2-4 BECKFORD ST - BUILDING INSPECTION The Commonwealth ofMassachusett� E� AXL' �.
n W
OF
Board of Building Regulations and Sfaiitt rr s CITY M
�_`t Massachusetts State Building Code, 780 CMR ,L 1 �,t �j a SAMar
V6 ��pp���� A Rev�sedMar2011
Building Permit Application To Construct,Repair,Rendddfe r Demolish a
' One-or Two-Family Dwelling
n This Section For Official Use Co
Building Permit Number: Date A ied`.
1
Building'Official(PPrum3t Rame) Signature. '- Date ...
SECTION 1:SITE)1�1FORi13ATTON
1.1 Property ddress: 1.2 Assessors Map&Parcel Numbers
11 a 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 R) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yazd
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 OWNARSII 1"
2.1 Owner'of Record:
rVXX S_lf(407A ut/�
Name(Pont) City,Suite,ZIP
-07
No.and Str6et Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(Check all that apply)
New Construction❑TExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ ` Indicate how fee is determined:
2.Electrical $ / ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire r $ Total All Fees:$
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
u
SECTIONS: CONSTRUCTION SERVICES
5.1 Con cfion Supery tsorUcense(CSL) c 5—c�1�l 7 I
License Number 7�7 E ti nD e
Name of Pl,Holder
/� Lis[CSL Type(see below)
No.and Street
t-- �t �T ;Type - Description,
City/I'o_w�n,31�e,ZIP ^f U Unrestricted(Buildingsu to 000 c .ft.
&2 Family Dwelling
Masonry
RC I Routing Covering
S WS window and Siding
1 Solid Fuel Burning Appliances I Insulation
Telephone Email address D Demolition
5.2 Re istered Home Improvement Contractor(HIC) 1 S
0<,k1 U-C HIC Refgistration Number Mplratioik
HIC C pany Name or C Registrant Name
2 r �r 7u� 5� JJ�� St/Ga co e)
No.and�SM Email address
CCi—/�1 own\\ thaatte ZIP Te
SECTION 6:WORKERS°COMPENSATION INSI R NCE AFTMAVIT(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 lac OWNER AI7THORIZATION TO BE COMPLETER WHEN
OWNER'S AGENT R CONTRACTOR AP ]FOR fIUUDING`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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b OWNER` OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the inforiliation
con Id/in this
1appl�icatioonn is true and accurate to the best of my knowledge and understanding.
, /—,�c
Print Owner' or u gent's Name(Electronic Signature) ate
NOTES:
1. An Owner who obtains 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 can be found at
alvw.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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"
The Commonwealth ofDfassaehusetts
Deparbisent oflnduslrialAccidents
I Congress Street,Suite 100
Boston,MA 02114--2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contrastors/Electricians/Plumbers.
TO BE FH ED WITH THE PERM MG AUTHORITY.
A licant Information Please Print Le 'b
ly
Name(Business/OrgmrizationQndividual): ."14 ( ��� 6
0(4
.. Address: J �` i � V
City/State/Zip: � ��/� Phone M S
Are you an employer?Check the appropriate box:
UV
1 I am a employer with / `/ employees(fill and/or ). T9Pe°f Project(required).
T 7. ❑New construction
2. 1 am a sole proprietor or partnership and have no employees working form m
any capacity [No workers'"comp instance required.] 8. Remodeling
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
4.❑1 am a homeowner and mL be hiring contractors to camdua all work on my property, 1 will 10 Q Building addition
emme that all contractors either bare workers•enmpemstion insmmtw or are sole I].Q Electrical repairs or additions
pn*—Wn with no employees.
12.0 Plumbing repairs or additions
5.❑I am a general contractor and I lave hired the subcom m mrs listed on the attached shwL
These sub-contractors have employees and have workers•comp.his mantx.t 13.❑Roof repairs
6.�We are a corporation and its officers have exercised their risk of exemption per MGL c. 14.Q Other
15Z PDX and we have no employees.INo workers'comp.mummice rrquked.]
-Any applicant that checks box#1 most also fill am the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and than hire outside convect=must submit a new affidavit indicating such.
k0aftam"that check this box mutt attached an additional sheet showing the name of the sub-com m mis and state whets or not those entities have
employees. Ifthe sub contractos have employees,they must provide ten wmium,comp,policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is thepoliey andjob site
information. e
Insurance Company Name:
Policy#or Self-ins.Lic.# Expiration Date:
Job Site Address: , -V 9tito (ki<,_A1� City/��p.
Attach a copy of the wor rs'compensation policy declaration page(showing the policy number an e>cpirattlon date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 pains and penakfes ofperjury that the information provided above is true And Abirrect.
S, ate:
Phone M
Orici it use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written." -An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for-confirmation of insurance coverage. Also be sure to sign and date the aMdavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate lime.
