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111 BROADWAY ST - BPA-14-1941 The Commonwealth ofMassaclN6RECTIONAL SERVIC �� Board of Building Regulations and Standards SAL O Massachusetts State Building Code, 718f� UCL 1 8 P 0 5 evised,tlar 201 `�— Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Only I Building Permit Number: I Date.A lied r Building Otticial(Print Name). Signature _ Date SECTION 1:SITE INFORMATION' t 1.1 Property Address: 1.2 Assessors Map di Parcel Numbers �n h/P I 2jaol .iG�l� ��' �L I.I a Is this an acce ted street?yes no M1tap Nwnber Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: _ "Coning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(It) Front Y - Side Yards Rear Yana O,ard Provided Required Provided Required Provided M.G.L c.d0,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal On site disposal systum ❑❑ Check if es❑ SECTION2: PROPERTY OWNERSHIP!` 2.1 Ownerr of Record: ►tfv�vE+r/ M, wy �Ge.-r �� i97o NN me(Print) City.State,ZIP III L)I&OA(YA,,�14y s� 975?-7ZtS-LJ21f No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Altemtion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Cl Specify: Brief Description of Proposed Work': ( t , ' t? r r F AK-,, SECTION J: ESTIMATED CONSTRUCTION COSTS "C3 Estimated Costs: Official Use Only Labor and Materials) ng S Q c9Oc�.C7 I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee cal S 6 00 . U ❑Total Project Cost}(Item 6)x multiplier x ing $ D.C7Q ,QtherFees: S nical (hIVAC) S List: nical (Fire i Total All Fees:Son) Check No. Check Amount: Cash Amount: Project G S ❑ Paid in Full ❑Outstanding balance Due: S gi � SECTION5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Cs —V-3 191k 0-C,!_2(o 1f1%I�HEN Pl _ MlrGS License Number Expiration Date Name of CSL Holder IN List CSL'rype(see below) U ALI/ SY Type Description No. and Street U Unrcslricted Ouildin s tip to 35,W0 cu. Il. SAC,6i--, !� �) I7 f 9 7U R Restricted l&2 F:unil Dwellin Oty/rown,State,ZIP Ibl Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) f — .✓ HIC Registration Number Expiration Date I C Cum any Name or HIC Registrant Name ox47 .y©2tN 5i CV ,. Y~&l�ax.7lL7n., No. and Street Email address Sf�4 r„, IA 921- 21eti 4) Cityrrown.State ZIP 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........... O SECTION 70:OWNER AUTHORIZATION TO BE COMPLETED W HEN.= ' OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERIMIT' 1,as Owner of the subject property,hereby authorize LIH2 t— tom C>d �e t9 act on my behalf,in all matters relative to work authorized by this building permit application. PrintOwner's Narne ettronic Signature) _ Date SECTION 7brOWNERt OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contain ed in this application is true and accurate to the best of my knowledge and understanding. . Print or Authorized Agent'sc(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program),will got have access to the arbitration program or guaranty fund under I.G.L.c. I42A.Other important information on the HIC Program can be found at �eww mass eov.'oca Information on the Construction Supervisor License can be found at wwvv.mass.�ov!dns _ 2. When substantial work is planned,provide the information below: 'total floor area(sq. R.) (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 'rypeofcoolingSystem Enclosed Open_ 3. `Total Prujcct Square Footage" may be snbstitutcd Rtr"'rut:d Project Cost" Massachusetts -Department of Public Safety Board of Building Regulations and Standards Constructs it $upun'iior License CSO83956 Stephen D Commi. is r� 241 North Street � I§ ... Salem MA 01970% Expiration Commissioner 10/01/2016 . ..,:a5lerGo�xrna�nc�rll�o� .. ate of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Type: is ration- '140576 piration. 102712015 - DBA CUMMINGS CONSTRUCTION STEPHEN CUMMINGS 244 NORTH ST SALEM,MA 01970 Undersecretary ;T Q-I•Y OF S:U ENI, 21L-1SS.ICHUSETI-S 4 BUILDING DEPARTMENT 120 WASHLNGTON STREET, 3'a FLOOR mod. TEL (978) 745-9595 FA.r(978) 740-9846 KI\IBERLHY DRISCOLL THOhtAS ST.PIFM9 ",�L-%YOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CO.\LNI3RSIONER Workers' Compensation Insurance Affidavit: Builders/Cont rue tors/Electricians/Plurn bar$ Anolicant Information n Please Print Leeibly V;1111C 113usimss.Organimlinm•Individual): �C'!"7YNywJI�S C ,C9N S��1_J C.�� Address: A ., Cb)CO" S� City/State/Zip: .#9Cdf---r n)Q C3/970 Phone N: 9 7,F- 9 p A re you an employer!Check the appropriate boa: 'type of project(required): am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction entplayees(full and/or part-time).