8 BECKET - BUILDING INSPECTION (2) � Z�(-�• ao
' • • �,�s o Ge��.cr��-160 /
�� _ • _ . — ---
� :1, I he Cumnwn�rr;ihh uf'Massarhuu:its -- _ _ �
��� ° y; i,j� Ilu;ird uF13uiWing K�gulations ;mJ St:mJards CI'I'1't)F
�t��;� ��1;�ssachusetts Siatc Duilding CuJc. 790 CMR ti,�Ll:��i
�L���•' R��iisrJ.Il�u _'�I//
BuilJing Prnnit Applicatiun To ConsinicL Rcpair, Rcnovate Or Dcmulish a
Uri��-urTuu•fiunih Dirrllin,��
This Steiiun Fur OlTciul Ux Onl
liuildiny Pemiit Ninnber. Uate A licd:
_V" I.�c.t4s�noC . � � a,o/n� - t� t
lluildiny UlTici�l�Print N;uncl . i urc I)��� ;
SECTION I:SITE INFORIIIATIOIV
I.I P op ty.1JJ e�e: 1,2 ,1�eeseun��lap� Purcel Numben
Q C �i �
I.IA IS tAl7 011 1CCG ICA Sf�CtIT 't9 no M1lnp Numbur I'orccl Nwnfkr .
I.J ZonlnQ Informetlon: I.J Praperty Dimenelon�:
Z�ming Diytrict I'n�poscJ Usc Lol Arcn Isy It) PronWg¢�1p
I.3 BuIIJinQ SetbAclu(R)
Frunl Y;vd SiJc YurJs
Ncar Y�rd
Rnyuircd I'ruviJcd Reyuircd Provid.d Neyuind PNvi1IC� I
. 1.6 Wwter Supply:�M.G.1.c.aU,§S�) 1,7 Flood Zone Informatlon: 1.8 Sews�e Dlapoeal System;
Puhlic O Pnvotc❑ Z°nr: _ UuLviJn Flood'Lune? Muniei el O On sitn dis �
Chrck il' �cs0 P powl s-sWm ❑
SECTION2: PROPERTYOWNERSHIP�
S.I Owner�qf R9cor , /,�
p cY t/! Gt �U rs �i' / .S 4' �� n—i /�Cq°
N;uno 1 PnnQ C uy.Simc.l.IP �
8 � ec f�e �
Nu.:mJ Stremi fdephune Finail AJdmss
SECTION J: DESCRIPTION OF PROPOSED WORK�(check all thrt apply)
New Construction O Existing Building p Owner-Occupied O Repairs�s) O AltFration�s) ❑ Additiun ❑
Demolition O Accessory Bldg. ❑ NumberoFUnits Other ❑ Speciry:
Oriaf%scrip�ionofPraposed \Vork': /� e � „2 P
� ��r o S
P / i: c ct� roo
SECTION J; 6STI�1IATED CONSTRUCTIO�V COSTS
I��i�� Esiimmed Costs:
I�.lhJf:117A.�I:IICfI0I9) 011lciol Use Only
I. DuilJing S � QO I. Building Permit Fee:f Indicam how f'ee is determineJ:
� '. (ilceirir�l S ❑Siandud CiryiTu�rn App�ication Fee
❑Torol Pro'at Cusl'�hem 6)x multi her _ __x
� 1. I'hunhin6 5 ,. pther Frre: 5 D � - -
� J. \Ic:h.mit,d III1 \('1 S Lish
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tiu,�rtssiunl S f�rt;d ,\IIFc¢S: S - _
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' o. Tul�l Prnject CnsC 5 � ❑p;�iJ in F'ull� ❑Uuisr.mJing Ilul:mcc Duc: ..
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st:c rioN s: � orvsrai�rno� st:Kvu F:s ' , .
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tiF SuliJ I'ual Durning Applianca
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I'cic hunu P.inuil uddre.a
51 RrgletcreJ Ilume Impruv/nm� ent Cuntrnctor.J�(IIIC) (Z�,G 7� ���3
� � �y-q ��i.Q [i/�ry� �y�(C I /Q� IIIC Rcgistr;i�iun Nwnlwr .cpi ;iliun I)we
I II 'C npa}� N.ync or I IIC agi,�J�• u N�nu /
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/Town,Stnte,ZIP Telc hana
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. IS].� 25C(6))
Workers Compensation Insurance oflidevit must be completed and submitted with this applicetion. Failure lo provide
this ufTidavit will resull in the denie�of the Issuance of�he building permit.
