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COMMUNITY BUILDING, LEE FORT TERRACE - BPA-12-468 The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF 1 Q Massachusetts State Building Code, 780 CMR SALEM W Building Permit Application To Construct,Repair,Renovate Or Demolish Revised Mar 1011 One-or Two-Family Dwelling This Section For Official Use Only Btuilding Permit Number: . Date Applied: Building Official(Print Name) Si a Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers community Building.Lee Fat Ten 1.1 a Is this an accepted street?yes no Map Number Parcel Number 13 Zoning Information: 1.4 Properly 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? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: Salem Housing Authority Salem, MA 01970 Name(Print) City,State,ZIP 27 Charter Street 978-744-4431 dtucker@salemha.org No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building ZI Owner-Occupied ® Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work : Replacement of Entry doors, New vinyl Soffit, Wrapping of existing fascia SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ -�L 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/TownApplication Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ 6.Total Project Cost: $ y�v Check No. Check Amount: Cash Amount: / I ❑Paid in Full ❑Outstanding Balance Due: I t a SECTION 5: :CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS 71077 7/25/2013 Charles J. Minasalli License Number Expiration Date Name of CSL Holder List CSL Type(see below) 9 Epping Ave No.and Street , Type: Description U Unrestricted(Buildings up to 35,000 cu.ft. Hampton, NH 03842 R Restricted 1&2 Family Dwelling City/1'own,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 603-234-9213 Cminasalli@gmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 117430 10-3-2012 Environmental Restorations, Inc./Charles Minasalli HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 10 Hazel Drive Cminasalli@gmail.com No.and Street Email address Hampstead. NH 03841 603-329-6101 City/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 Issuance of the building permit. Signed Affidavit Attached? Yes .......... go 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 Environmental Restorations, Inc. to act my behalf,in all matters relative to work authorized by this building permit application. er's Name(Electronic .gna SECTION 7b:OWNEW OR AUTHORIZED AGENT:DECL ION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained 11 iss appliiccation is�truue and accurate to the best of my knowledge and understanding. / (�/� iJ�. A4yi/ //-/0- 70/l Printer's o Autitnzed Age is 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 HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 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"may be substituted for"Total Project Cost" i CITY OF S.1L INJ, 1AXSSACHL'SETTS • BUILDING DEPART IUNT • ' 120 WASHINGTON STREET,3"FLOOR TEL (978)745-9595 FAX(978)740-9846 KIMBERLEY DRISCOLL MAYOR •ITfObtAS ST.PIERR6 DIRECTOR OF PUBLIC PROPERTY/BL'Q.DLNG CMMUSSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(.BushxswOrganizatiomindividuat):Environmental Restorations, Inc. Address:10 Hazel Drive City/State/Zip:Hampstead, NH 03841 phone#:603-329-6101 Are you as employer?Check the appropriate box: Type of project(t'equlred): I.® 1 am a employer with 75 4. ❑ I am a general contractor and 1 6. ❑New construction employees(fidl and/or part-time).' have hired the subcontractors 2.❑ 1 am a sole proprietor or partner- listed m1 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. C Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL t I.O Plumbing repairs m additions myself.[No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repass insurance required.)t employees.