0003 BARNES AVENUE - BPA-11-74 ��
. ,.
�ji�� ri� 4�--�j�
� fhe Commomvealth uf Massachuset[s
,;►, .r poard oFBuilding Regulations and StanJards ��TY
�a � Massachusrtts Slate Building Cude, 780 CMR. 7'h cJition ��F SALEM
A� Rrvisrd Juruu.ry
� l3uilding Prrmit Application To Construct, Rrpair, Renovate Or Demolish a /. ?!ilAY
� (Jnr-or Tivo-Familv Dwr!linX
� This Section For OfTicial Use Onl
� BuilJing Prrmi� Number: Date Applied:
� SignaWre: � �"l/l
HuilJing Cummissioncr/Inspecro uf 8uildings Date
SECTION I:SITE INFORMATION
1.1 Property Addreu: 1.2 Aeaeeeon Map& Parcel Numben
'i 1�a,-..z5_ a.�� Sn1�,--.
I.I a I5 ihis an accep[ed streat?yrs no Map NumDer Pareel Number
13 Zoning Informatlon: I.a Property Dimenslons:
luning Disirict ProposeJ Use Lo�Area(sy tl) Froniage(ft)
, 13 Building Setbaclu(R)
Fron�Yard Side Yards Reaz Yard
Require�l ProviJed RequireJ Provided Requircd Provided
1.6 Water Supply: (M.G.L c.Jo,§54) 1.7 Flood Zone Informatlon: 1.8 Sewage DVposal System:
Public Zune: _ OutsideFloodZane?
�_ Pf1°°1O� Check if es� Municipel O On site disposel system ❑
SECTION 2: PROPERTY OWNERSHIP�
2.l Ow �ot Recor�• 2
. r�J �r.,.c5 Nv � S-9��..-� .
Num (Prin Addrcssl'orService:
`�� �3�- �iSY
Signot4 Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK�(c6eck all that rpply)
New Constrvction❑ Existing Building O Owner-Occupied Repeirs(s) O Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other O Speciy:
BriefDescriptionofProposedWork': 1���-\2 �o.r.,.c.� *�c*e��-, a�"� SZc�o-�
�A\\:5�'n-'�� _ pv�: ���c� 4 . 2 S�r,:. cysc.S , A-D'NroX
��r" o fF, g� x �2 —� "�—
SECTIOIV J:ESTIMATED COIVSTRUCTIOIY COSTS
Item Estimated Custs: OfRcial Use Only
Labor and Materials
I. I3uilJing S �S pOb'� �• Duilding Permit Fee: S Indicate how ke is detertnined:
2. Electrical S ❑S�andard Citylfown Application Fee
O Total Project Cosf��Item 6)s multiplier x
3. Plumbing S 2. O�her Fees: 5
�. Mechaniwl (HVAC) S List:
5. Me�:honical (Fire S
Su ression Total All Fees:S
6. Total Project Cost: 5 �S bop • °� Check No. _Check Amount: Cash Amount:
i ❑Paid in Full ❑Owstanding Balance Due:
r �
1ECTION 3: CONSTRUCTION SERV ICES
5.1 Licemed Con�trucllon Supervl�or(CSL) `�c f��� ��_ � �p
/
. ��_^ ��` C�g` �/��uv,.Cy�$� I.iccnuNumAer I:XpIf�11U�lUJIC
1 �N:unr ul'C5L-I IulJer Lisi CSL"fype�see below)
7..E'g : �_ �CQ�r1 A�� ` N".� 4�'.
'�� �Jl3{:fl IlOfl
ss U llnrestrictnl u tu 35.000 Cu. F�.
R RestricteJ IR2 Fynil Uwellin
tiign�tu �c M Muso Onl
�( —.�<�:��� RC Residential Raitin Covcrin
Td. one � WS Residen�ial WinJowonJSiJin ��
tiF Ra�idenlial Sulid Fuel Bumin A liance Inatallutiun
D Rosidtntial Demoli�ion
5.2��te�Home mpfpveme�Con`I-ncror(HIC) �����p
f IIC Com on y�m e yr HIC R gQnm�N.une Registmtion Number
O P YC— 6 �&v2 C� �"�" ��y / ( �
Al4IT5 �
���-.�-( ���-�j �El�tion Date ..
ti1�11J1U 1 elephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.u 152.4 25C(6))
Workers Compensation Insurance afTidavit must be completed and submitted with this application. Failure[o provide
Ihis aflidavit will result in the denial of the Issuance of the building pertnit.
