11 CHURCH ST - BUILDING INSPECTION 320 $zs
S (c, M lf-(e- $s� (
The Commonwealth of Massachusetts RVICES
Board of Building Regulations and StandaASPECT1�t1AL 5 CITY OF
Massachusetts State Building Code, 780 CMR $A{EM
R�rs /ur 20/l
Building Permit Application To Construct, Repair, Renovate wbMttD7ish a
One-or Tivo-Family Dtvelling
This Section For Officia a Only
Building Permit Number. Date plied
Building Official(Pont Name). Signature . . Date
SECTION 1:SITE INFORIIVIATION
�1 Pro erty Address: 1.2 Assessors binp 5l Parcel Numbers
� !Uo II �urChS7" pP�
Ma Number Parcel Number
I.l a Is this an accepted street?yes no P
1.3 Zoning Information: I.J Property Dimensions:
"Coning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§SJ) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ po y
SECTION 2: PROPERTY OWNERSHIP!'
2.1 Owners or Rec d: S Q j R A �G p I q-70
eft 'Jn 6 ee -se dA
i�tlme(Print) 7 �1 City,State,ZIP
C�JrCh S749 ✓a75'ly- 6-do-
No. 1705
Nu.and Street lI Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK°(check all that apply)
New Construction❑ Existing Building Cl Owner-Occupied ❑ 1 Repairs(s)Q& Alteration(s) ❑ Addition O
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': f\
n }� 11 V to, ce m e+I K da nS
vc 7Q OL,
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Casts: Official Use Only
Labor and Materials -
1. Building $ l�9(p— I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost(item 6)x multiplier x
3. Plumbing $ 1 a01her Fees: S
4. Mcchanical (FIVAC) $ List:
i. Mechanical (Fire Total All Fees:S
Su ression)
r� Check No. Check Amount: Cash Amount:
6. Total Project Cost: .$ �( � 1�a ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�'obef 1 - �6 e z d LryC� License Number Expiration Date
Name of CSL Holder '" List CSL'fype(see below)
I,C`�er,f "`V1 Type - Description
No. ;md Street
S� � -\ n^ � I J U Unrestricted(Dui Family
s u 35,000 eu. Il.)
"-\ R Restricted l&2 F:uni1 Dwelling
Cityfrown,State,ZIP tM Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email uddrcss D Demolition
5.2 Registered Home Improvement Contractor(HIC) 7 0 �,��3 `�/' 3
fylp)- i S42 2) HIC Registration Number Expiration Date
III Cui}�pan am qqr HIC Registrant N:une �qq t 1
U r0� 'pia/n d)v ICg
No and Street / �(_ (�`l+_ a`�3�1 Email address
ShreWI
Ci /Town,State ZIP TAl hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.IL 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 W HEN'
OWNER'S AGENT OR CONTRACTORAPAPLIES FOR BUILDING PEM11T
I,as Owner of the subject property,hereby authorize M ..
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
SE E CD\4-r'<,W ) e - l6 1y
Print owner's Name(Electronic Signature) Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that ail of the information
contained in this application is truef�nd accurate to the best ofrny knowledge and understanding.
b
M flRK �r�9 `�C �, I2 _ IG -la
Print Owner's or Autl rized Agent Name(Electronic Sigt attire) Date
NOTES:
I. An Owner who obtains a building per to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will naf have access to the arbitration
program or guara»ty fund under 1M.G.L.c. I42A. Other important information on the HIC Program can be found at
w%vcv mass eov:'ocut Information on the Construction Supervisor License can be found at wvv\v.nriss.,ov!J1L%
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 covert
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 titr"Total Project Cost"
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS I
ICERTIFICATE 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 INSUREP.(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
r IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pohcy(.les) must be endorsed. If SUBROGATION IS WAIVED, subject to
Ithe terns 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 endomement(s).
CONTACT
PRODUCER NAME:
MARSH USA,INC. PHONE FAX
TWO ALLIANCE CENTER
I(Arc Nc):
3560 LENOX ROAD,SUITE 24CO
ADDRESS: _—
ATLANT.A,'GA 30326
- INSURER(SI AFFORDING COVERAGE NA:Ce
100492-HorneD-GAW-14-15 _ INSURERA:Steatlad lrsuranm Carnpaany 12397
INSURED INSURER 9:211nMAnlelantrlsL¢aROCO _18535
THD AT-HOME SERVICES,INC. - NewH n..InS Co 123841
'DBA THE HOME DEPOT AT-HOME SERVICES INSURER c: ' '
2455 PACES FERRY ROAD INSURER D:Minds National Insurance Company 2381i
ATLANTA,GA .A:Ci9 INSURER E:
INSURER F: -
COVERAGES CERTIFICATE NUMBER: ATL-Dm242Ee5-0t REVISION NUMBER:3
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTVWTHSTANDING 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICY EFF PODCYEXP LIMITS
LTR TYPE OF INSURANCE I DL POLICYNUMBER Mh4DD MMIDDNYYY
A GENERALLIABILITY GL04BB7714-04 03/012014 031012015 EACH OCCURRENCE S 9.000.000
5-1 000.MD
X COMMERCIALGE-ERA'_LIABMT PREMISES E.occurrence)
LIMITS OF POLICY XS MEO EXP(An,..person) S EXCLUDED
CLAIMS-MADE OCCUR
OF SIR:$1M PER OCC _ PERSONAL a qDV IIUURY S 9000,000,
GENERALAGGREGATE 5 9•em•—
GEi TL AGGREGATE LIGiTAFPLIES PER:. PRODUCTS-COMPIOPAGG S 9D00,000
I-]POLICY P ECT R6 LOC. - - S -
J II nl SINGLE LIMIT
B AUTCh1061LE LIABILITYILITY � BAP'[938863-11 03/0112014 113j0120 (Ea a¢idenl
15 � $ 1,OOD,OOD
X ANY AUTO - BODILY INJURY(Per person) S _.
