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14 CLIFTON AVE - BUILDING INSPECTION a The (',tnunuirttralth of�11as,:trhusetts V t Board of Buildinc RegulationS aril Stand:rJ sIt I � III \11 Nlt 'IP \1 I I 1 �blassarhusetts State Building Code, 73(1 ('M11R, 7 eJitio;; I ; Building Permit ,lpPlic:uion To ('onsu"urt. Rrpair. Renu�;rte Or Ih•nwli.h a Krl r,rJ.6 u,r, n, 0'W- nr' To',r-Fmnill Di,rllmg �SecrtonTis r Ofcial Lise Only 3u,IJing Permi on erD;ue \PPhed. Signauredd cirnlh u n�Buing Contnn.s i •i/ Inslto 3ddgs SCIOI: 1 PN S7E INFOJ :\ f1O�N�� 1f--r7--/----�---b---_-----__..-_- -- .! !.1 aruperh'/'+\� ress: 1.2 Assessors `L,p �Yz Parccl Numbers an ;ruej�teJ=Irt. r! Ji`.._- n•.. 1.: II h:r In:off rttation. - — _— i f J F . .Dcrt 1.5 Building Setbacks (ft) Front Yard Sale Yards Rear ford Requirrd Provided Required Provided Re uoed _ 4 P" d-d F1.6 Water Supply: (M G L r 10, §51) 1.7 Flood Zone Informat3or.: 1.8 Sewage Disposal Sy strnr: ! PLlhlk ❑ Private❑ Zone: Outside Flood Zone? Check it'yes❑ Municipal ❑ On ate disposal Syaen, ❑ 1 _ SECTION 3: PROPERTY OWNERSHIP' 1 :.1 Owner'of !tecord: N.w.e nt address for Service: .S!gn—`f --__ Telephone SEC:'ION ?: DESCRIPTIO OF PROPOSED "NOR K2 tchev all tha! apply) --- -- n'h , L.nin:clan .� ! Exisu ng R uiiding ❑ Owner Occupied U 1 Repo,rsf s) �Aiter.0 wrtsl ❑ :AJJinl,n ❑T- ..I Denn:ntp,o ❑❑�Accessoly Gldg. ❑ I�•nber_d-Units Other ❑ Spcnly.r i:! .. iptiun i,!Prapused %Vork': .p --g -- -- --- C h� 1 f1.P_T-G✓1 �C tvsS..c-� �P,;PI FIC I r _ -. _.k•�S.C'_(.ur1-.G I —_i{.7 • LcSt'�� --- i�d- So_.�,.ks—�,.. 4 L2`f_�r ._Qs,+y!��.o,�,{.._t,K'C.'�.4rn--G r.�,4 C-I' . cn SECTION 4: ESTIMATED CONSTRUCTION COSTS liern Estimated Costs: - -� _ 11 abor ::nd Rlaterialsl OfYcial Use Only L13 alJing S OQ I. building Perm Fee S _ InJlrate h„u fec is JrtermnrrJ I F.!cr[rical S CJ Standard Cityfl'own Application Fee ❑Total Project Coat' Item G) x multiplier_ x 7. Plunihing g 3 ( - _ —1 I Other Fees: 'S �j �4. Nlerhanical (H\'AC) $ List: •-� (F ftchunn:al (Fire Su t res5 n,n; 5 ! Total :\II Fees: S Check No. Check .\mount ('a>h Avioum t o Total Project Cost: 5 _ i ( U O . �I ❑ PuiJ in Full ❑ Outslandin'r B:Dance Uuc:—_----.— k' Lt rpp SECTION 5: CONSTRUCTION SERVICES �r __—_—__ 5.1 Licensed Construction Supervisor ICS1.1 © T? — tDj __�� Liranse Nutuhrr I`.ynrauon U.tic I Ndnn• ul ('St. IIOIJer � I_ul CSI. ft lie txc below 1 Ucsin roan L Lnrl�nlr lrJ nl t IU}?.lN)0(lt I-l. WJrry — F.i r —~ -- Runctrd I fir'_ nu lt Dw:lhnc .� lt_nauue - \i \lawns Only ---� 3 7 ----KC KraJrnUal Kut.line Cotrtme A 11 S Kradcntial iF RcaJruo,il SuItJ Furl ISw nine \Igtl i.mr.' lu�t.d Lit ini, p Kradcno,d Urn ud won — .--- 5.2 Re�(st-red Home iproserntil 66 /L C r. - S --12r�g u-ra-uun Vumh.•r (,r)Illndll'VIC of NIC Kcgi r:yrt Vamc Q — o/Gl.Z ,\, f" Addres. /) /J� �c'�( 37a:7 F.x lirunrit U:nr I Sienuturc SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(b)i Worker Compensation Insurance affidavit must be completed and submitted with this appliratiun. F:ulurc to pro iJe this affidavit will result in the denial of the issuance rt the building permit. Signed Affidavit Attached'' Yes .......... Imo' No _ ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT — ,t e U2XLA V.. as Owner of the subject property hereby to act on my behalf. in all nutters authurizr �e!ative o6�ncr thoriz d by his building permit application. — -- - I Si nature O SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION P®��,� �J ,[ 1 J�e✓1 as Owner o uthorized Agent erehy declare 1 1\ that the statements and information on the foregoing application are true and accurate, to the es o my knowledge and behalfC,Print N Date Sienature of Owner