Signed Affidavit Attached? Yes .......... ❑ No...........O I
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S ACENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT !I
��� ��� , av Owner of lhe subject property hereby
�� .C,"t� Go�S�-, Cd. to act on m behalf, in all ma[ters
au�horize ti o�. S��' � 5 y �
relalive to work authorized by lhis buildi g permit application. I�
J� � � � I
tu o Owner - �� ° �I
' SECTION 7b:OWNER�OR AUTHORIZED AGEIVT DEC RATION ,
�. �o�„J S�;�� ,as Owner or Authorized Agent hereby declare �
that the sWtements and infortnation on the foregoing application are true and accurate,to the best of my knowledge and
behalf. C
^� C1� J �<�J �,
Print Name S/ )y/�� I,
Signaturc of Owner or uth ized Agent U°« � I!
Si ncd underthe ai and n ' 'u �
NOTES•
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered conlractor
(nol registered in lhe Home Improvement ConVactor(HIC)Program),will�have access to�he�rbitration
"program or guaranry fund under M.G.L.c. 142A.Other important infortnation on the HIC Program and
Construc�ion Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively. ,
? When substan�ial work is planneJ,provide the inf'ortnation below:
Tutal Iluors area(Sq. Ft.) (including garage, finished basemenUattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number oY bedrooms
Numbe�of bathrooms Number of half%baths
� Type uf'heating system Number of decks/porches
� Type uf awling system flnclosed Open
). "Tu�al Projeet Syuare Foo�age"may be subslituteJ 1'or'Total Projec�Cust"
� -� CITY OF S.�LE.`[, I�L�SS.�CHL'SET'TS
Bl'Q.DL�IG DEP.��TIF.�iT
• 1'_0 �.�SFIL�IGTON S'TxE6T. )�O FZOOR
�. (97� 7�S�9S9S
F.�x(97� 7�496�6
KI�IBERLFY DIl15COlL ZIiOMASST.PIEL�i
�,tAYo� p��aR o f�ec�c r�wvERr►/e�anNC co��nssio��
Wurkers' Compen�stton Insursne� ��tlidrrit: OuilderslContractoNEleetrlclrn�IPlumsees
a i Ileant Infnrm�tlon Pleaat Print Ledbht
Va�Td IBu�uw+rOr�amrs�ionl�rLv�M.all� �v2.,-� `r�-r� ST� � . L.L. ` •
A�drc�t: �-{o`f ��S'�e�� �� —
City/State/Zip: �Y.•`�v-' l�'L'a• C�1�� 2-1'�one M• ��(" ��'�.S}� ��'
,�re ra •empMrs'Ch��ly-e�!+�V�np�q bsss 7'rpt olproJect(reqrlred):
dr 4. � 1 am a�enenl contraeaor aod 1 6. Na�r conam�ctioa
I. I am�unpbyer wi�D . hav�hind tM audcarnemes �
.mplo�(full and�ot pact-ame)• listed on ths artaclwd�Ant� 7. ❑ Remaklin�
1.� 1 am a�oN pmprieiar or paruier
ah�p�I�K nu Cmpbyee T}�w w�contnetas h�w tl. ❑fkmolition
�vohin� fa�ms ia any cap�ciry. ��m'eomy.imunaaa 9. ❑OuiWin�addiuos
�No wohera'comp in�uranc� i. O W�an�corponaae and id 10.0 Ebctrical rep�in ar addi�iom
��quirrJ.� of'lkas haw e�uaciaed thrir
ri of ioe MOL �� �%�bn+i�Wn a rdditioro
).0 1 am�homeo�rn�m Join�all woh � �� �
mysslt.(�o vrarkm'camP. c. 1l7.,1(4��nd wt h�vs no 12.�Rao[mp�iw
�
inswancere9uired.)� ��^VbYc�-LNowatYas 17.0011tt��a�.•,e�-Z_'�i� uc
coma insuranas requi�ed.J
-n�r��onnr��w�.ea.n �r�.+no w m...��sww+r.�n�sar.or..•�.o�.w��i��e.
