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112 BROADWAY - BPA-2009-620
oThe Commonwealth of Massachusetts Town of Board of Building Regulations and Standards I Massachusetts State Building Code, 780 CMR, 7ib edition Building Dept Building Permit Application To Consplet—. Repair—, Renovate Or Demolish a � One- or Ttr eFanuly Dive ling This ction For Off iat Us Only Building Permit Number Da pli 7 Signature: - Building Commissioner/Ins for o uildings ate SEC ION 1: SITE ORMATION 1.1 P!e dress:p 5� 1.2 Assessors Map& Parcel Numbers CeU Ma Number Parcel Number I.1a Is this an accepted street?yes_ no . P 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq II) Frontage(II) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L C.40,9341 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' / 2.1 2_ 7er'of corfd/ 11adG!/oGi Name Pint) ter— Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials how fee is determined: I. Building S ( 5� 1 Building Permit Fee: S Indicate ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees: S suppression) Check No. Check Amount: Cash Amount: 6. Total Project Cost: S 0paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Su ervisor(CSL) /�(y�}�prytCs�'$Ppl7 License Number L Expi aeon ate N;)meCSL-. Id 7- /4jr4/J, 16 Addre List CSL Type(sec below) / `'!` T Description 01 q,60 U Unrestricted(up to 35,000 Cu. Ft.) Signatures R Restricted I&2 Family Dwellin aq 5 � 2n 3 {( M Mason Only Z rJ RC Residential RoofingCovering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Regist red Home 1 rov en t Contractor(HIC) ril [9 HIC Company Name or HIC Registrant Name Ristratior ' C-7 � Ad ress GrJ' r _ Expiration Date Signature TelePone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.J 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 ..........0, No........... Cl 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b:OWNEF ! W OR AUTHORIZED AGENT DECLARATION 1• ✓v Q� j/S�i, i r 7/ 4 t�,,C— , 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 behalf. Print Name J / Signature of Owner or Authorized Agent Date rGrossliving under the ains and penalties of ru NOTES: Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor t registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration gram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and nstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5, respectively. en substantial work is planned, provide the information below: oors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch) iving area(Sq. Ft.) Habitable room count r of fireplaces Number ofbedrooms of bathrooms Number of half/bathsheating system Number ofdecks/porches cooling system Enclosed Open 3. "Total Project Syuare Footage"may be substituted for"Total Project Cost" CITY OF SALEM ce, PUBLIC PROPRERTY `-` DEPARTMENT I SC W,wstii NG IoN S 1%l.L 1 • 5nt r N. M 11v.a1 nl No I I,3197: li.l. )78-713-9345 • 1:wu 9711.74C '+446 Workers' Cumpensation Insurunce %t6davit: Builders/Contractors/Electricians/Plumbers li ) alicant Inrormation Pleas iv e Print Le t hl_ Name v.tiiuNl nddi,I dual f. �/ � ^ 5 A/�Ic laldros: 7 y / ` Ci1y,Statc.%ill / t9J�/Gte 1'hunr i!: 6 7� � � Are y uu an vinployer:' Check the appropriate bus: Type of project(required): 1.❑ 1 um u employer with 4. ❑ I ;un a genl:ral h)ulfaClOf and I G, ❑ new cunstrucuuat employees(lull anlL'ur part-tinge).• hace hired the ,uh-con(ricturs 7. Q Remodeling 2.❑ 1 .In1 a sole proprietor or partner- listed on the anachcal sheet. : ship and have no empluyccs These sub-contractors have 9. ❑ Demolition working for me in any capacity. weorkers' comp. insurance- 9. Q Building additiun No workers' cum insurance 5. We are a corporation and its I P 10.Q Electrical repairs or additions I required.] officers have exa�ascd their ri ht of cxem tion per MQL 11.0 Plumbing repairs or additions 3.❑ 1 ys i homeownero% or s'doing all work c 5152. g 1(4),Pmd we have no myself. [No workers' cunlp, 12.Q Ruul'repairs insurance required.) t empluyccs. IKo workers' 13.❑ Other cotn a. in,urancc rcquired.l •tin ..,q+toul that checks box nI must also till out the rclwn Imlow,.Gowiny Thor wurkms'cumpunsatiun l+ulivy 1411w radon. _ ' I Iamcuwrwp who ulbmil this anldav it indiuliny Ihcy are doina all work in d Ihcn hire o wde cUttrxtun mull whmil In.al f::davit mil"my umh. 'r.nlGwl\Ml Ihot LIw,k this box mlWl Jllwilud ran]ddnlunal J tntl,huwiny law panto of the sub-connxt)rs and then wurkun'comp rndlcy mrwm:Inun /ant air employer that it prurfdirtr luurkers•e•utnpounrion insurance for ury employees. Behov is the pu/iay and job efts nfunnutiun. In,urancc Company 2 - _- - --------- 53 . .. Expirunun Data: f 7 l0 Job -Sire Address; -2 �6e ` City;Slate/zip: SGLGa. 1,1;47 612-2CJ Attack it copy of file workers'compensation Palle) declaration page (allowing the policy number and expiration date). Failure to secure cuserage as required under Section 25A of VIOL c. 152 can lead to the imposition oferiminal penalties of a tine op to 51.50.00 jn&ur une-year imprisonment,as tecll as cis d penalties in the form of STOP WORK ORDER and a fine of till u) S250.00 a Jay .igainst the violator. Ile,ad%i.wd that a copy of(his,mtcmenl may be lorss Jrded to the Office of I raw:alitta onus ui ; is DIA :or n),io jrcC C,,w cr.hc %Cri INatalia. /du hereby a ertifv wader th/e paiav and it hies of perjury thus the infur7rtlrtion provided above is true and correct. 11/Jiciu/nee mdy. Dd ant Ivrire in this area, to hr cuntpla•Itd by city ur to+vn a//i<iu/. 1 ( ilv or fawn: .. _ - Permit/Licences 0_ Issuing .