3 BARNES CIR - BPA-10-758 DECK !ILI The Commonwealth of Massachusetts
Board of Building Regulations and Standards OF SALEM
CITY
- Massachusetts State Building Code,780 CMR,T"edition RevvisedJanuary
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Ntunb :�J Date Applied:
signature::�. �pohb:
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
3 F3,. eS C,k /,49
1.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? Municipal❑ On site disposal system ❑
Check if yes❑
F SECTION 2:".PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Si4Etl E ( P• /IFN6IICD 3 5A►2gtr, ( IApzL1=, Q1.ey% mA oKl-7o
Name(Print) Address for Service:
g-78— -7q4--7619
Sigpature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) W1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
COS 4VC "-IV izlr to Qg;clz /v, /,h LAAo
/�n•f� S rs �S'
.SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ ao 1. Building Permit Fee:$ `Indicate how fee is determined:>
2.Electrical $ ❑Standard City/Town Application Fee
`❑Total Project Cose(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: $ �ppp , ❑Paid in Full ❑Outstanding Balance DueIle -IT e
yv
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) l
6�Z License Niuriber Expiration Date
Name of CSL-Holder 5d1✓�'1
9 m 4zi i5 e)1, JP� List CSL Type(see below)
7 t a20u
Add Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Signature M Masonry Only
L 37 RC Residential Roofing Covering
TelepTelep one WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 R red Home Improveme Contractor(HIC)o� // �L A�'ln HIC Company Name or HIC Registmnt Name Registration Number
Address
�� 4'7(( 7Wrg-�Y7 Expiration Date
Signature C 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— 120(3C-r/T 1449t A eCE�, to act on my behalf,in all matters
relative to work authorized by this building permit application.
4/z-i /2010
Signature of Owner Date
SECTION 7b:OWNER';OR AUTHORIZED AGENT DECLARATION
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
behal �n
Q V k3
Print N
afore o Owner or A 'zed Age Date
Si ad under the ains 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(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I10.R5,respectively.
2. 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 S.U.E.`I, NLXSS.XCHUSEM
3LMDLNG Dfl.\RMLNT
1_O W.%smI NGTON STT1i11k'T. 1's FLOOR
TM. (978)743.9595
FAX(978) 740-96"
KIN®EIUEY ORISCOLL T)tphW ST.PIERRS
4{AY01L E)IRECTOROf 111.BLIC ROPERTY/KI DLNGCOMIISSIONER
Workers' Compensation Insurance AlMdevih guilders/ContractorslElectrlelonslPLumben
-%nolleant Informallas ^ n Please Print Legibly
VarnaltluameuOrynrranenlnr6vdu11' �/LIJa�// /�/. Mi/0/`�r��
City/Stste/Iip min lr.v, lJ/ �,a� Phone N
Are you as emplayer!Check the appropriate bast Type of Prefect(requkea
I.0 1 am a cmploym with 4. Cl 1 am a animal costriss r ad 1 6 0 Now consiffuction
employees(Adl and/or put-time).• have hired the atb.cowrssws
2.01 am a sale pmprieta ar partner. listed on tho attached shod I Y• ❑Renadelins
.hip and have no employees Then sub•commeewe hew L 0 Demolition
%working fa ono in any capacity. workers'comp inaaasoa 9. 0 Building addition
1 No warksrs'comp in$Ur&Ma !. 0 We am a corpwnsiw and is
nquiral.) .
ookes haw eranekud their I0.0 Electrical repsire or addition'
).0 1 am a honwownm doing all want rids of eaamplioa par MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp C. 132.f 1(4).aM we have no 12.0 Roar Mint"
insurance requised.1 t ampbycaa.LNGwakma' I).❑Other
comp insurance required.]
•Aay appawd iti'isms bur e1 aura air.on wit uo atariw/der ADWias twit wvkee'cmgndwn policy insarnnW
't 6wruwss who sub"eib.AldeY indicating te.y aw doiq all wnk gel Ase Mon ou"costumes wow vAnk a row d&.a insbriaq;aaak
<'..nr.irn flat climb rYa two~aawtad as adetivai l Astor/abewiq do row ores"boonreraen oM rhdr warbao'G0096 policy idb"Nown.
l ow as ewPkyer tharlr powieNesR workers'cowpatassdra ltuerowce jN at f eay/oyars sinew iL di pN4T tee/Ill!sfrr
injorarorlaa
In.urance Company Name:
Policy M or Self•ins.Lis.M: Expiration Ditto:
Job Site Addnas: City/Statst/Zip:
Attach a copy a<The workers'compeustles policy dochrollee page(skewing the polky numbas and inspired"dab)6
Puilurs to%exits coverage a required under SalIm 23A of%IGL c. 152 can lead to the imposition of miminall penalties of
fne up to S1,300.00 and/or one-year imprisonment.as well as civil penalties in the fare of a STOP WORK ORDER aM a floe
of up to S270.00 a day atlainsl the violator. Ile adviwvP that a copy of this stalemem maybe forwarded to the OIYlca of
I nrcau ymiuns of iIts MA for insurancs covcrap vaitUatwe.