DLL OWMEO SCHEDULED SELF INSURED AUTO PHY DMG BODILY IN URY(Peraccideng S
AUTOS AUTOS FROPOn DAMAGE
NONOS
DIN D eracddaa $
HIREDAUTOS AUTOS 3
UMBRELLA L.IAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTIONS
C WORKERS wMPErlSpnox WC049101882(ADS) 03I012014 03D72015 X IWC STIMTR VB
fTfTi-
ANDEMPLOYERS•LIABILRY YIN W0049101884(AK.AZ,VA) 03MV2014 03101I2D15 EL EACH ACCIDENT S 1'W0.000
C ANY PROPRIETOMPARTNERIEXECUTIVE
D OFFICEWEMBER EXCLUDED? NIA W0049101BO(FL) 03MI12014 03N112015 EL DISEASE-EA EMFID 8 1,000.000
(Mandatory In NN
lip de `Ne`unxr EL DISEASE-POLICY UMm $ 1'�'�
DESCRIPTION OF OPERATIONS below
C WORKERS COMPENSATION WC049101885(KY.NC,NH,VT) 03012D14 031012015 (EL)LIMIT 1,0W,Ow
C 100049101885(W) 031012014 09r012015
DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES(AHaN ACORD t01,Adtlitlanal Remarks ScheduR,H more space Isrequkedj
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATIANTA.GA 30339
AUTHORIZED REPRESENTATIVE
- of Marsh USA Inc.
Manashi Mukherjee
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
p� The Commonwealth of Massachusetts
'\ Department oflndustrial Accidents
Office of Investigations
600 Washington Street
r' Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
licant Information Please Print Legibly
Name (Btzsiness/Organization/Individual):, fl
Vi cz5
Address S cZ/CCS /1'nq�i2��
City/State/Zip: tA. Lo b ff. 30.33f Phone #: 17 1r7 y` V r21 3 /
Are you an employer? Check the appropriate tpa: Type of project(required):
1.El am a employer with 4. Ej I am a general contractor and I
s have hired the sub-contractors 6. El construction
employees(full and/or part-time).* ?, Remodeling
2.❑ 1 am a sole proprietor or partner- listed s the attached sheet. ❑ g
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers'comp. insurance comp.insurance.t
required.]
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their11.❑ Plumbing repays or additions
right of exemption per MGL
myself. [No workers' comp. 12.❑ Roof repairs
,,
insurance required.]t c. 152, §1(4), and we have no 13.�Q.ther I wtlr �c ' AA
employees.[No workers —T
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'camp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. /
Insurance Company Name: 1/�l ew #am 5fl i/"e- J /V/� �® .
uu g g o� S
Policy#or Self-ins. Li`c.#: W C D 7 Q j O � �7 Expiration Date: .31
Job Site Address: � I �"VC � ° 3e"D City/State/Zip: ='
Attach a copy of the workers'compensation 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
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. Be advised that a copy of this statement may be forwarded to the Office of
_Investieations of the DIA for insurance coverage verification.
I do hereby certify thepains✓annd pE alties ofperjury that the information provided above is true and correct.
Signature. to , V t `-- J�,C_ Date:
Phone#: � � q ` - c2 ( 3 `9
Official 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#:
ilp Pn7L f8n10VB UIl[II OI1B�CUGB It7;JEIX1011. a3i21ab0 I i0i iL'iUrA r3idr2i1G2jined for area indicated.
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P'oductType: Double Hung
ENERGY PERFORMANCE RATINGS
U-Factor Solar Heat Gain Coefficient
0.29 1 .65 0 . 21
" u.S.4-P Metdc/SI "
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
0 .4. 8 E:H:
ManWacO]r!nupNJtes Org,Nese rt,, mnNrmte:IDlL,atUetlF ,nt,.En sr.U!t!r.we" hPk prviEve
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d)nirrLdyz�eT.�,
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvern :Contractor Registration
Registration: 126893
Type:
r - yp Supplement Card -
THD AT HOME SERVICES, INC Expiration: 8/3/2016
MARK NIADNA :: -- ----.---- ------ ---
2690 CUMBERLAND PARKWAY SUITE-300
ATLANTA, GA 30339
Update Address and return card.,Mark reason for change.