\uillurily (circle rite): I. Ih,ard of Ilc.dlh !. Iluddiny Ihpartncat 1. Cii)A own Clerk J. Llccarical Inspector 5. Plumbing; lospcclor G. Other _ Omaict I'cnuo; .. _ Phone 1: er Information and Instructions \l.lssachusetti Gcncral Laws chapter 1 i2 requires all einplo)ers to provide workers' compensation for their employees. 1'urou.rnl to arts aatule, an empkgee Is defined as" .wary poison in tale service of inuher under any contract of hire, spress or unphed, oral or wrnten." : \n vnplayer is defined as"in individual, partnership, associatwu, corporation or other legal entity, or,nny two or more ,a the tomgolng engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the rCe C1%Cr or trustee of .al Il ldlvldual,painicrhhlp, assoelallon 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 in 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." Wdinunally, MGL dlapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ul-puhlic work until acceptable evidence ul'cumpliance with the insurance requirements oft his chapter have been presented to the contracting authority." Applicant Please rill out the workers' compensation affidavit completely, by checking ilia boxes that apply to your situation and, if necessary, supply sub-contractor(s)nanle(s), address(es)and phone nunlber(s)along with their cerrificate(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 .\ccidents for confirnmtion of insurance coverage. Also be sure to sign and dale the affidavit. The alf idavit should he rctunmd to the city or town that the application for the permit or license is being requested, not the (hpartment of Indllitrnal Accident. Should you have any questions regarding the law or If yoll are required to obtain u 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 line. City or Town Ofllclats please he sure that the affidavit is complete and printed legibly. The Department his provided a space ut the bottom of the affidavit for you to till out in the event the Olfice of Investigations has to contact you regarding the applicant. I'taase be sure to till in the permit/license number which will be used as a reference number. In addition, an applicant Ilrat mum submit multiple pennitAicense 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 lucatiuns in (city or town)." \ 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 hone owner or citizen is obtaining a license or permit not related to any business or commercial venture I i.e. a dog license or permit to bun leaves etc.)said person is NOT required to complete this affidavit. I Il: r)I ilea 11 Inv Cl7agallUna wuuld llee to thank )'ou III advance fir your cooperation and should you have .my gaehl Wlli, please do not hesitate to give us a call. the Deparnnenl's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents OfAce of Iovestiptions_—_ --------_-_-- - 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax M 617-727-7749 www.mass.gov/dia y CITY OF SALEM PUBLIC PROPRERTY �,..r•^° DEPARTtiIENT J11 r ♦ N.\I I \I, 11.\"V I :I'I - III. 7'a.v;.1i4? • 1 \C- ;'8 '4_'"4h Construction Debris Disposal affidavit (required lirr all demolition and renovation wurk) In accordance 11 ith the sixth edition of the State Building Code, 7S0 Ch1R section 11 L5 Debris, and the provisions of fbiGL c 40, S 54; Building Permit K is issued with the condition that the debris resultin.- from this work shall be disposed of in it properly licensed waste disposal lacility as defined by NIGL c 111, S 150A. The debris will be transported by: I name of hauler) I he debris will be disposed of in : (name of facility) loddres.of Ianlitvl NIunjtulc of permit applicant dale Y .4COR^O® CERTIFICATE OF LIABILITY INSURANCE ��'�i6 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Phil Richard 6 Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 491 Maple Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 102 Danvers, MA 01923 - - INSURERS AFFORDING COVERAGE NAIC# VOLMED INSURER A: SCOTTSDALE INSURANCE COMPANY Pearson Builders, Inc. - INSURER e: Arbella Protection 15OR Winona Street INSURERC Granite State Ins AIG Peabody, MA 01960 1NSURERD INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEFORTHE 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH � POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS. WSR ADD' 'POLICY NUMBER POLICY OF POLICY EXPI BATON LIMITS GENERALLIABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY CLS1445653 11/28/08 11/28/09 PREMISES(Ea amartenee $ 100,000 CLAIMS MADE ❑X OO:UR _ MEDEXP(ARlonepesm) $ $ 000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2 000 000 GENLAGGREGATE LIMIT APPLIES PER PRODUCTS-ODMP/OPAGG $ 2,000,000 X1 POLICY PR0. LOC AUTOMO&LEUAIMUW COMBINED SINGLE LIMIT B ANY AUTO 37262400001 7/18/08 7/18/09 (Ea Odder") $ ALLOWhEDAUTOS BODILY INJURY X SCHEDULEDAUTOS _ (Perpason) $ 2$0.000 HIRED AUTOS BODILY INJURY NONOWNEDAUTOS (Peraoddent) $ 500,000 PROPERTY DAMAGE $ 100.000 (Peraoddent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN HA AOC $ AUTO ONLY: AGG S EXCESS UMBRELLALUABILITY EACH OCCURRENCE $ OCCIR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION WORKERS COMPENSATION X WC$TATU- OTH- AND EMPLOYERS'LUABILRY C O ANY PROPRIE RTN EEDERIEXECUTRIE Y� TBD 3/17/09 3/17/10 E.L.EACHACOLENT $ 100,000 peand desall,e under amry in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 UEIAl-PROMSONS D9ow E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEMI=/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHEABOVE DESCRBEDPOLICIES BECAHCELLED BEFORE THEEXPIRATION TO WHOM IT MAY CONCERN DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 OAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORMW REPRESENTATIVE - ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The AC ORD name and logo are registered marks of ACORD