0 CLARK AVE - BUILDING INSPECTION I �
SAM
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
k Massachusetts State Building Code, 780 CMR, 7"edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Fanlil} Dwelling
This Section For Official Use Only
p Building Permit Number Date Applied:
Signature:
Building Comm- sioer nspectorof Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
U CiCirk- CZye• Salem,PA
L I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(fl)
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? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Al and Marcia Pszerxny O Clark QVe . SaleM
Name(Print) Address for Service:
�-d'el 0&/,; g-1s--74ti 8z-7s
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) X Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
Install One prt' �lv dca) Irr+r) -exlshn 01?cfningc
2C t
ECTION 4: STIMATED CONST CTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building s 8 oCl o(3 1 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) s List: r
5. Mechanical (Fire $
Suppression) Total All Fees:s
va Check No. Check Amount: Cash Amount:
6. Total Project Cos[: s (p g O Q. 13 paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 2 g 0 0 0 I I I q �O j
+•., License Number Expiration Date
N.4me of CSL-p9lder P �oxor List CSL Type(see below)
Nomas
Type Description
Addressto
a Co GP.d Gr S� VWOburrl U Restricted
1 u amity 00 Cu. Ft)
R Restncled I&2 Family Dwelling
Signature $1 a33 830U M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) I q to S R cI
N,eWPro
HIC Company Name or HIC Registrant Name Registration Number
Zto Cedars+ wyburn 5-5-0q
Address —7 61 q'6a g 300 Expiration Date
Sign3f"ure Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 ..........4 No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I A ( or �(C(PC t Q hZ c nr\Y as Owner of the subject property hereby
authorize N e i.�Pr a to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date — I
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Th OrnC, g P wu , 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.
T4l Orn G S r 0"(or—)
Print Name Mieu A4 - _T
a A4
Signatur of Owner or Aut orize Agent Dat
Si ned under the p,,ns and en Ities of r'u
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. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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" may be substituted for"Total Project Cost"
1/9/2009 12:07 PM FROM: Mackintire Insurance Mackintire Insurance Agency TO: 8,17819320860 PAGE: 002 OF 003
DATE(NIMIDDlYYYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE 01/09/200
PRODUCER SD$ X66—G-�6j--—FA^ \+�$J+"6—SZD2 THIS-CERTIFICATETSISSUEDASWMATTER-OFINFORMATION--"- -""-
Mackintire Insurance Agency, Inc. ONLYANDCONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
11 West Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Westborough, MA 01581-1931
INSURERS AFFORDING COVERAGE MAIC#
INSURED Newpro Operating LLC INSURER.A: Peerless Insurance Co. 24198
26 Cedar St. INSURER B:
Woburn, MA 01$01 INSURER C:
INSURER D:
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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.
INSRD' TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POUCYEXPIRATION LIMITS
GENERAL LIABILITY - TBD 01/01/2009 01/01/2010 EACH OCCURRENCE 5. 1,000,00
X COMMERCIAL GENERAL LIABILITY - - DAMAGE TO RENTED 8 100.000
CLAIMS MADE OCCUR - MED EXP(Any one Parson) It 5,000
A PERSONAL&ADV INJURY - $ 1,000.000
GENERAL AGGREGATE $ 2,000.000
GEN'L AGGREGATE L IMIT APPLIES PER:. PRODUCTS-COMP/OP AGO S 2,000,00
POLICY JECT
P" LOC
AUTOMOOILE LMBILITV TBD 12/31/200$ 12/31/2009 COMBINED SINGLE LIMIT $ .
ANY AUTO (Ea accident) 1,000,000
ALL OWNED AUTOS - - SOOILY INJURY It
X
SCHEDULED AUTOS (Per Person)
A X HIRED AUTOS BODILY INJURY -
X NOWDANED AUTOS (Per accident) $
PROPERTY DAMAGE $
(Par accident)
GARAGE LMSILRY AUTO ONLY-EA ACCIDENT $
ANYAWO OTHER THAN EAACC $
AUTO ONLY: AGG S
EXCESSNMBRELLA LIABILITY TBD 01/01/2009 01/01/2010 EACH OCCURRENCE $ 5 000.000
X OCCUR CLAIMS MADE - AGGREGATE $ 5,000.00C
A $
DEDUCTIBLE - it
X RETENTION $ 10,00C $
OR STA DTH
WORKERS COMPENSATION ANDLIMPR
EMPLOYERS'LIABILITY - .EL.EACH ACCIDENT $
ANY PROPRIETOR/PARTNEWEXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $
K yes,deacnbe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
OESCMPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT$SPECML PROVISIONS -'
CERTIFICATE O R CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 -DANS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE -
Timothy Mo na h
ACORD 25(2001/08) OACORD CORPORATION 1088
01/09/09 09:43 FAX 16177709683 AMERICAN FIRST INSURANCE Ig)UU1
.. OPID DC DATE(MWI)DIYYYV).