SCA1 .; 20M-05/11 - -- Address ❑ Renewal Employment —� Lost Card
Y(-,11ruruurncrrl/l
s(O(�''��--Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
$61WIE IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
Re ts[ration Office of Consumer Affairs and Business Regulation
9 126893 Type: 10 Park Plaza-Suite 5170
Expiration:.8/3/2pj6.. Supplement Card Boston,MA 02116
THD AT HOME SERVICESANC THE HOME DEPOT.AT yC?MESERVICES
_ MARK NIADNA
2690 CUMBERLAND PARKWAY S � 6,.2�—. `�
GA 30339 - Undersecretary Rpt valid withou signature
t
fA! Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialh
License:CSSL-0Y9899
.�`'
ROBSRTPOCZOOOT r-
Sal WHALERSm MA 0191F _
,1 re`�19 Expiration'
Commissioner 02/0OMIG
CITY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
120 WASHINGTONSTREET,3' FLOOR
\ TEL (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAs STYIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING 00AMSSIONER
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: 6c)
/�lady :S i�t ! �- 1)(4
(name
^of facility)
(address of facility)
e
Signature 4 applicant
la - l7_ � `f
Date
r v a
r `# r 6 "•� }? �' . `,.,,2 . P�`'"O2G' I L�vTL
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Permit Services 401 246 2868 p.14
2014-11-02 03:28 2686RTV. 9787401417 >> 19783360372 P 1/7
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71=Rom-Depot rcewars the right to:nauc a Closings Order w aarmimre W s Cvtvoct w any individw)hodact(s)included hradn,at
ib dixrel:ort.i f7he Bamc Dgroe a ib mdhmieatl sOvlca ptaviderdckxmincs tut a eaMal parfmm ils ubhlgatians due br a spOetutal
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n ayntAts set forth in Wm Agrament or arlwed under appl&abl AE He Iaw. TOW DEPOT MAY W ITaIHALD AMOUNTS
OWED TO TM,, HOME DEPOT PROM THE DHMIRfT PAYMENP OR OTID;R PAYMPIM MADE. IN MOUT
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and TFro Home epm wi ,tegatd to the Produces and Imadlutiun sorritaa and apersdov ull prior discaasiata and Agr ecarcu .either
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CANCELLATION r CUNTIMER MAY CANCT.L TBIS i rn aaptupu
A(.RFICMRNT WMWUT PENALTY OR M1.IC.ATyM,
BY DELIVERING WktTTPN NOTICE TO THE 110MR
DUIC01 ST MMNWHT ON TFM THIRD MMMS
DAY AFTER SItaNDYO TM AGREUdENT. INC"
RTATF SCPPLF3i$NI' ATTACHED RF.RP.TO
CONTAINS A WORM TO U5E IF ONE IS
SPEWICALLY PRESCRIBED BY TAW IN
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Permit Services 401 246 2868 P.1
The Essex Condominium
Telephone: 978-532-48001 Fax: 978-532-6023
c/o Crouminslrfeld Management Corp.
18 Crouminshield Street
Peabody, MA o1g6o
Ms. Jeon
Unit 320,The Essex Condominium
11 Church St.
Salem,MA 01970
Dear Ms.Jeon,
The Essex Trustees have reviewed your request to replace the windows of your unit. The Trustees
have given their consent for you to proceed with your project, but tagth the following
qualifications:
The Trustees are not in a position to assess the engineering details of your request nor can they be
assured that the final product will be in accord with the plans.Thus you the Owner retain the
responsibility for ensuring that the finished work does not"affect the appearance or structure of
the Condominium,or the integrity of its systems", that"all materials used and Work performed
shall comply with all OSHA,other federal,state,county,and municipal laws,rules,ordinances,
codes and regulations,"and that the work is carried out by the contractor in the manner specified
by the Essex Condo Documents* (vis a vis hours, removal of refuse,noise,etc.).
Regarding replacement windows and doors,please be aware that:
Windows must be of a quality equal or greater to the original windows;
Installation shall be done by a reputable contractor with a good work record and
references;
The appearance from the outside must be identical to that of the original windows,
specifically as to color(white),number and spacing of mullions(grids),and location
of mullions/grids on the outside the outer pane(not between the panes);
Screens must cover only the bottom half of the windows to match those throughout the
rest of the building;
Flashing must be to Massachusetts code standards.
Please contact the Management Company if you have additional questions.
Good luck with your project.
Signed: !" as managing agent Date:October 28,2014
for the Essex Trustees
*Exhibit C of the Certificate as to the Rules and Regulations,Book 232241 Pg. 241, South Essex
Registry of Deeds and Sections 3.2 and 5.15 of the Declaration of Trust,Book 101169, Pg. 84.
Both are available in the black bound copies of the Essex Condo Documents available from the
front office.
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