I Signed Affidavit Attached7 Yes .........: O No...........O
SECTIOIV 7�:OWNER AUTHORIZATION TO BE C0111PLETED�VHEN
OWNER'S ACENT ORCONTRACTOR APPLIES FOR BUILDIIVC PERMIT
I,ae Owner of the subject property,hcreby autharize
to act on my behnlf,in all matten relative to work euthorited by this building permit applicaUon.
Pnnt U�wcr'�Nwne(Elcctrunic lign�wrc) D�IC
SECTION 7b:OWNER�OR AUTf10RIZED AGENT DECLAILITION
By entering iny naine below, I hereby a�test under the pains and penalties of perjury that ail uf the informntiun
contained in this applicalion is true�nd�ccurote to ihe best of my knowledge and understanding.
I'rini�l��ncr'+ur:\whoriicJ�\gcm's Nxnw Ifittlrunic`ignalum) ��t�
�o�rEs:
I. An Owner��hu obiains a building permit io do his.har uwn wurk,ur an owner who hires an unrcgistercd cumrocror
�iwt registtrcd in ihr Hume Improvemrnt Cuntracwr�HICI Proyraml,�vill no have aaes� w iha arbiinliun
prognm ur guor;mly I'unJ under�I.G.L.c. I a'.1.Uther impon�nt inl'ormation on the HIC Program can be li�und ai
������ n�.i.. ��� ,�� i Infonnaiiun un�he Cunstruction Supervisor License can be found al������ i���•� �:�� ��I^
? N'han subsiamial�wrk is planneJ,pro�iJe�ht inl'umioiiun below:
foi�l Ilour arc�i;y. fl.l . ____.._I ineluding g;vogt, linishad basemenCaUics,Jeeks or purcln
(iruisli�ingare�isy. 11.l --_- - Habilabitroumcuunt __. .__ . . .
_
� ♦umF¢ruFlircpls..s _. -_ _ - \umherol'bcJruunts
_. _ . _ _ _
i \'umhcrafh�thruoms . . _ . . \lunbcrul'halfhadu
I\pa of h¢.uing s�a�.in �'umb.r al'J.cks, pordizs . I
i _
i �\��C��I iJU�llll i�ilClll ��OC�VSd� (1�iC0
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i t, "I���Idl PfojCCt Si�U1fC�'aa1,14C�itla) b¢�uh:�ituicJ Ibr..l',�i;d I'ruj¢ci CusY' i
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,,,;:�°��r • Ct'I�( OE S.1I.E�,[, l�L1SS.ICHL'SETI'S
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�] � ��`�� ' +`� l30 VV.\SHLVGTON ST1tEET, 3�°F1.00(t �
,�4 'i
��ti�"`�"� 'i�L (978) 7�5-9595
F.i�c(979) 7•f0-9846
!���pE(tL.EY DRISC0L1.
�,L{YOR THos�.is Sr.P�axxs
DIAECTOR OF PCBLIC PROPEN7Y/BCII.DfNG CO�L�I155IONER � ,
Wnrkers' Compensation insurance ��fltdavit: Ouildcrs/Contractor9lElectrlcian�/Piumber�
Apii��c:�nt lnfnrmatinn Plcaqe Prtnt LeQibiv
V;Ii11C ll)usiix�.oUrg.tni�atiaroimlividir,d): /1 — I 'G�''�-�111��P � . .
;1�dress: �3� S' CP f � T �� 1��'1 b+� G S �� '�-i Q
City/Statc/Zip: O � Phone K: .`j" ��_`1� / .2 S ��
,\rc y��u an employerY Cheek the eppropriate ba:: 'Pypa ut prnJect(requlreJ):
L Q I am a employnr with ' ;• � � ��gcn�r�l cuntractot and 1 6, �Ncw cuneuuciim �
zmpinycea(full am1/ot pan-time).• hava hircd ihn subcanlnatoo
2.� 1 om a sola proprictor ur p:utnco- listed on iha auached.rheet: 1. ❑RemaJeling .
.hip unJ hava nu cmployeey These subcontractan havo N. �]nentolition
wurking ti�r ma in any capuity, worknn'comp,inewnnce. 9, � Duilding adJition
(No warken:coinp. insurance 5. Q We are a corpom�ion md ib
rcquireJ.� offlcm have exercised their 10.0 Eleetrieal repain or additione
3.� i am a homeuwner duing ail work right of exampliun per MGL 1 I.Q Plumbing repuirs or udJi�iom '
myulf. (\o workera'cump. c. 152,¢I(4),�nJ we have no �2,0 Roof n:poir9
insuranct reyuireJ.J � cmpluyeea. �No worleen' �},Q Olher
cump. in�urance reyuimJ.J
•,4ry applic:un du,.�hceYt baa�I muu nlyu fill uW ih�meliuo below ahowiny ihoir wmken'compenudue puliry infurmmion.