or:\uthonzrd :agent (.Signed under tilt earns and eenaltieS of Peru 't NOTES: I. An Owner who obtains ❑ building permit to do his/her own stork. ur an otener who hires ❑n unregistrred rrnura.ux� ontractor (HIC) Program). will nor have access to the :ii ind uon (not registered in the Home Improvement C program or guaranty fund under M.G.L. c. la'_A. Other important intolmation on the MC Pro and Construction Supervisor Licensing ICSLI can be tOUnd in 780 CMR Regulations I IO.R6 and 1 IO.RS, rcspecntcic tion below: When +ubswnual work is planned, pnlvtJe the infircmancludmg garage. finished basemenUatucs, decks or Parch' Total flours area (Sq. Ft.I Habitable room count —---- I Gross living area (Sq. Ft.l Number tit hedroums — ---.._ Number of ['replaces Number ,I halt/h,uhs _--_—_-----.---- .- Number ,rt bathrooms Number tit decks/ p,u.hc.Lj-�pe of heating system I:n:b-sedc of cooling system'�Tt'tal Pmj a't Syuare Footage' may be �ubstiluled for �rolal 11mlect C—l" CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT I'_ \\ ,.t . .. ,\ i. .III • <,,. �I. \I�..\ . .It : 1� ,'s.-1;.,;.); r f s\. NN orkers' (,Out pen sat ion Insurance asit: flu ilders/Cuntrrc torsi Elect riciansiPlumbers \ t iltkant Information 1\ Q CC Please Print Legibly In.h,:Jual t. r \dclrcis: 071 Y 60C3'srr'4� S� I Ua) slate.zip:�"c_'6 �^G/Y� Lf- DI�IY�rhone 631 37S-7 \re you an employer? Check the spprlpriate bolt: Type of project(required): 1 1 :tin a unployer w ith �_ 4, h. ❑❑ 1 till a general contractor and I New construction � cinpluyees(full and'ur part-thine)." ha\e hired file sub-contracture ❑ listed on the attached sheet. Remodeling _'.❑ I sun a sole proprietor or partner- ,htp and have no employees these sub-contracture have s. ❑ Demolition Dorking for me in any capacity workers' comp. insurance. y, ❑ Building addition No workers' cons insurance 5. ❑ We are corporation and ifs pns a officers have C%CfClsed IhCI[ It)'❑ Electrical repairs or additions required.[ 1 1. Plumbing repairs or additions 3.❑ 1 am a homeowner cluing all work right of exemption per N1GL ❑ g F• myself. [No workers' camp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] f employees. [No workers' 13.0 Other comp. insurance required.] •;\oy.,pp i'ant that Checks box MI moot also till out the section below ahuwing their workers'compnnsauun policy information.- I iomeuwners who submit this affidavit indicating they are doing-if work and then hire outside contractors most wbmit a new affidavit indicating such. C nitrite tors that,heck this hux n,u..t attached an additional sheet,hu'ving the name of the sub-contractors and their workers'comp,policy information. l um an employer that is providing workers'Compensation insurance jar my employees. Bylaw is Ilse policy and job site information. Insurance(•umpany Name:_ )s4l�T Su•CWhC-'� / Policy x or Self=ins. Lilt. As: (� �� �C_r_`___ Expiration Date: vZ' 3 fl lt)b Site Address: t YI Tg�a City,state/zip: S��(6V kqA— d t,57,3 .\Bach a copy of the w(irkers' compensation pulley declaration page (showing the policy number and expiration date). Failure m) secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a line up to S 1.9oo.oft and'or one-year imprisonment, as well as cis it penalties in the torn of a STOP WORK ORDER and a fine „I up to S.50 Oq a Jay .lgaltl,t file %iolaor. Be ads i,ed that a copy of this statement may be forwarded to the Office of Itnc,nc-Itl,nu of the DIA 1„r mstnan,:c eo\crage \rnlicanon. /Ju havrhy rrni/r under pas u u penuhhrr uJ pa•rprry that theur/r,rmun uv on prtJ'Ihgt r is true and correct. I/llitiol use ,qr. no not it in this area, n, he c,implefted by tiry or town fi iciu2 ( its or I wsnt - Permo/Liceme q 771npelor