�I l.w�ru�nw wM�ubwill�Y aAIMi i�lode�Or�ae Joary�II we�k ad d�hb eurii ewwebA n�rl mAwh��rw�tllGinil fndirril wel►
'l'.nus+w��M c�k�li�Ma�u/aOaclM�a�rYi�w�l Jrw J�swuY Jr iry e!IM w►arinslw��wi�Mr worYw�'tn�F id'�7 iJawiWa�
/us aw rw0loytr�Ad b�nri//n;wwlirs'CaU�II�fI/Ml�/MY/IACI fN�tlllp/11yfI� Srl�r b��pNle�u//a�1 i/Y
in/anwWlaa
In.urrnceCompanr Vama ��� •1�C � �C o —
Policy N ur Self•ins. Cit. M: tN� Op��a3 Fa�piralion Dot�• 3 �6 ��_
lub�irsAd�truss: ��^� C Ciry/StarNZip: Kalc�--� V " `/a-.
.�nac��coOr ot thr w��'Wn'com�uub�po0ry deeWaN��Wp(iYow'in�tV polle�s�aMr�N�ipinMw dN�►
f ailure to�uct covon4e as requiied unJrt Scctio�2SA of�tUL a 172 can Idd to th�impwition of erimin�l p�naltia�af�
f ne up�o S I,S00.00 anJ/w ont-yeu impriwnment,ar wall o�civil penrlties is i!u fam uf a STOP WORK ORDEA and�flo�
,�f up io 5250.00 r Jar ayninY �h�violuw. H�aJvi.xxl ehot a co�ry uf thit watrmenl msy b+ Wrwurdnd io�M 017tce af
I nv.aliy��ion�„i a��nu ro.���.�.��.�o..��r,..w.,ri.�i�a�
/Je hii b�� rrr ' mrJn • iwa un/yinr/1/o o�per/rry eAo�rAi iajw+ur/ow OroriJe�uMw it erri rn/••wr�d
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P`�i a. � � " ��' -� S ��
I O/JJrid ua n/p. Do nW wrili iw ihu rie�N M.u�nO/ire/br ciry or ioaw��J/7trvL I
I
iCiryo� fu�rn: __ PermiNl.leenu�/__. _. - -- �
hwinr.\Whun�r Icircl�ueel: �
� I. Itw�J u(IIr�ItA t. HuilAlnu D.�p�nmenl J. C�Ir/fown CIer4 !. ftectriul In+pec�or 'S. Plumbin� In�p�etoi
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ACOR�,� , CERTIFICATE OF LIABILITY 1NSURANCE DATE�MMIDD � ,
OS/07 2010
oaooucea �g�8) 745-6464 TNIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONIV AND CONFERS NO RIGHT3 UPON THE CERTIFICATE
Rose Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEN� OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BV THE POLIGES BE�OW.
P.O. Hox 958 �
3alam - MA 01970- INSURERS AFFORDING COVERAGE NAIC#
INSURED � . INSURERA'NBUCl.SUB IAS CO.
Serven Construction Company LLC iNsuaeae�.Guard Znsurance
14 Griffen Terrace INSIIRERC:
INSURER 0: �
L MA OL9OZ— IN5URERE:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW MAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANOING ANY
REQUIREMENT,TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUMEN7 WITH RESPECT TO WHICH THIS CERTIFICATE MAY BEiSSUE�OR MAY PERTAIN, .
THE WSURANGE AFPORDED BY THE POLIGES DESCRIBED HEREIN IS SUBJECT TO ALl THE TERMS, EXGWSIONS AND CONOITIONS OF BUCH POLIqES.
