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11 CHURCH ST - BUILDING INSPECTION (34) $38S c..K zb z3 The Commonwealth of MassachuseW CF-1 L$EkY10E$ Board of Building Regulations an �� CITY OF Massachusetts State Building Code,780 CMR SALEM ��1I pp ��jj C, Revised Mar 2011 Building Permit Application To Construct Repait�( t{c�tfaE�r Demrolish a One- or Two-Family Dwelling C� This Section For OfficiA Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 11 C�c �t�t ST U rl if 4 03 L I a is this an accepted street?yes no Map Number Parcel Number 13 Zoning lnformation: 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: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: -a-M.eS C'xr�t•�la ScIrv... i/�k, aI �t"1v Name(Print) City,State,ZIP �i Z`h- No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Workz: r) l� 'rn xlc; a view SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Labor and Materials Official Use Only 1. Building $ Z ei p 1. Building Permit Fee:$ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ 5:F-b ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ ( . el) 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ i's/p-tra ❑Paid in Full ❑ Outstanding Balance Due: 1V1PILA 70 -ra GOUT z12s CITY OF S�U.&N4 AN'LkSSACHUSETTS &:ILDLN)G DEPART%I&rT a 13O WASHINGTON STREET.S'e FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KI\BERLEY DRLSCOLL MAYOR THODLiS ST.PIERRRB DIRECTOR OF Punic PROPERTY/BUI DLNIG CO.%L%aSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Businesslorganization/individual): Its ��sy[' I f'uG �ti{—w'. Address: 86( St I City/State/Zip: t! l i 015(j Phone #:G 7q GI Are Ypd an employer?Check the appropriate box: Type of project(required): I.CyI am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the subcontractors 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 S. ❑Demolition working for me in any capacity, workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrital repairs or additions required.] officers have exercised thew 3.❑ 1 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.[No workers' comp- insurance required.) 13.❑Otha •Any applicant that checks box Ill must also fie not the section below showing their workers'compensation Policy intermatioo. 'Ilntrteewrten who sebmil this affidavit indicating they ate doing all work and then hire maside commpprs mum submit a new affidavit indiWing arclL :Contrwann that cheek this box must anacha)an additional sheet showing the tame of Me aub.eontractorx and their workers'comp.policy information. lain an employer that is providing workers'coinpensadon insurance jar my eatplayee% Below is the policy and fob site information. Insurance Company dame: ©/V V U�`' Y�. 6O Policy#or Self-ins.Lie. Expiration Date: Job Site Address: l f C12 u,.6,4 cST l/Yr.it- /f03 City/State/zip: S s, Attach a copy of the workers'compensation polity 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 S 1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby certh render tbepalas and penalties ofperfury that the informadon provided above Is true and correct. Sit:naiurr / Date- r ' Phone# 225� CL-f/ Oflicial use only. Do not write in this area,to be completed by city or town off/ciat City or Town: Permit/I.icense# Issuing Authority(circle one): 1.Board of Ifeallh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) r 2- License Number Exp' lion Dale Name of CSL Holder CIO List CSL Type(see below) No.and Street Type Description 3 eU NI� 1 C I nres tricted(Buildings u to 35,000 cu.ft.) b R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding °I.],i7` 3 > b Y SF Solid Fuel Burning Appliances I insulation Telephone Email address D Demolition 5.2- Registered —Home Improvement Contractor(HIC) 10-1 2-2 A I-IIC Registration Number Expiratidn Date HIC Company Name or HiC Registrant Name 2A1 f�4 P Rrta M No.and Stre.errt�� 't {' Email address 4- -o1SLk Cit /Town;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 Issuanc 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 2A-4� authorized by this building permit application. Print Owner's Name(Electronic t9p ure) V If Dale SECTi 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 information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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. 142A. Other important information on the MC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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"maybe substituted for"Total Project Cost" Office of Consumer Affairs&Business Regulation UrJVOME'MPR OVEMENTCONTRACTORegistrahon :'10T 25 .....: - _ __._... .". Type: Expiration: 7t 201t DBA C�le�po7vneoox ue o�C/��aeac�uaetta j RAFFA CONSTRUCTI 3 Office of Consumer Affairs&Business Regulation I _ , � UVExpiratlon--,,- DBA0 E IMPROVE ENT CONTRACTOR —� egistration: - 25 Type: Frank Raffia �E , 801 Hale Street RAFFA CONSTRUCJ n J Beverly, MA 01915 Undersecretary � Frank Raffia 801 Hale Street Beverly, MA 01915 - �— Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-007285 r Is FRANK D RAFFA= ' Department of Public Safe 801 HALE STREI 9 Massachusetts -De s P Safety BEVERLY MA 0i91 lug Board of Building Regulations and Standards Construction Supervisor , r 'i s. JI ). o", License: CS-007285 Expiration ` of Commissioner 04/07/2016 FRANK D RAFFA- -- 801 HALE STREli7 BEVERLYMA 17 J � 11 lit Expiration Commissioner 0 410 712 01 6 �\ Office of Consumer Affairs&Business Regulation q0ME IMPR VE�AENT CONTRACTOR f- egist2tion: A.07?25 TYPe Expiration*p�7% 01 016, DBA { RAFFA CONSTRUC'FIDN' K " -n( i, Frank Raffa 801 Hale Street I" \YM. giy Beverly,MA 01915 -- -'J `ry Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-007285 rrs