[No workers' !3 Other comp. insurance required.) ;Any applivam that stwdts box#1 must also Ill out the section below showing their work,,'compensation policy mrurmmion. f l huneowneus who submit this affidavit indicating they ate doing all work and then hire maside cmtranms must submit a new affidavit iodising suck =('unto voss thin cheek this Ism mutt anwhed an additional sheet showing she more of the sab.contmctom and their workem'comp,pal icy information. lam an employer that is providing workers'compensation Laurance for my employees. Below is the polfey and jab site information. insurance Company Name:Commerce& Industry Ins. co Policy#or Self-ins.Lic.#: WC003603167 Expiration Date:8/1/12 Job Site Address:Lee Fort Terrace City/State/Zip: Salem, MA 01970 Attack 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 S 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 or the DIA for insurance coverage verification. l do hereby certify under, pains rd penalties of perjury that the information provided above is true and correct Siiniture' �` 'i,tAi� Date. 11-4-11 Phone eel:603-329-6101 F01her enly. Do not write in this urea,to be completed by city or town official Town: _ PermittLicense# ority(circle one): Ilealth 2.Building Department 1.Cityffown Clerk 4.Electrical Inspector S. Plumbing Inspector son• Phone#: 1 i1 OP ID:TF ACORO' Dare(f!WDDNYYY) CERTIFICATE OF LIABILITY INSURANCE o8108111 F S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LOW. 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 policylies)must be endorsed. If SUBROGATION IS WANED,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 781-935-WO CONTACT NAME: DeSanctis Insurance Agcy,Inc. 781-933-5645 PHONE FAX 36 Cummings Park E-mAa MC No: Woburn,MA 01801 ADM Ess: PR11 ODUCER I .ENVIR-2 INSURER(SI AFFORDING COVERAGE NAICI INSURED Environmental Restorations Inc INSURER A:Everest Indemnity Insurance 10 Hazel Drive - INSURER B:Harleysville Insurance Hampstead, NH 03841 INSURER c:Commerce&Industry Ins.Co. 19410 INSURERD:Acadia Insurance Company INSURER E: INSURER F 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 INSURANCE ADDL SUB POUCYEFF POUCYEXP LTR .5a Me POUCY NUMBER IMMMDMWI lmwleIYYVYlUNITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY EF4ML01532111 06/01111 06,01,12 pREMISE a occurrence) $ 50,00 DLAutiontla ®OCCUR MED EXP(Anyone person) $ 5,00 X Inc.PollutlonLiab PERSONAL 8 ADV INJURY $ 1,000,00 Asbestos/Lead GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X PRO- JECT p LOG $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ 1,000,00 ANY AUTO (Ee accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ B X SCHEDULED AUTOS BA00000064339E 04/12111 04/12/12 BODILY INJURY(Per accitlenq $ X HIRED AUTOS PROPERTY DAMAGE $ (Per ecrddent) X NON-OWNED AUTOS $ $ UMBRELLA LUIB X OCCUR EACH OCCURRENCE $ 5,000,00 EXCESS DAD CLAIMS-MADE A ]EF4CU00090111 06/01111 06/01/12 AGGREGATE $ 5,000,00 DEDUCTIBLE $ X RETENTION $ 1 O OOO - $ WORKERS COMPENSATION WC STATU- OTM- AND EMPLOYERS'LWBIUTY - X C ANY PROPRIETORPARTNERIEXECUTIVE YIN C003603167 08/01111 08/01112 OFFICERMEMBER EXCLUDED? NIA EL EACH ACCIDENT Y 1,000,00 (Mandatory le NH) MA,NH,RI,NY E1.DISEASE-EA EMPLOYE S 1,000,00 n yes,dearrice uncle, DESCRIPTION OF OPERATIONSDeIaw E.L.DISEASE-POLICY LIMIT $ 1,000,00 D Equipment CIM025607013 04123/11 04/23112 Scheduled 152,78 D Stored Materials CIM025607813 04/23/11 04/23/12 Stored. 50,0 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101.Addltlonal Rema-Is Schedule,if more apace la reeuhed) ILLUSTRATION OF COVERAGE. CERTIFICATE HOLDER CANCELLATION TO WHOM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TO WHOM IT MAY CONCERN THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. / AUTHORIZED R I VE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD �fc usut(fEr '$IS�i es Office a HOME IMPROVEMENT CONTRACTOR Registration: 5�117430 -type: Expiration: 0'12 Private Corporation ONMENT INC I - 1 CHARLES MINIS,it 10 HAZEL DR f HAMPSTEAD,NH 0� —4 Undersecretary e i Mas.sachusctts - Dcpmtment of Public Saict\ Board of Building Regulations and Stantlartls Construction Supervisor License License: CS 71077 CHARLES J MINASALLI 9 EPPING AVE HAMPTON, NH 03842 Expiration: 7/25/2013 ('munisviuner Tom: 998