� �I h,mauvncn who.uBmi��hi��HIMvi�indiwinp ihq un doind all�wrk��ihcn hiro uutlide ccnlmctan mm1�uhmil a naw afl!Jaril indiain�.uck
�Gm�mcmn�hal ch�sk�hi�Eux mu+t��Wch.d an aJdiliuruil.hee/ehuwiny iho nwno of the iubaumrulw�and�halt wnrYen'wmp.yuliry infwmmioa.
!uiN un ex�pluyer rhut!r pruvlJlnx ivarkrn'cumprumNun Lieu�unce%r my empluyerx Be(uw/s rG�poflry und/ob xlt�
in�onnu�ian. ..
Insur�ncc Cumpany Vame _....... . .
Pulicy 4 ur Self-inn. Lic. N: __ Hnpiration Date: '
lub Site AdJresy: Ci�ylSt�tr2ip:
.\u�c6 a cnpy u(lhe o�orkerf'compens�tlon pulley declaratlon paK�(�howing iha polley number and espira�lon data).
P�.�iluro w xecum cuver�ga av required undcr Sectian 2JA uCb(GL c. I S2 can InnJ to�he impoai�ian oferiminal penaltias of a
rinc up ta i1,5a0.U0 unJ/ur one-yea�imprivonmen4�y acll�y civil penaltiee in thu fortn uf u STOP WURK URDER anJ u�ina
oFup ro S'_S0.(10�Jay��gainst ihe viulnmr. Ile ndvi.iad�hot�cupy ul ihie s�atcmcnt muy Iw iurwarJud�o ihe OI'licu uf
lin�rsiigaiiuna�ii ihe �I.1 tor insunnce toverage veriti�•alion.
/�lu lrrrrby rrrr� u / int m�J i rlrx u�parjury rhut rAt L�/bnnuNu��pruvidrJ abuvr ir trut aud tunrc4
ii•�� i i ' � . � � I)ata: / /�2
rr�� ;�
.qT�---?��' �j
�� O/)icru!u.rt ouly. D�i nof rvrile irc d�ix��ru.(u ba cunryl[l✓d by rity ui lown n/firioL I
I
iCiry nr'fu�vn: � _ . . __. Pcrmiul.ltcnye.�
� I��uiuK,\u�hurily (circluunc): -- . _.. ._�--- _._--
� I. Ifuurd ul Ilivlih '. Ouildlnq Ucparimcu� .1. Ci�y;fu�vn Clcrk a. El,ctri..�l h�rp.ctur i. Plumbfng Inepectur I
� C. Od�er . __,_ I
� __... _
Cunl�.�cl 1'enun: . PAonc;l: I
I_-- - _ _-'_ ..._ .. ---
I �
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���au-�a���r� �au��l �a���r�c��o�s � •
\tassachuseus General Laws chaptec 152 rcyuices all employcrs to provide wurkers'compensation lor ehtir empluyees.
Pursuane tu�his sta�ute,an einployre is dttined as"...zvery person in�he service uf�no�ur under:iny contrac[of hire,
cspress ur implied,oral ur written."
An rmplayer is detined as"an individual,partnership,association,coryurativn ur ocher leyal entity,ur uiy two or more
u[�he Foregoing engaged in ajoint encerprise,and including che legal representatives oFa deceasad employer,or ihe
racziver or erustne uf an individual,partnarship,associatian or uther lagal entiry,employing employees. However the
uwncr uf a dwclling hou�having not more thun three apartmencs and who resides therein,or the cecupxnt of the
dwelling huuse of anothtr who bmploys persons ro do meintanance,cwsttuction ar repau work on such dwelling houve
or un the grounJx ur building appurtenant�hercro shalt not because of such employmcnt 6e dcemed ro be an cmployer."
�1GL chapter 152, �25C(6)also st�tes ehut"every st�te or local Ilceusing agency shall wilhhold the issunnce or
rcncwal o(a Ilccnae or perm[t to uperatt a businesa or to construct buildln��in the commouwealth for any
applicant who has not produced acceptable evldenca af compll�nce wlth the Insurance coverage requlred."