pFi FRANK D RAFFA` 801 HALE STRE$T BEVERLY MA 0191 ` l 'Y Expiration Commissioner 04/07/2016 The Essex Condominium Telephone: 978-532-4800 1 Fax: 978-532-6023 clo Crowninshield Management Corp. 18 Crowninshield Street Peabody, AM o196o James Garfield Unit 403,The Essex Condominium 11 Church St. Salem, MA 01970 Dear James Garfield, The Essex Trustees have reviewed your request for extensive refurbishments in your kitchen and surrounding areas, including electrical and plumbing work. The Trustees have given their consent for you to proceed with your project, but with 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 is in accord with the Essex Condo Documents* in that it 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 this work please be aware that: • The contractor must remove from the Essex Condominium property all discarded materials used in the refurbishing, including paint cans and also all furnishings,plumbing, and electrical fixtures formerly installed in the unit. • The contractor may not use the front circle for parking of vehicles but may use the West Alley if space is available and should leave a note on the windshield with phone#and unit information. • The hallway carts are intended for residents' use.They may be used by the contractor only for transport of materials that will not damage or deface the cart and must be immediately returned after each such use.They are not to be used at any time for temporary storage of materials or as a workbench or paint cart. • If the stainless steel three-button buzzer box near the doorway is still in place, it may be removed. It serves no function; it has been replaced by a telephone system. • The refurbishment shall be done by a reputable contractor with a good work record and references, and,as required by State Building Code, the contractor must obtain a building permit from the City of Salem.This ensures that the contractor is properly licensed and insured. • *Exhibit C of the Certificate as to the Rules and Regulations, Book 23224,Pg.241, South Essex Registry of Deeds and Sections 5.2 and 5.15 of the Declaration of Trust, Book 101 169, Pg. 84. Both are available in the black bound copies of the Essex Condo Documents available from the front office. Please contact the management company if you have additional questions. Good luck with your project. Signed: �&,Zy tn-" Date: January 8, 2016 For the Essex Trustees AcoRo® CERTIFICATE OF LIABILITY INSURANCE DATE(MM DD/YYYY) (h.� 1 02/24/2016 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: It the certificate holder is an ADDITIONAL INSURED,the policy(iss) 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 endorsements. PRODUCER CONTACT NAME: AP INTEGO INSURANCE GROUP -PHONE FAX No: 333 W. Commercial Street -MAIL Suite 2500 ADDRESS: East Rochester, NY 14445 INSURERS AFFORDING COVERAGE NAIC# INSURER A: INSURED INSURERS: NOrGUARD Insurance Company 31470 Frank Raffa INSURERC: Raffa Construction 801 Hale Street INSURER D: Beverly, MA 01915 INSURER E: NSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCEIN= POLICY NUMBER M�1W D/YYEYYY MhVDMYYYY LIMITS LTR COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 0 CI-AIMS-MADEOCCUR PREMISES Ea occurrence $ 0 MED EXP(Any ane Person) $ 0 PERSONAL S ADV INJURY $ 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0 POLICY ECT LOC 0PO OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per Person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIREDAUTOS AUTO) NED PeOraccdenj SAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS IJABB CLAIMS-MADE AGGREGATE $ DIED RI ETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY YIN B OFFICERRMEMBEANY REEXCL Y EXCLUDED?ECUTIVE NlA FRWC640458 06/19/2015 06/19/2016 eL.EACH Acc1DENT $ 100000 (Mandatory in NH) E.L DISEASE-EA EMPLOYE $ 10 OQ If yes.describe muter DESCRIPTION OF OPERATIONS beb E.L DISEASE-POLICY UMIT $ 500 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 1D1,Additional Remarks SchWule,may be aUached K more spew Is requlrad) Exclusions: Frank Raffa; CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington Street Salem, MA 01970 AUTHORIZED REPRESENTATIVE 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD A ® DATE(MM/DDIYYYY) /A CERTIFICATE OF LIABILITY INSURANCE1 2/24/2016 „ 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 endomement(s). PRODUCER CONTACT Gale FdRClll110 NAME: J.J. Ruddy Insurance Agency Inc. PHONE (761)396-4900 RIC No: (781)391-7597 153 Main St. EMAIL faaciullo@jjruc® ADDRESS:9 ddinsurance.c P INSURER$ AFFORDING COVERAGE NAIC N Medford MA 02155 INSURERA:Safetv Insurance Company INSURED INSURER B: Frank Raffa INSURERC: DBA Raffa Construction INSURER D: 801 Hale Street INSURER E: Beverly MA 01915 INSURER F: COVERAGES CERTIFICATE NUMBER:02/24/2016 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OFINSURANCE ADDL BUBft POLICY NUMBER MWDDIYLICY EYYY FF POLICY LIMITS XP TR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 A CLAIMB-MADE �OCCUR PREMISESEaoccunl $ BMA0021174 2/16/2016 2/16/2017 MED EXP(My one person) $ 10,000 PERSONAL B ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOG PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-DWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Par acddent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ H yes,describe racer DESCRIPTION OF OPERATIONSbelm E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space k required) CERTIFICATE HOLDER CANCELLATION hwagg@salemcom SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington Street ACCORDANCE WITH THE POLICY PROVISIONS. Salem, MA 01970 AUTHORIZED REPRESENTATIVE Gale Fanciullo/GAF ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)