qEg B CER-T-IFI.CATES ULABILITTY INSURANCE R-1 01/09/09
THIS CERTIFICATE IS ISSUED ASAINATTER-OFINFORIuFATION
PRODUCER. - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
American First Ins Agency Inc ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
122 Quincy Shore Drioe
North Quincy NA 02171 INSURERS AFFORDING COVERAGE NAIC#
Phone: 617-770-9000
INSURER Arbella Protection Ins. Co
INSURED
INSURER B:
INSURER C:
New2ro OppDerating LLC - INSURER D:
20 "Ox 2
Woburn MA96
INSURER E
COVERAGESrEN-
THE
AN?REQUIREMENT,TENM LISTtU BELOW HAVE 6
OF ANY CONIAIACT OR OTHER SSUED TOTHE IDOCUMEENT WINS RED TH RESPECT TOO WHIICHABOVE FOR THE ITHIS CERTIFICATE M SE ISSUED OR
DING
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. LIMITS
nGE�Nl
7UMIT
URANCE
POLICY NUMBER DATE MIODIW DATE MMID EACH OCCURRENCE $
$
PREMISES Ea amurerlce
NERAL LIABILITY MED EXP(Any one person) $
E- XO OCCUR _ PERSONAL&ADV INJURY $
F_I
GENERAL AGGREGATE $
PRODUCTS-COMFJOP AGG $
MB APPLIES PERO- LOC
POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB §
fM
TO
BODILY INJURY §
NED AUTOS (Per person)
ULED AUTOS
BODILY INJURY §
AUTOS (Par'audden0
WNED AUTOS
PROPERTY DAMAGE §
(Per eocidenl)
AUTO ONLY EA ACCIDENT $
BILITY OTHER THAN EA AGC $
TO AUTO ONLY: NSG $
EACH OCCURRENCE $
BRELLA LIABILITY AGGREGATE $
R ❑CLAIMS MADE $
CIBLE $
TION $ X TORY LIMITS ER
WORKERS COMPENSATION AND
A EMPLOYERS'LIABILITY 90967005 05/01/08 05/01/09 E.L.EACH ACCIDENT $500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L DISEASE-EA EMPLOYE $500,000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE.POLICY LIMB Is500,000
11yyeea6 deaoribe under -
SPECIALPROVISIONSbelow
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CANCELLATIOtd
CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
SPEC001
DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO Sp SHALL
S•PECINLI'�+N IMPOSE NO OBLIGATION OR LIABILITY OF AN UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
James J. Farren CPC
®A C RPOIIATION 1988
.n,.on ec MnMMAI _
ouu wasningron career
{on, M<4 02��F
y www mass og v/dia
'�V�gkelst-Gomtl�nsatlon�►suranee�l�idav>L:.,Buildelrs/ContractorslElectr-lclanslPlunabers
Applicant Information Please Print Legibly
Name(Business/organization/Individual): NEWPRO
Address: 26 CEDAR STREET
City/State/Zip: WOBURN,MA 01801 Phone#: 781-932-8300 Ext.251
Are you an employer? Check the appropriate box:. Type of project(required):
1,X I am a employer with 50+. 4. ❑ I 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. $ 7. X Remodeling
ship and have no employees ' These sub-contractors have 8. ❑ Demolition
workers' coin insurance.
working for me in any capacity. p'. 9• ❑ Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL 11.❑ Plumbing repairs or additions
3. ❑ I am a homeowner doing all work g P p
myself. [No workers' comp. c. 152, § 1(4),and we have no 12.❑ Roof repairs
insurance required.)+ employees. [No workers' . 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
+Homeowners who submit this affidavit indicating they aro doing all work and then hire outside contractors must submit a new affidavit indicating such.
tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing worirers'compensation insurance for my employees.Below is the policy andlob site information..
Insurance Company Name: ARBELLA PROTECTION INSURANCE
Policy#or Self-ins.Lie.#- 909670.05- / Expiration Date: 05/01/2008
Job Site Address: Q �i�CJ/l�L- �/yJG• 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
Investigations of the DIA for insurance coverage verification.
X do hereby certify under thepains andpenalties o eriury that the tnformatton provided above is true and correct.
Si atura: tr FOR NEWPRO Date: 3 A
Phone#: 781-953-8146
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 .Buildin De artmen 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
.� Ji[C 70Mr/mi0?a[I/ea�p�✓Yut�utde� P
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` f - CgnstrsuctiortSupervisor-License--
CS 29090 t
/1.P,/2009 Tr# 8131
4
THOMAS P
230:WALNUT
j
READING,MA.01867 ""r� Commtssioner
7'e �omi�maazlnaal!/ a�✓ ygaacfuraeQ2 j
Board of Building ttegulation6 and,Staddarbs
HOME04PROVEMENT CONTRACTOR
Re tCstt'a'ton X46589
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� R "IementCard'
HEWPRO OPERA ? L �7
THOMAS FOXON'� -
i 26 CEDAR ST.
WOBURN,MA 01801 Ad st.
ENERGY
Highlightedin
=qualified in all zones
NEWPRO MANUFACTURING
^'N�a�" NEWPRO 2000 DOUBLE HUNG
Cellular PVC frame,Triple glazed,
Ndt n811 eneslre0on Low E coating(e=0:034, S2&5),
Rating Coundl® Krypton/Argon/air filled
'- DEV-K-27.00015.00001
ENERGY PERFORMANCE RATINGS
U-Factor(U.SJI-P) Solar Heat Gain Coefficient
0.19 0.27
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance Air Leakage (U.SA-P)
OrTnsAO 0. 1
Condensation Resistance
ate
70
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CITY OF SALEM
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DEPARTMENT
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'I I(I: '1,8-'4;'1;1)5 ♦ 1: N: 'P8.74=-4846
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 1 1 L5
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
I 11, S 150A.
The debris will be transported by:
(name of hatder)
The debris will be disposed of in :
(name offacility)�
(address of facif y
signature of permit applicant
date —