Issuing \uihurity (circle unc):I. board of Ilealih 2. Building Department J. ( its, I'ossn Clerk 4. Electrical Inspector 5. plu6. other('ontactl'crsorr: I hone q: Information and Instructions %I.i,,.n !u,cu, lJencr.tl 1 .its, ch.gncr I icyuur, .ill empl,%er, n, pro%ide %%orkcrs' compen,awm for their enlplmecs. I'.u,u.uu To (Ills ,[.itule. :ul rutpfoi ee i, Jcl:n.cd is ' c%cr% per,on tit the ,en ice of .unahcr under ails .ontria „t hire. \I,i c„ or inp!ii:& oriI or %%linen . \:: ,mpforrr i, deli tied .t,, .ill :n%h%nl u.d. I,.n n:cr,h l p. a„tic i.o I'tit. .„rporanon or other !rgdl cnuh. ,r it its,,or more I the fin:_oinL: crr_.igcd in a joint cutctpn,e. .uid incluJine the Ic_al reprr,cntin%c, of3 Jace.i,eJ .•nlp meta or dte ci%er or u'u,tcc %,I in indi%iJw 1, p.0 titer,lop, .t„ociatwn ,R Ul tier Ic_iI el t t i t%, elil p losing cin p Io%"., I to%%e%er the „•%%ncr of e d%%elhng house hi%ing not snore thin three ipirnnents and %%ho rr,nlc, iticicin. or The oc:updnt of the J%%c i'iiw li,ni,c If .inother %%ho enq,lot, pervono to du ntduurnince. :on.arucnon or repair %%ork on ,uch d%velbng house ,.r ,m the _sounds or builJing .ippullen.int 111e1cN1 ,hall not hec.ur,e ot,uch eniplo%inent he Jccnicd to he .in cmplo}er. \II,I. chaplcr I�', ,_'i(if,) also ,talc, than -'c%cry %late or local licensing agency ,hall s%ithhuld the issuance or rene%s al of a license or permit to operate a business or to construct buildings in the commonwcalth for any applicant is ho has not produced acceptable e%idence of cumplia nee ss if the insurance co%crige required." \Jdirtondlly. SIGL chapter 152, ,_'?( I -) ,lanes Neither the conunonwed It nor any of its pot mcil :uhdis i,ions ;hall enter into any contract for the per to rill a nee of public work until acceptable e%idence of compliance \soh the insurance regllll el11eI1t5 it this chapter hate been presented to file contracting authority." \pplicants Plc;ise fill out the workers' compensation affidavit completely, by checking the boxes that apply W your Situation and, If necessary, supply sub-contraclorls) nanlel s), dddress(cs) and phone numberis)along with their certiticatels)of insurance. Limited Liability Companies ILLC) or Limited Liability Partnerships (LLP) with no employees other than the iuembers or partners, are not required to carry workers' compensation insurance. If an LLC or LLP dues have employees,a policy is required. Be advised that this affidavit may he submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the of iclavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their ;elf-insurance license number on the appropriate line. City or -town OfOcials Please he sure ilia[the affidavit is complete and printed legibly. The Department has provided a space at the bottom tit the affidavit for you to till out In (lie event the f)Ifice of Insestigatlons has to contact you regarding the applicant. Please he sure to till in the permit,license number which will be used as a reference number. In addition, an applicant that must submit multiple pemlivlicense applications in any given year, need only submit one affidavit indicating current policy intbrmation (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or low n)." A 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 the for future permits or licemes. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture I I e. i Jog license or permit to burn lea%cs etc.) ,aid person is .\QT required to complete this-dlfida%it, Ilie t Mice of Imestigations would like to think you in advance for your cooperalion and should you ha%e any questions, Idc.t,e do nol he,rtate to gyve us a ,ill. I fir 1),pat nnctn': iddress. telephone and tas mother: . . