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7 COUNTRYSIDE LN - BPA r The Commonwealth of Massachusetts �� � Board of Building Regulations and Standards CITY 1 y �' Massachusetts State Building Code, 780 CMR, 7"edition OF SALF.M ��1✓✓✓ Revised Jonutiry Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. d008 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Numbe • Date Applied: Signature: I Buil gCommissioner nsliector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Adgress: 1.2 Assessors Map& Parcel Numbers �I . Sr W_LAAL_ 1.[a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Prupe..y Dimensions: Zoning District Proposed Use Lot Area(sq Il) Frontage(tt) 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: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 7 C,7wl-¢r7 4t de Lo SQ 6?4/ Vt Na a rint) Address for Service: (q7&) ?Cf® - Z7g7 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ I Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Des;rip�ion of Proposed Work': �� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building 5v, 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S p vU 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Su ression Tutal All Fees: S Check No. Check Amount: Cash Amount: 6.Total Project Cost: S () `(O � ❑Paid in Full El Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 000 rD?O I t / 1/ �U �� �z� I.icense Number Espira ton Da Name f C' -1 uWer JY� List CSL Type(see below) TUT Description .Address Unrestricted u to 35,0W Cu.Ft. -� R Restricted 1&2 Family Dwelling Sign-t rc y ��Ci7 M Masonry Only 706 S�f JO RC Residential Roofing Covering fclephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation F— D Residential Demolition 5.2 Kl�� d ye proveent Contr or(H)�,_ f1O t��8 Ij [Jma�y2mtc��i y J rf16Gf 1 -I H ny IC Company N- a or IIIC Pk islraN:u ^ Registration Number 44€ .s Os �f �a ao to Addres Expiation Date Mgnu Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 AUTHORIZATrON TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize , 6� IT L.CO `v to act on my behalf, in all matters relative to work authorized by this buildingitermit application. � 6-�2- 12-0 l0 Si ature of Owner Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION p— / "q ,asQwee br Authorized Agent hereby declare that the statements and information efin the foregoing application are true and accurate,to the best of my knowledge and behalf. _ Print Name Signature of er or Authorize Ag t Date Si ncd undo a am and n ties of n. 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. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS, respectively. ? 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" . , CITY, OF SALEM PUBLIC PROPRERTY DEPARTMENT MI rl • Illy ,dl l,C�'.,.IO�I..,p15fOkcT 1.111\I.fit.\�{\I 111y 1,••1'r'• I'rl:v:1.70- 95 construction Debris brisI) pnal llldavit f llm I renovation work) In accurda me with the sixth edition of the State Building Code, 730 CMR scctiun 111.5 Debris, and the Provisions ofMGL c 4U,S s4; MGL c is issued with the condition that the debris resulting fro", Permit q rl licensed waste disposal facility a2 defined by this work shall be disposed of in a Prope Y t 11. S I50A. The debris will be transported by: 1110 of hauler) l The debris will be disposed of in (name ul su Ity taJJrlevl ul'1'xJuy! arnature 4, ni 4pi)11 � 7 late CITY OF S.U.E.`(, ISSACHUSE'I'IS 3LULDC4G DEPAIMM14T 120 W.%imINGTON STRalT. is FLOOR TM. (978) 743.9"S FAx(97� 7�4961f KlN®FAEY OIl1SCOLL T1WswST.Plans MAYOIL DIRWWR O/rL ecu PROIERTT/K MDLMG CM011151CM ER Workers' Campensstloe Instwanca AfIldsvit: guilders/Contractors/Elmtric(analPlumben annlleant Informatlots Plesse Print Leuibtft Valnelsu,rne+rOrgarrrsnonlrrbv�duall: �� � ��'e'`7 Address: �oi�l1�S City/Studzip: 40 Phone F; epnw em plew. Chock low app"p�u ben Type o/proiad(rpttkrtdk enpkiyw with d• ara a gel eeaeaese anal 1 6. ❑Now construction ees If and/or part•dove).e have hired the adicatr sun oM prspriesor ar pattrw• liatd m the aaaehd sheet t L. `Remalrling d have no amplayso Tlwe sub•commearro haw a. Demolition far an in as c work rs'camp.inwaaaap` y !. Wa ers•e 9. DuiWiry addltioa tken•corn insurance °�°rs MW is 10.Q ELarical repairs or additions reoted.1 oRlers low taaeiatd lhtir 5.