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7-9 CEDAR ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF O Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate e olish a One- or Two-Family Dwelling This Section For Official Use my Building Permit Number Dat"Appl',d: zx signature Date Building Official(Print Name) ✓ g SECTION 1. SITE I. FORMA N 1.1 Property Addreesss,:: 1.2 Assessors Map& Parcel Numbers Parcel Number ]I.la Is this an accepted street? yes_ no_ Map 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: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public ❑ Private❑ Check if yes❑ SECTION PROPE) TY'OWNERSHIP'i . _. 2.1 Ownert of Record: S / 1 Name(Pont) City,Stale,ZIP _ o Telephone Email Address No. and Street .- SECTION 3: DESCRIPTION OF PROPOSED WORK2 (che.ck all that;apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition Cl Accessory Bldg. ❑ NumberofUnits_ Other _❑ Specify: Brief Description of Proposed Work` � b e r^ L SECTION 4: ESTI VIA'TEDUCONSTRUCTION COSTS: Estimated Costs: Official Use Only Item Labor and Ntaterials " I. Building $ I Building PermitBee $ Indtcatehow feeds determined:, ❑ Standard City(Town Application Fee 2. Electrical $ ❑TotalPi6je&Cost, (Item.6)x multiplier- x 3. Plumbing $ 2- OtlierFees: $ 4. Mechanical (HVAC) S Llst 5. Mechanical (Fire $ TotaCAll Fees: $ Su ression Check No. Check Amount, ,: Cash Amount'. 6. Total sP�roject/Cost: $ //f Oa4o�-e&4 El paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) q r ,� ' ✓ License Number Expiration Date 3 Name of CS�olkr �/ / List CSL Type(see below) No. and Street (/�� Type,., Description : U Unrestricted(Buildings up to 35,000 cu. ft. Gtywn, State,ZIP `� Restricted I&2 Famil Dwellin Nf Nlasonr RC Roofin Coverin WS Window and Si(lin SF Solid Fuel Burning Appliances I Insulation Tclz hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HI Company Name or HICr Rep-istrant ame 'T ST— No. and Street Email address � �r7 �rf I C'7frd Ct /Town, State, ZIP Tele hone 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' 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: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest tinder the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Prix wner's r Authorized Agent's Nan e(Electronic Signature) p42 NOTES: I. 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. I42A. Other important information on the HIC Program can be found at www.mass.-gov/pe Information on the Construction Supervisor License can be found at www.mass. ov21 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) (including garage, finished basement/attics, (leeks or porch) Gross living area (sq. R) Flabitable room Count Number of fireplaces Number of bedrooms Number of bathrooms Number of halUbaths 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" ACORD CERTIFICATE OF LIABILITY INSURANCE � (MM8/2/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsementil _ PRODUCER NAME, MARTIN TILDSLEY JR Daniel N. O'Rourke Insurance PHONE l` (781) 396-8249 a/X No: (791> 391-2975 429 High Street EDa1Ess: MARTY@ORourkeInsurance.net Medford, MA 02155 INSURIERISZAFFORDING COVERAGE __- NAIC# INSURER A: SAFETY INSURED INSURER B: JASON TRANT INSURER C: D13A JST CARPENTRY INSURER D: 76 WALNUT ST INSURER E: EVERETT, MA 02149, 1 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OFINSURPN CE POLICY NUMBER MMIMN MM/DD?YYYY LIMITS A GENERALLIANUTY TBD 8/27/12 8/27/12 EACH OCCURRENCE $ 300 QQQ COERCIAL GENE HAL LAB ILITY DAMAGE E _LEE R r MM $ 100,000 DAMAGE TO NTE CLAIMSMADE aOCCUR ME O EXP( rry a se prim) $ —_ 10,000 PERSONAL&ADV INJURY $ 300 QQQ GENERAL AGGREGATE $ 600,000 GEN LAGGREGATE LIMITAPPLIES PER PRODUCTS-OOMP/OP AGG $ 600,000 POLICY 7 PRO- LOC $ AUTOMOBILE LIABIUTY C OMB INED IN LE LIMIT Ea accisent __ $ ANYAUTO BODILY INJURY(Per parson) $ ALL OWNED SCHEDULED