AGGREGATE lIM1T5 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
w5R AOD'L TypE Of iNSURANCE POIICY NI/MBER OATEYMMID�n���AiE MM DUIYY� LIMii$
LTF INSRO
A GENERAIUABILITY NN00'7523 0$�16�2010 03/16/2011 EACHOCCURRENCE 5 500000
X COMMERCIALGENERALLIABILITY PpAEMI3E5�eEoNcwrrence 6 SOOOO
CLAIMS MADE �OGCUR � � � � MEO EXP An one rson 5 5000
PERSONALBF�VINJUftV B 5���0�
� � � � GENERA�AGGftEGATE S 1000000
GEN'LAC�GREGATELIMITAPPLIESPER: PROOUCTS-COMPIOPAGG 9 lO00000
POLICV JECT LOC I I I I NOWND
AUTOMOBIIE LIABIUTY � � � � COMBINED SINC�LE LIMIT
PNY AUTO (E0 BCCitlanp S
AILOWNEDAUT05 � � � � 00�ILVINJURV
SCHE�ULEDAUTOS (Pw���) 5
NIqEOAUTOS � � � � 60DILYINJUNY -
NON-OWNEDAUTOS �P����� 5
� � � � PROPERTYDAMqGE
(Peraa9Cent) 8
GARAGELIABILIN AUTOONLY-EAACCIDENT 9
ANY AUTO � � � � OTHER THAN EA ACC 9
AUTOONLV�. A� g
E%CESSNMBRELUI LIABILITY � � � � EACH CC RRENCE 4
OCCUR � CIAIMS MADE AGGREGATE 6
5
OEDUCTBLE . � � / I 5
RETENTION $ yy� u �ry y
$ WORKERSCOMPENSFTIONAND S&WC131�6� O4�OZ�ZOlO 09/O1/2011 TORYLIAMITS �ER
EMPLOVERS'LIABII,I7Y �
ANVPROPRIETORlPARTNERIEXECUTIVE EL.EACHACCIDENT 5 SO0000
OPFlCERRAEMOEREXCLUDED? � � � � E.LDISEASE-EAEMPLOYEEB IOOOOO
I(yes,tlescribe urqer
SPEGIAIPROVIS10N5below E.L,OISEASE-POUCYLIMIT S $OOOOO
OTHER � � � �
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UESCPoiTON OF OPERATIONS/IOCATONSNEHIQ,ES/E%CLUSIONS AD�EO BV ENOpRSEMENTlSPECIAI PROVISIONS
CERTIFICATE HOLDER CANCELLATION
� �. — ( ) � SHOUID ANY OF THE ABOVE DESCRIBED POLICIE9 BE CANCELIED BEiORE 7HE
E%PIRAi10N DATE THEREOF, iHE ISS�ING INSURER WILL ENDEAVOR TO MAIL
3� DAYS WRITTEN NOTCE TO 7HE GERTIFlCATE HOLOER NAMEC TO THE LEF1',BUT
Mr. 6 Mrs. Jeff Lubas FAI�URE TO 00 SO SNALL IMPOSE NO OBLIGATION OR I.IABILRY OF ANV 1(INO UPON 7HE
Salem, MA OZg�/O ' INSURER,ITSAGENTSORREPRESEMATVES.
AUTHORIZE�REPRESENTATNE -
— ' � �
� ACORD 25(2001/08) m ACORD CORPORATION'1988
INS025�oioe�,os - aaaa t w2
. -.-� UF SALEM
���.,�� CITY
'�`� � PUBLIC PROPRERTY
���I DEPARTMENT
a ..���j
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\I`.���e L'C �'A;IIIXb:��NSCNIIt �5.11I�\I. �1.NiA� I11 :I I 1.'('� '
rF�:��-ea�;:,;�,s . r�r:v�s.�,a��v�
Constructlon Debris DlsposAl Aftiduvit
(rc��uircd 1'ur all dcnwlitiun :mJ rcnuv�tiun wurk)
in accurJm�cc wi�h th� �ixd� �Jition of thc State Duilding CoJe, 780 CMR scetiun I I 1.5
Debris, and the provisiuns uF MGL c 40, S 54;
puilding I'ermit # _ .._ is ixvued with the condition that the dcbris resulting &om
this work shall he dis{wscd ot in a properly licansed waste Jisposal facility as dafined by MGL c
l l 1. S I SUA.
The d�bris will be transported by:
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I'he dcbris will be disposed of in :
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