❑ I am a homeowner Join/all work ^sla eftort"Prion por MOL, 1 I.Q PlumbinE repairs or addition myself(No workers'carp. c• 13%f 1(1).and we hove no 12.C]Roof repairs insurenco required)► arnvlayeae.LNe w'arkew 13.0 Ogler — camp insurance regairedl •Aq apyaw tba Chun on of eats ales no w aw rids baM,twleg rbrir watw'rrnpoeme n peary iadwredab 't6rrwws wrr nnrr able alabvir iadlraaq nwy ar dais as workout rbs hire aaaeit.sttraeaw ese aabrab•crew ar awit indhrirrs cad 'C.wtrrr,,4%t cbrk ibis bs rear awarbed as&brat W Am,baw4q on aces rift w►ternmon aed drb..a.e'carp,v+wr?•�rww.r► lam an Soho6rAePN6lour//alsfb in/wars/iea Insurance Company Name: Policy a or Self-ins Lis.M: Expiration Darr. Job Sire Address: CityislaoiZip .%cracle a copy of the wort are'cesponaolMe petley doelarstlso pap(shewlnE the pdkay aeobr sad aspl►allae dob)6 F ailune to,"urn coverage as regtaired under gallon 11A of NGL e. 152 can lead to the imposition of criminal penalties of a f ne up to S 1.500.00 and/or ono-year imprissnmear as wig as civil penalties in ter farm of a STOP WORK ORDER and a Bd .if up to SI50.00 a Jay iWinsl the violator. Ile adWArd that a arpy of this slatement maybe rurwurdsd to the 01VIce of Inrcaieatius al'itnr DIA for insurance covcrap verillcatiaL r do hnebp rerd unI rAe iea end I /per/aq eAae rAe in/wwadM pmvjde l abw i* resat ed:.red ;,,• G I?urar P•nre A• ; r7 -S ne not write he Mitt ereq to 61♦sates rN+f/ a'i N/Iave n Yell Of >< City at ruwn: errmicrucen+e/__ laving Awhonty(circle tine): 1. Iluwrd u(Ilvallb 1. Ruddana Mparemcne I. Cityfrown Clerk 1. Electrical Lrtpector 1. Plumbing In.peetor 6.Other L..nlacl Pertaa: _ _ .. Photo t: CERTIFICATE OF LIABILITY INSURANCE DATE,MMDDVYYV) OP ID DJ JBA M 02 25 10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION McSweeney & Ricci Ins Ag Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 420 Washington Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 850984 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Braintree MA 02185 Phonea781-848-8600 Pax:781-843-8807 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Peerless Insurance Company 24198 INSURER B: - J Barnes Electric Inc INSURER C: - 313- Eastern Avenue INSURER D: Lynn MA 01902 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 ANV 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMID V DATE MMIE POLICY DO TION LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CBP8735787 01/01/10 01/01/11 PREMISES(Ea o rence - S100,000 CLAIMS MADE X❑OCCUR N ED EXP(Any one Person) $ 5 r 0 0 0 PERSONAL 8 ADV INJURY S1,000,000 GENERAL AGGREGATE $ 2r OOO�OOO GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO 52r OOOr OOO f'OLICV X JECOT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S1,000,000 A ANY AUTO BA 8737887 01/01/10 01/01/11 (Ea accident ALL OWNED AUTOS BODILY INJURY S (Per peg n) X SCHFnw Fn AUTOS X HIRED AUTOS BODILY INJURY S X NON-OWNED AUTOS - _ (Per accident) - '- PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGO S EXCESS I UMBREI I A LIABILITY EACH OCCURRENCE $ 5 r 00 0 r 0 0 0 A OCCUR � CLAIMSMADE CU8739187 01/01/10 01/01/11 AGGREGATE $ 5,000,000 S DEDUCTIBLE $ X RETENTION $10,000 _ S WORKERS COMPENSATDN X I TORYLIMRS I 1W AND EMPLOYERS'LIABILITY YIN A ANY PROPRIETORIPARTNER/EXECUIT WC8734987 01/01/10 01/01/11 E.L.EACH ACCIDENT S 500000 OFFICERIMEMBER EXCLUDED? ELDLSEASE-F<FrnP (Mandatory_In Ityes,describe under EL DISEASE-POLICY LIMIT $ 500000 SPECIAL PROVISIONS Uei OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION JKELLY1 DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR J. Kelley REPRESENTATIVES. 6 Arbutus Rd. AUTHORIZED REPRESENTATIVE Swampscott MA 01907 L_//jr'V(1 \ atA- ACORD 25(2009101) ©1 8-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1p,ay., p4 201p 11 : 26RM R JRMES LYNCH IMSURRMCE R 7SISS90580 5/4/2010 12 :01 : 53 PM 8936 0 02/02 CERTIFICATE OF LlABaJTV INSURANCE I S41e mmWIKeATi ie SAYase Im a iY.Tt;n u )IftvAAofIll MLT We Wp doss OatW SAW QAT)mZCAWn nn(AaA. TAtW LSATim CAts av33 Sal Ats10Y0l T=31 DA sa4AT2 Cdo l 21M pRs® Ob NSet i3t LaYPAAn, ATJnstoD at Tas snL)tTle nCen. SQL CEASxtTo, or 1 mn 1KC3 MDoMMOMo QGT LOPBTITPID A tsR)gS. S�9 T8 tiT3)W GtBOn®19). Aei9eCt® KniTe[RaTS G ns 9btNm, Aso TO sMTYGa3 YnWA. i INPORTAgT, 1] Gb vee +eante tgldgr is es ACaT:OigL ies WP, the p:lcYlies: usa ba wlarel. !f s'v'nx3:ATrpn le mu3a, G: itn lain 0.'1C collaa:iC s Of to. '-'1'i:p. C@m.= peli4¢e vav raq its m: engecevn<6i. A iLbLgLd^d Cb tali Certi ic't, Apes fat Af+: rigetl m et C•rttfic.le rp dtv A. 1)e_ a! 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