees. (No workers' 13.❑Other ✓�� I.-"comp. insurance ruquired.)
Ain Vphcam she chcckm bee al moo also fie uu the scene below AhoWiaa IhAr vwtao•ewnPw+yi u pwwy ioaxmarws
4omc owners who submit uw aftleork indicartng they arse deiaa A out attd thee Elea ouulds eomr ommi mot.Want a new,anhiavin iniiarina me►.
'C.. fort that chuck the bra macs attached an adduiaw.Est towing the mama aretsN&MManersand their wurters'cents.pWiry inraam lua
/art an arrrp/oyer fiat is providing workers'coarpensaden Luarance for my employees. Below is the pa/&y and Job site
.e... _
Insurance Company Name: �J Cf' rs S L ��d,Te_�
Policy a or Sclf--ins. Lic.A: C7110Oh S i 1. 6 S EApuutlon Date:
6
Job Site Address: - '-" �r1
CityiStatuZip:
Attach a copy or the workers' compensation policy declaratiaa Page(showing the policy number and expiration date).
Failure us secum coverage as required under Section 25A uf.IGL c. 152 can lead to the imposition of criminal penalties of a
604 up to S1.500.00 and/or one-year imprisonment•as well as civil penalties in the form of a STOP WORK ORDER attd a fine
of up to S250.00 a Jay against the violator. Ile advised that a copy urthis slatcrnent may be forwarded to the Office of
6ts.•,hgaunu ul'thc DIA for insurance carvcragc verification.
/Jv herby r.nijy a er hr pie pain:tad pens/l&s vjperjary Met the injormWion provided above is true and correct.
Date
Plume a:
D/Jlrirer au vsgv Do sot wrJre is tkis area,to b<completed by r4 or town o/jleigi
City or Town: Pcrmit/Lleense M
Issuing Authority (circle one): --
1. Iloard of llcalth 1. Building Departtncut 3.City/rosin Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Of her
C nuact Persmr: _ Phone p:
02/12/2008 11:25 7815937260 DUFFY INSURANCE AGCY PAGE 01
laK i irICATE OF LIABILITY INSURANCE DATE(MNIIOO"yM
PRODUCER (781)593-1200 FAX (781)593-7260 02RMATION
Duffy In urance Agency, ONLY
CERTIFICATE IS ISSUED T UMATTER OF INFORMATION 9 n'I Inc.IRc• ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE
317 Broadflay HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Wyoma Spare ALTER'THE COVERAGE AFFORDED BY THE POLIC9E BE
Lynn, MA 01904-2602 INSURERS AFFORDING COVERAGE
INSURED D G Mace COnstrUCtion NAIC#
INSURERA: Providence Mutual Fire Ins Co C/o Dana G Mace INSURERS; Associated EmPloyers Ins CO 15040
218 Jersey Street INSURER C:
Marblehead, MA 01945-1306 INeURCRD:
NSURER E
OVE E�
ANY THE POUOIRb OF INSURANCE LISTED ULLION OF HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
MAY PERTAIIN THE INSURANCE AFFORDED BY THE O ANY PLICES DESCRIBED HEREIN 5 SUBJECT TO ALL THE TERMS,EXCLUSIONS ANO CONDITIT OR OTHER DOCUMCNT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ONS OF SUCH
UCH
POLICIES.Ad6REGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIN CLAIMS.
INSK DD' TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION
POLICY NUMBER
GENERAL LIABILITY CPPOOSS37604 04/12/2007 Q4/12/2008 EACH OCCURRENCE LIMITS
X COMMERCIALOCNCRALLIABILITY b 11000 000
CLAIMS WOE X❑OCCUR DAMAGE TO RENTED $ S01 00Q
A MED EAP(Any one Pereen) b 5.000
PERSONAL a AOV INJURY 5 1,000 00
GEN'LAGGREGATE LIMITAPpLIE3 PER: GENERAL AGGREGATE 6 2 000100
X PULICY PRO.JGCT LOC PRODUCTS-COMP/CP AOG $ 2 QQQ QQ
AUTOMOBILE UABILRY
AINYAUTO COMBINED LIMIT 6
ALL OWNED AUTOS
SCHEDULED AUTOS BODILY INJURY
HIIREDAUTOS (Per Person) b
NON-OWNED AUTOS BODILY INJURY 6
(Paraccldent)
PROPCRTYDAMACE 6
YAUTO (Per acdclenC
AN AUTD
OARAI AUTO ONLY-EA ACCIDENT 6
OTHER THAN EA ACC 6
AUTO ONLY: AGO S
EXC OSICURBRELU LIABILITY UMCOOSG432 0$/01/20Q7 D8/01/2008 EACHOCCURRENCE 6 1 000.00
OtWF ❑ ULAImD MADE AGGREGATE 6
A 6
DEDUCTIBLE
9
R�TENTION 6 b
WORXERSS UARILITY NANO WCC5004554012007 06/11/2007 06/11 2008 WC5TATU- OTH.
EMPIVERS COMPENSATION
/ X
g ANY PROPRIE`TO R/PARTNEIVEXECUTIVE E.L.EACHA
OFFICERmaEMBER EXCLUDEDP CCIDENT S jQQ,QQ
If yes,Descabd uWar E.L.DISEASE-FA EMPLOYEE E 100,QQ
SPECIAL PROVISIONS below
OTHER E.L.DISEASE•PDI ICY I Iurr S 500,00
XSCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
:E ION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES OE CANCELLED BEFORE THE
MUPIRATION ITE TN F/ E ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYIT NDta:P, HE CERTIFICATE HOLDER NAMED TO TIIE LEFT,
BUT FAILURE SUCN TN:E BA BENDOBLIGATIONORLUIBILRY�lty f Salem OF ANY INDN UREP, AGE RBP0.ESEXTATNES.
Salem` MA A DP0
1CORD 25(20dl/08) FAX: (978)740-9846 f �' p CORD CORPORATION 1988
02/12/2008 11:25 7815937260 DUFFY INSURANCE AGCY PAGE 02
IMPORTANT
If the Certificate holder is an ADDITIONAL_INSURED,the polioy(ies)must be endorsed.A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROCATION 1^a 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).
DISCLAIMER
I he certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s),authorized representative or producer, and the certificate holder,nor does it
affirmatively or negatively amend,extend or alter the wverage afforded by the policies listed thereon.
.CORD 25(200ifea)