• have hind the sub-contractorstam a sole proprietor or punner- listed on the attached sheet. t �• Remodeling :hip and have no employees These sub-contractors have 8. I3emolition working far me in any capacity. workers'camp.insurance. 9• Building addition No workers'coat insurance - 5. ❑ We are a corporation and its l P• 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.(No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.) t employees. (No workers' 13.❑Other cutup. insurance mquircd.J •Ant.fri oat gut ducks but d 1 must ilia full out the suction below showing their wodm'campenaadan Pulky iuLmnmlon. 'I h.muuwners who oubmit this amdwit indicating they am doing all work and then him outside cunoaeton must submit a rrosv amdavit indicting such C�umacwn that ih vk this box must attached an additiurul shot showing the nwne of the subaontnctun and their workem'camp.policy inronmatiun. /one un employer that 4 proviJlnK workers'cuntpeararlun lnsuruace jot my crap/uyers. Lfeluw is fhs poflcy turd Jub rile inn/urnratian. Insurance Company Name: _.---- Policy 4 or Self-inn. Lic. d:IAJ•l. 00-(mil ZT,.2CJ/c-//+ Expiration lob Site Address: /I/ 11if roq t'�o FVP=PY S A. City/Stain/Zip: 0 r9>0 Anach a copy of the workers'compensailoo pulley declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of,LIGL c. 132 can lead to the imposition afcriminal penalties of a line up to SI•-500.00 under one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a line Of up rn SM.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the 011ice of In vcstiguiions of the MA fur insurance cnvcmge verification. - l du hereby certify under Nat puhor cud penal(/ex u/perjury that floe btfurnrurluu provided ubuae is true and c•orrrcY Si••n I Dom: f)J/trio!use anfy. Ou not r✓rite in this area, tube cuunplefed by city ur town n/Jleiat. Citvnrfuwn: PcrmitR.lcemcp_--------- .._ Issuing Authority(circle one): 1. 13oard of ileallh 2. Iluildinq Depa,iment 1.coy/ruwn Clerk J. F.leetriul 3uspcctur 5. Plnntbing inspector b. Other ( unWd 1'crvrn: Phone :r: I ACORD CERTIFICATE OF LIABILITY INSURANCE 1DATE 2/1M/DD/ 1 12/15/2O14014 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 INSURERA;ESSEX INSURANCE COMPANY Cummings Construction Inc INSURER B:AIM 241 North Street INSURER C; 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 POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ID' POLICY EFFECTIVE POLICY EXPIRATION L SI NSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDIYY) DATE(MM/DDIM LIMITS A GENERAL LIABILRY 3DS1B10 11/21/2014 11/21/2015 EACHOCCURRENCE 9 1000000 X COMMERCIALGENERALLIABIL11Y I DAMAGE TO RENTED SOOOO PREMISES Ea nxurrence 5 CLAIMS MADE O OCCUR { { { { MOD EXP( Pne on) 5 5000 PERSONAL S ADV INJURY 5 1000000 { { { { GENERAL AGGREGATE a 2000000 GEN.L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 1000000 X1 POLICYF-1 PR - LOG AUTOMOBILE LIABILITY { { { { COMBINED SINGLE LIMN ANY AUTO (Ea accident) 5 ALL OWNED AUTOS { { -{ { BODILY INJURY SCHEDULEDAUICS (Per Person) HIRED AUTOS { / { { BODILY INJURY NON-OWNEDAUTOS (Per accdent) e PROPERTY DAMAGE (Per accidarY) 9 GARAGE LIABILITY PAUTOONLY'- ONLYACCIDENT $ ANY AUTO { { { { EA 6 AGG s EXCESSNMBRELLA LIABILITY { { { { NCE 5 OCCUR CLAIMS MADE 5 5 DEDUCTIBLE RETENTION S WWCC 5 B WORMERS COMPENSATION AND WC100-6018868-2014A D6/19/2014 06/19/2015 X TORYu NM s ER EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERrEXECl-ffNE E.L.EACHACCIDENT $ 100000 OFFICEMMEMBER EXCLUDED? { { / { EL.013EASE-EA EMPLOYEE s 100000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-PouGY LIMIT J 500000 OTHER DESCRIPRON OF OPERATONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD` 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 Town of Danvers FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS OR REPRESENTATIVES. AUTHORIZEDR TIVE Salem MA 01970- C ACORD 25(2001/08) __ ® D CORPORATION 1988 INS025(wom DE Page I a z CITY OF SALEM, MASSACHUSEM aB UILDING DEPARTMENT 120 WASHINGTONSTREET,3ADFLOOR " TEL.(978) 745-9595 KIMBBRLEYDRIS FAX(978)740-9846' �LI. MAYOR THOMAS STYmRRE DIRECTOR OF PUBLICPROPERTY/BUILDING CONSUSSIONER Construction-Debris Disposal Affidavit (required for all demolition and renovation work) . In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, S 54; Building Permit# 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 MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: f3 r s (name of facility) (address of facility) Si ature of applica Date