BODILY INJURY(Per xcidenp $ AUTOS AUTOS NOWOWMED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraxitlent 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION VJC STATU- OTH- ANDEMPLOYERS'LIABIUTY Y/N IMII --ER- MY .I -- PROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT $ OFFICERMIEMBER EXCLLOED9 N/A -- '— (Mandatory inNH) E.L.DISEASE EA EMPLOYEE S _ If yes Oesuibe untler DE SGRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DE SCRIP TON OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional RenerMs Schedule,It more space is mgui red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN VI14FEN HOUSING ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are regi ered marks of ACO RD Phone: Fax: E-Mail: CITY OF SiUE615 lr'L1SSACHUSETTS BUILDING DEPAR-M&NT • ) ' r. 120 WASHINGTON STREET, 3'o FLOOR TM (978) 745-9595 F.kx(978) 740-9846 KIN fBERI.EY DRISCOLL MAYORT�iOhtAS ST.PIERRI3 DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONNISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busitxs&OrgtnizatioNlndividual): 1 CC,/L e Al�2✓ Andress: 76 City/State/Zip: 4.o . t/ gs l o a/j/S Phone #: G / 2 IF�fy Are you an employer?Check the appropriate^bion 'type of project(required): 1.El am a employer with 4. 9M am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner• listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have V. ❑ Demolition working fur me in any capacity. workers'comp. insurance. 9. ❑ Building addition (No workers'comp. insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 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.❑ Roof repairs insurance required.]t employees.END workers' 13.❑Other comp,insurance required.) ;Any applicant than ehccW bar tl must also rill out the section below showing their wwkus•compenudun policy infurmation. I bwneuwners who submit this affidavit indicating they am doing all work and then him outride contractors must submit a new amdavil indicating such �Cuntravioro that chick this box most attached an additional short showing the name of the suh ontractors and their workers'comp,policy infomunon. I am an employer that Is providing workers'campensadon Lrsurance for my employees. Below Is the policy and Jab slits information. Insurance Company Name: Policy 4 or Self-ins.Lic, d: !T .✓J Expiration Date• ,R—.57 — /a-- Job Site Address: 7—!j' C )nr. 'TJ City/State/Zip: dad Attach a copy of the workers'compensatfoo policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the Conn of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Oflice of Investigations of the DIA for insurance coverage verification I do hereby certify under tba pants and penuldes of perjury that flea brfornrurlou provlded ubuve,is true and correct. Si-mat ire, Phone X: OJJic ial use anly. Do not virile in thin area, lobe courpleled by city ar lowm alftful City or Town: Ptrmlt/Llccnse k _ ___ Issuing Au parity(circle one): I.Buurd of licalth 2. Building Department .I.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing inspector 6.Other --_---.-- Cunt•act Person: _ _--- _ Phone B: CITY OF S.U..F-M, 1N`LASSACHUSETTS • BUILDING DEPARTMENT p 130 WASHINGTON STREET, 3° FLOOR TEL (978) 745-9595 F.Ax(978) 740-9846 IcStBFRT RY DRISCOLL MAYORTHO�tAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUILDING COb12MRSSIONER 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 c 40, 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 disposal 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 (name of facility) (address of facility) signature of permit applicant date .lcbriia lT.Jw ) asslarbusctts. Department of Public Sant) 1 Bt aril of Building Regulations and Sand ards 1 Cohstruction Supervisor License L Luense: CS .76414 'JOSEPH S TRANT x -4413RADBURYAVE 4 MEDFORD, MA 02156 ` Expiration V132013. •' ( � tei3sinnci• '' Tr#[ 8np, .