Additionally, MGL chapter 152, §25C(7)states"Neithet the commonwealth nor any of iu political subdivisionn shall
znter into any cuntract for rhe perfocmance of public woh until acceptable evidence of compliance with the insurance
rcquirementy of ihis cfupter have been presznced to tha conhacting auWurity."
Applicant�
Pleusn fill out the workecs'compensation aFfidavit completely,by checking the boxes that appty to your aituation and,if
nacessazy,supply sub-controctor(s)nume(s),address(es)and phone number(s)along with their certificate(s)of
insurance. [.imited Liability Companiea(LLC)or Limited Liabiliry Parmerships(LLP)wich no employees other than the
mtmbcrs ur pannen,are not required to carry workere'compensatian insurance. iP•rn LLC or LLP daea have
cmpbyees,a policy ia required. Ba advised�hat thia uflidnvit may be submitted to tha Depe�romant of Indusati�l
Accidcnts for confumatian oF insurance coverega. Abo he�ure to ei�n aod date the aCiidavit. ihe affidavit should
he rctumcd to the ciry ur town that the applicatian for the permit or license is bcing requested,not the Departrnent of
(ndusvial Accidene�. Siwuld you have any qunstions rogazding t6e law or if you are required to obtain a workers'
cmnpcnsation palicy,ples�ve call thc Depaztment at[he number listod belaw. Sclf-inaurcd compania should cnter thcir
self•in.surance licensa number an the appropri�te line.
City or'fuwn Ofitclala
Please be sure ehat the affidavit is cumplete and pnnted legibly. The Bepartment has provided a space at the burrom
of�ha aftidavic for you ro fill uut in ehe even�cha Office af investigadons has to wncact you regazding che applicant
Please bn sure to till in�he permiVlicense number which will6e ustd as a refcrence number. In adJitian,an applicant
chat muvt submit multiple pertnidiicense applications in any given yeaz,nzed only submit one atlidavit indicating current
policy information(if necessary)and under"Jub Site Address"tha applicant shauld writn"all tocaduns in (city or
rown)."A copy of the affidavit that has been officially stamped oc marked by tha ciry or town may be provided to the �
opplicunt as proaf that a v�lid�IFJavi�is on tila for Cuture parmita or licenses. A naw affidavit muyt be filled out each
y¢ar. Where a hume owner or citizen is obtaining a license or permit not related ta any busiaess or commercial venture
(i.e.a dog license or permit to bum Icavca ctc.)said pcnon ia YOT reyuircd ro complcte thi9 afRciavit.
The Oitice of Inves[igadu�u would liko lu thank yuu in advance for you[coaperation and should you have any questione,
pltase du not hesitam to giva us a cyll.
I'he Dcpartment'y aJdruss, telephune and i�x numbar:
The Commonwealth of hiassnchusetts
Depaztment of Industrial Accidenb
Offlce of Iavestigallon�
600 Washington Street
Boston, MA 02l I I
Tcl. ;�b 17-727-4900 cxt a06 or 1-877-MASSAFE
., . - ,
Fax N 617-727-7749
;t�;:.;�d,-_e-as svww.mass.gov/dia
.
--:,
, C��r oF 5.�,�[, �1,L�ss.�cHt,'sErrs
` Ol'��G DEP.1RTtF.`t
I_'O W.1.iHCVGTON S1aF8T. 3iO FLOOIt
h+t. �97� 7�S-9S93
KlJ�ERLfiY DRI3COCL F.V�(9�� 1aQ.98d6
,tiUYOR I}{O.tW SLPtEiu �
D IftECTOR OP PC 8L1C PROPBRTY/8C RD4YC G0101fS3(O.V E!{
Con9tructton Debr1� Dl�posal Afttdavlt
(requircd for all demolitton and renovation work)
In sccardanca wiih the sixth editfon otthe Stata Building Cade, 780 CMR section I l 1.S
Debri�, �d �e p�y���oy of MCL a 40, 9 J4;
Building p����p i� is���d W�� ya condJtion that the dcbria rciulting fiom
ihi� wurk ahal) be diaposcd of in a properly licenud wn�te dl�poaal faciliry aa dc8ncd by MCL c
111, S I JOA.
Tha debd� will be tranepan�d by:
_�_ �c r�� f ! R r�Q S��
(eama uf Aaular)
The debri� will ba disposed of in :
(��e o�w�ljy� .'�'--
l�ddre�i oYf�,d�iY)
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��M CERTIFICATE OF LIABILITY INSURANCE °^'E'M"",°°,�.,.,,,
�, PRODUCER
a THIS CERTIFICATE IS ISSUED AS A MATTER OF INfORMATION
MathiaS InSUrdilc0 Agency� Ii1C . ONLY AND CONFERS NO RIGHTS UPON THE CEqTIPICATE
200 SIIttOII Street, Su.lt2 160 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
� North Andover, MA 01845 ALTER THE COVERqGE AFFORDED BY THE POLICIES BELOW.