City or Town Officials
Please be sure that the affidavit is complete 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 applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
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 bum leaves etc.)said person is NOT required to complete this affidavit
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02 1 14-20 1 7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Q l Y OF SALM MASSAaiME M
BULDnaGDsreaMrr
s>a�rl?rD>srsmu
FArjM)7Va9W
MAYCR 71raWssSTAEM
DnuacrretcFptzuc Em/BumDmaammmcm
Construction Debris DisposaiAfdavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CAR, Section 111.5 Debris,
and the provisions of AGL coo, S 54; Building Permit B is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by AGL c 111,S 15oA.
The debris will be transported by.
'T
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
ate
Salem Historical Commission
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970
(978)619-5685 FAX(978)740.0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction U Alteration.
❑ Demolition ❑ Painting
❑ Signage ✓ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire District
Address of Property: a u ck[Qrd Street
Name of Record Owner: Essex Beckfbrd Condos
Description of Work Proposed:
Repaint exterior with existing colors: Benjamin Moore Philipsburg Blue and Lancaster Whitewash
Replace wood shiplap siding on Essex Street elevation and rotted trim on Beckford Street elevation.
There will be no changes to the color, material, design, location or outward appearance of the house.
Non-applicable due to being in-kind replacement.
Dated: April 4. 2016 SALEM HISTORICAL COMMISSION
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
Once completed,please submit a photograph(s) of the final result (maximum of four- i.e. one photograph of
each affected fafade).
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
Essex-Beckford Condominum
346 Essex Street and 2-4 Beckford Street, Salem
April 30, 2016
To Whom it May Concern:
As a 4-unit condominium association the owners are in agreement to have Preserve Services
replace & paint front clapboards and replace front and side crown molding.
We have obtained the required Certificate of Non-Applicability for the historic district.
Pamela McKee, Association Representative
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-093403
Construction Supervisor
sxw ,
SEAN OCONNOR
26 CHESTNUT
ST '
SALEM MA 01970
_JZnA \�_ Expiration:
Commissioner 12/3112017
of consumerAffhirs
` �.JOMWriteE IMPROVEMENT &Business Regulation
�Registratlom 553 CONTRACTOR
Expiration: 3/6/2017 Type:
Preserve painting DBA
Sean O'Connor
203 WASHINGTON ST.#256
SALEM. MA 01970 m
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Undersecretaryy
ACORD,, CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD)YYYY)
05/24/2016
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 958
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A WESTERN WORLD INSURANCE C
Byron Inc. dba Preserve services INSURER B:Hartford
203 Washington Street #256 INSURER c:Travelers
INSURER D:Great American
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.NOTMTHSTANDING 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.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AOUL POLICY EFFECTIVE-0 CYEXRRATION
LTR INSRO TYPE OF INSURANCE POLICY NUMBER DATEWNUD IW) DATEUdMIOOIYY) LIMITS
A GENERAL LIABILITY NPP8236095 05/22/2016 05/22/2017 EACHOCCURRENCE s 1000000
X COMMERCIALGENERAL LIABILITY DAMAGE TOR WEED 100000
PREMISES Ea umurnrn $
CLAIMS MADE ❑OCCUR f / / / MED E>rP(Any one penuY,j $ 5000
PERSONAL S ADV INJURY $ 1000000
GENERAL AGGREGATE $ 2000000
GEW.AGGREGATEpLRIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S 2000000
X PoUCY JEGT LOG / / / /
C AUTOMOBILE LIABILITY 46BCS5787 06/05/2015 06/05/2016 COMBINED SINGLE LIMIT
ANY AUTO (Ea 3cciden0 $ 1000000
ALL OWNED AUTOS / / / / BODILY INJURY
SCHEOULEDAUTOS (Par Fe.) S
X HIRED AUTOS / / / / BODILY INJURY
X NCN-OWNEO AUTOS (Per amident) S
PROPERTY DAMAGE
(Per amiden0
GARAGE LIABILITY
AUTO ONLY-EA ACCIDENT 5
ANY AUTO f / f / OTHER THAN EA ACC 5
AUTO ONLY: AGG s
D RESSIumBRELLA LIABILITY ZBS0040350 06/01/2015 06/01/2016 EACH OCCURRENCE _ $ 2000000
OCCUR a CLAIMS MADE AGGREGATE s 2000000
S
DEDUCTIBLE
RETENTION S
F
B WORKERS COMPENSATION AND 6S6OUB0523NO0916 05/20/2016 05/20/2017 X I TORSTAIUS OER
EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE EL EACHACCIDENr S 500000
OFFICER/MEMBER EXCLUDED?
It yes,desalbe under / f / / EL.DISEASE-EA EMPLOYE $ 500000
SPECIALPROVISIONSI, be EL DISEASE-POLICY LIMIT 5 500000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSVEHICLES[EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
City of Somerville FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UASIDTY OF ANY KIND UPON THE
INSURER,ITS AGENTS OR REPRESENTATIVES.
AUT ORIZE�EP ESENTATME
ACORD 25(2001/08) 4D ACORD CORPORATION 1988
1UCAD6 n„ne,