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia 1 CITY OF SALEM y\ PUBLIC PROPRERTY •,,, „�, ` DEPAR"I''�IENT I Construction Debris Disposal Affidavit (required lbr all demolition and renovation work) In accordance �N ith the sixth edition orthe State Building Code, 780 CNlR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit N 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: C�CU� n, CZJcV(- 0 T _ - -- (name of hauler) The debris will be disposed of in (name of tacility) S,4 rem 94,4-5,S (address of tacilily) 11_L•nalui'c of,permit applicant - � `Lt° a- - date 06/02/2008 11 :00 FAX 15084290099 Risk Strategies - Heidi goo 1/001 f1 02M CERTIFICATE OF LIABILITY INSURANCE ellnu008' PRODUCER (781)985-4d00 SAX: (781)963-4420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Risk Strategies Company HOLDER. THIS CERTIFICATE GOES NOT AMEND, EXTEND OR 400 North Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Raindoliph MA 02368 INSURERS AFFORDING COVERAGE NAIC B INSURED INSURERA:NQ4 Insurance Company Gashouse, Inc. INSURFAWNOrGAlard Insurance Co d/b/a Sullivan Construction INSURER C, 27 Norman Street INSURER O• Marblehead NA 01945 INSURERS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY it 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 INBR ADD'L TYPE OF INSURANCE POLICY NUMBER PWITEIMMIO�S DATE POLICY YNSIOOTION LIMITS GENERAL LIABILITY EACH OCCURRENCE 1 11000,00 DAMAG X COMMERCIAL GENERAL LABILITY M ETO gENTEO 1TEO A S 500,000 A CLAIMS MADE Q% OCCUR HYD83105 10/9/2007 10/9/2008 5 10,000 PERSONAL AADV INJURY 3 1,000,000 GENERAL AGGREGATE S 2,000,000 GENLAGGREGATE LIMITAPPLIES PER: pgonuCTS_COMPLOP AGG S 2,000,000 X Poucy F LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 6 ANYAUTO IES eOWMII ALLOMNBOAUTOS BODILY INJURY S SCHEDULED AUTOS (Per FA�AAAI HIREDAVTOE BODILY INJURY $ NON-OWNED AUTOS (Pm.,AAml PROPBRTY DAMAGE 6 (Per eAtmMI) GARAGE LIABILITY AUTO ONLY•EA ACCIDENT ANY AUTO OTHER THAN 6 AUTO ONLY: AG 6 EXCEOWUMBRELLA LIABILITY OCCUR CLAMS MADE - AGGREGATE S F DEDUCTIBLE _ 6 RETENTION B WORMERS COMPENSATION ANG - - X WC STATII- I ION- EMPLOYERS'LABILITY ANY PROPRIETOWPARTNEIVEXECLRIVE E.L.EA IOENT S 50D,OOD OFFICER/MEMBER EXCLUDE09 BUWC707415 12/3/2007 12/3/2008 I E•EA EMPLO ES 500,000 SPECALLP VISIONSInb E.L.DISEASE I YLIMIT 500,000 OTHER OESCPJPTION OF OPERATIONSILOCATIONSIVEHICLENEXCLUS10N6 ADDED BY ENOORSEMENVSPECIAL PROVISIONS IEMund as Svi"um o8 SnRMIanm. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of Salem EXPIRATION OATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Salem City Nall 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT Attn: Building Department FAILURE TO 00 60 SMALL IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE 93 Washington Street INSURE&ITS AGENTS OR REPRE5ENTATIVSS. Salem, MA 01970 AUTNOMEO REPRESENTATIVE Michael Christian/HE ACORD 26(200 108) 0 ACORD CORPORATION 1988 POW I Al 2 INS026(DIDBIABe ✓he Tioynnnmuwwsuc° '7"'•.,�-._-- - s Board of Building Regulations and Standards HOME�IMPROVEMENT CONTRACTOR ;! Registration: 139971 `> - Expiration: 9/8/2009 Tr# 261842 Type: DBA ,Y SULLIVAN CONSTRUCTION. y ROBERT SULLIVAN g 27 NORMAN ST. �— MARBLEHEAD,MA 01945 Administrator- ` r%�te l0awt»ranr�eall�i o G�axtc�i<dr././d � BOARD OF BUILDIN(REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS O49371 a�V 'r Birthdate: 0 610 5/1 9 62 yai e• Expires: 06/05/2008 Tr: no: 28036 _ - Restricted: 00 _ ROBERT P SULLIVAN JR - 27 NORMAN ST �j" MARBLEHEAD, MA"01945 - Commissioner — 'v L i ==_ USETTS 5661. _042 fi � y F06 05=ES010 06-05 1962 �a CL PEST r i p.-" ;A S10`mg- F `SULLIVAN ROBERTPJfl ;R �mnssnc !. I. 27NORMANST A p MARBLEHEAD,MA ,V 4 4„ f 01945-2672