978-688-5531
INSURED INSURERS AFFORDING COVERAGE NAIC#
Rolf Franke Otten '"suRER^: Safet insurance com an
34 St. Anthon ' iNsuaeae:
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Gloucester, MA 01930
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'ERTIFICATE HOLDER
CANCELLATION
� - SHOULO ANY OF THE A80VE DESCPIBEO POUCIES BE CANCELLED BEFORE THE EXPIRATION
City Of Salem - Town H3L1 DATE THEREOF, THE ISSUING INSUREq WILL ENDEAVOR TO MAILZO DAYS WRITTEN
� 93 Washington Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFf,BUT FAIWRE TO 00 50 SHALL
Salem, MA 01970-3528 IMPOSE NO OBLIGATION9R LIABILITV OF ANV KINO UPON THE INSUFER, ITS AGENTS OR
. REPR�9ENTATI, S. �
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Attn: Building Inspector nurHoa�zeoa /a� s r .n,E� _�r
:ORD25(2001/08) � v/ "' -- l��
� �OACOqD CORPORATION 1988
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PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MathidS IpSUrdnCe Agency� Inc ONLY AND CONFER3 NO RIGHTS UPON THE CERTIFICATE
200 Sutton �Street Suite 160 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
� ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
North Andover, MA 01845
978-688-5531 INSURERS AFFORDING COVERAGE NAIC#
iNsuaeo
INSUFERA: SdEet Insurance com an
Rolf Franke Otten INSURERB:
34 St. Anthony's Lane INSURERC:
� Gloucester, MA 01930 INSURER��
INSURER E:
COVERAGES
iHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOfl THE POLICV PERIOD INDICATED.NOTW ITHSTANDING
ANY REQUIREMENT, TEFiM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI9 CERTIFICATE MAY-BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDEO BY THE POLICIE3 DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
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I DATE THEREOF, THE ISSUIN�INSURER WILL ENDEAVOR TO MAILZO OAVS WRITTEN
i City Of Salem - Town Hall
93 Washington StL'09t NOTICE TO THE CERTIFICATE HOIDER NAMED TO TME LEFf.BUT PAILURE TO DO SO SHALL
Salem, MA 01970-3528 IMPOSE NO OBLIOATION R LI 14TV OF ANY qND UPON THE INSURER, ITS AGENTS OR
IPEPR NTATI 9
� AUTH RIZED R T �
� Attn: Building Inspector
� ACORD25(2001/08)
�ACORD CORPORATION 1988
I CERTIFICATE OF LIABILITY INSURANCE
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PAO�UCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Mathias Insurance Aqency, Inc ONLY AND CONPERS NO RIGHTS �UPON 7HE CERTIFICATE
200 SpttO��Street, Sult9 160 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE APFORDED BY THE POLICIES BELOW.
North Andover, MA 01845
978-68$-5531 INSURERS AFFORDING COVERAGE
INSUREO � NAICJI
INSUFERA' Sd{et Insuraace com an
Rolf Franke Otten INSUREFB:
34 St. Anthony's Lane INSURERC:
CalOUCB3tB='� Z.�,q 01930 INSURERO�
COVERAGES INSVl7ER E:
7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NOTNITHSTANDING
ANY qEOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY-BE ISSUED OR
MAY PERTAIN,7HE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU&IECT TO ALL THE TERMS,EXCLUSIONS ANO CONDITIONS OF SUCH
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I CERTIFICATE HOLDER �
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� SHOUID PNV OF THE ABOVE OESCRIBED POUCIES BE CANCELLED BEFORE THE IXPIRATION
City Of Salem - Town Hall DATE TMEREOF,THE ISSUING INSUPER WILL ENDEAVOR TO MAll2O OAYS WqITTEN
' 93 Washington Street NOTICETOTHECERTIFICATEHOLDERNAMEDTOTHELEFT,BUTFNLURETODOSOSHALL
Salem, Mp 01970-3528 IMPoSE NO OBLI(3ATION R LI Il1TV OF ANY NIND UPON TNE INSUREH.ITS AGENTS OR
REPR NTATI 5.
Attn: 8uilding Inspector AurH aizeoa T
ACORD 25(2007/08)
mACORD CORPORATION 1988