/do hereby certify uq/ tors a / w t/rs ojporJary'Am$As injorwatlow provided uAaw it I and cw►ocs
�7 G
O/flciJ use ardyc Oo row write in this afro,to be,urnpietd 61 city of tewa allk a l
City or ruwn: _ Permif/I.IcenseM__.
Retain'.\uthsnty(tircle nne1:
1. Huard ut lirallh 1. Nuddtny Dcparlmunt 1. City/rows Clerk il. Electrical Imiacctor S. I'lumbing Inapeetar
6. I)Ihcr _
i L..nlactPcraon: _ _ _.. Phone is:
CITY OF SALEM
PUBLIC PROPRERTY
�• DEPARTMENT
,Itlli MI I1 ' MIa.NI
I'C \+I IL\L;,?`r 51'M krT )•111\I.St.\+i.11 I11 J 1.+:1'r
I'rr:v/11•743-9395 •F.\s:7747�J'rM16
,
Construction Debris Disposal Affidavit
(required I•ur all demolition mid rtrrtovaliun work)
In accordance with the sixth edition of tho State Building Code, 750 CMR section 111.5
Debris, and the provisions of MGL c 40,S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I1I. S 150A.
The debris will be transportccd by:
(///�i�E%'� �!//mill/�'z�
piatna u'hauler)
The debris will be disposed,of in
(n:une ut acl It� •
I;Iddms-if fwihty)
.Igna e'of hermit�pplicaM
late
S� 07 ..
L Map Index Outline I
0
oo s
Lot Number
12-0123
\ 032�g�9
s � � 03; � �^� 5500 . Land Area
��
03; d Frontage Dimension
�y 03- �i j 50
03'�Qtl O y" 155 f Street Address
r1f�7 03;
ao' 03i0000
y
y � O 5 �0
03i�Bd.. 03e98
0 j989a
3B9W a yy
DATASOURCE
O'zao 4 03 jQA34 j Parcel&Easement Data:
03 ^y Citywide automation by Camp Dresser
&McKee, 1999
1Q f
038 ^y 03 ��35 Subsequent parcel and building updates
completed by Applied Geographics&
yti / SalemGIS, 2003
i
0369 �45 A/ 0 6 99 <03 �03
� y � Town Boundary:
0 e / MassGIS 1:25,000
CD
R
ff11 R 29� '
r,
03; 8 2a. ...__ l O fTi9tG1 �?•;� i Q 1.9 � t ...
18 28 37 45A
zs fray/° Q ,
17 27 36 42 . 44 '
03- 7 �
i 6 26 35 41 43 '
03i��2 ; �zo
00-ff 03r89j �a ]0 15 25 34 40
A ORD CERTIFICATE OF LIABILITY INSURANCE OF ID KC DATE(MM/DD/YYYY)
CHARROI 1 04 29 10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Kilgore Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
5 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Peabody MA 01960
Phone: 978-531-6550 Fax:978-531-9442 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Commerce Insurance Company 40274
INSURER B:
Robert R. Charland INSURER C:
79 Marlborough Road INSURER D:
Salem MA 01970
INSURER E:
COVERAGES
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
$PPOLLIICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INTR O TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
DATE MFFE DATE MMIIRATI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $300000
A 7{ COMMERCIAL GENERAL LIABILITY VN6096 05/08/09 05/08/10 PREAMSEs�aoccwence $ 100000
CLAIMS MADEIOCCUR MED EXP(Any one person) $5000
POLICY RENEWS 05/08/10 05/08/11 PERSONAL BADVINJURY $300000
GENERAL AGGREGATE I $ 600000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG I $ 600000
POLICY 7 jEO n LOC
AUTOMOBILE LIABILITY
COMBINEDSINGLE LIMIT $
ANY AUTO (Ea acadent)dent)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON OWNED AUTOS (Perac dent) $
PROPERTY DAMAGE $
(Per ac dent)
GAR AGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGO $
EXCESSfUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND W STATU- I OTH-
EMPLOYERSLIABILITY TORY LIMITS ER
ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
E.L.DISEASE-EA EMPLOYE $
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Carpentry
CERTIFICATE HOLDER CANCELLATION
COSALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
City of Salem NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
Salem, MA 01970 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESEN IVES.
AUTHORI D R PRESEENNNTTATIVE
V
ACORD 25(2001108) ORD CORPORATION 1988
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