25 CRESCENT DR - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�( Massachusetts State Building Code,780 CMR SALEM
Build' Permit Application To Construe Re Aei*ed� 2011
m8 PP t, pair,Renovate Or Demolish a
p One-or Two-Family Dwelling
(� ���-������^'=Jt;Thts�Secham For()�c�al Usej � . �,•.
D1Itd..,6DI�1� rl'P teAPplledr
SjBuildingAf6elel(Prmt+Name] Syr r — - �� s
() 1.1 Properly Addrem: 12 Assessors Map&Parcel Numbers
25 Crescent Drive, Salem, MA 01970
l.la Is this en accepted street?yeses_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Properly Dimensions:
Zoniog District Proposed Uae Lot Area(s4 ft) Fromege(ft)
1.5 Buikliog Setbacks(2),
Front Yard Side Yards Rear Yard
Required Provided Required Provided
_ Requited 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 if °7 Municipal❑ On she disposal system ❑
W , _.h �y •� SEClION2 fPR
VI WNOF� '<,t5 '� �- _ =
2.1 Owner'of Record: `
Janis Hanson and Kathy an Roper Salem MA 01970
Name(Print) City,,State,ZIP
25 Crescent nriv 978-741-4620 v ri salemstate.edu
No.and Street -- _. ....._-,-- Telephone Email Address
�2 W
-. �,>—I , DE3CRIPTIOIvsOF•P�ROPOSED WO1tK (check_,a111kafap�ly) J .q.,
New Construction❑ Existing Building 16 Owner-Occupied.d Rgxdrs(s)4 Altetation(s) ❑ Addition ❑
Demolition ❑ AccessoryBldg.O Number of Units_ Other 9 Specify:Replacement
Brief Description of Proposed-WoW:
Replacing 1 patio door, no structural change
SECTIONA:ESTIMATED CONSTRUGTI GaOST3 P °
Item Estimated Costs: qtl i
abor and Materials � �i. '?r O�gl�iUserOa T p a
1.Building $ 3,4571ButldhtemntFee t$33 k Imdtiretehbwfee•isd8tammed'r
2.Electrical $ []Stffitdard /fownApphrafion Fee• ° "" % " "4
3.Plumb' ❑TotaFP#rgect Cosh(item 6)x malfiplier
$ 2�Othei�Fees $ 0
4.Mechanical (HVAC) $
5.Mechanical (Fire4td
Suppression) $ Total All Fees'$ tsi
6.Total Project Cost: $ 3,457 Check No. ` Chock Amount: `Cash A ouin; "t r
❑Paid'inFull "-a*,,, ❑'OutstandmgBalenceIhe`"`:''i`�, -,
1I3 �At�� LtJ SRSE
5.1 Construction Supervisor License(CSL) 90
125 10-06-18
Jamie ML License Number
Name of CSL Holder I75ira6on Date
86 Gardiner St List CSL Type(see below) U
Lynn, MA 01905 U Unrestricted uilgina UP to 35.000 cu.i
City/Town,State,ZIP R Restricu;d JA Fermi Dwellin
M
RC Roo Cored
WS Window end Si
508-351-2214 a SF Solid Fuel Burning Appliances
Tel bone Insulation
Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 170810 Renewal by Andersen 12-23-17
I o beany Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Sueet
Northborough, MA 01532 508-351-2214 Email address
I State,ZIP Tel e
n_. >SECTIONrti:'WORI{ERS COMPENSATION'1ISGRANCE AFFIDAVIT([yam c 15y QgC ''
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...........O — - -
"; SECTION 7e 'Ti
LETED ON'T 'BE C ! 01 R
«• _- OKNEB'S/AGE iTOB1-11,11MI-OKAPPLI S:FURiBI]II:DINGPF
I,as Owner of the subject property,hereby authorize Jamie Morin
to act on my behalt;in all matters relative to work authorized by this building permit application.
SEE
CONTRACT
Flint Owner's Name(Electronic Signature) 10127/9018
Date
CTIONd7tiiOWNER'OR'AUTHORiZED�AGENT'DE ►ION ""
BY Bering 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,
JAIME MORIN
_ Print Owner's or Authorized A -= 1 0/2 719 0 1 R
gent's Name(Electronic Signature) Date
1 An Owner-who a building permit to
do his her own work,or an owns who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IOC)program),will nor 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
J�v.mass aov/oca htformation on the Construction SSrpervisor Lic®se can be found at www. sea o,,.,I
2. When substantial work is phoned,provide the information below:
Total floor area(sq.ft.) (including gaage,finished basement/attics,decks or porch)
Gross living area(sq.ft) Habitable room count
Number of fireplaces Habitable
- -_
Nt�berofbathraoms umber of bedrooms
ofhalf/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 SALEAd, UASSACHUSETTS
BLIWDIG DEPA84'a mT
120 WAMNOTON STRW.Y*PLooa
TEL(979)745-9595
IMMMU EY DRISCOLL PAX(978)740.9M
MAYOR THOMAS ST.PMRU
DMEMI Of PUKX PR0PEM/8LT- C;c0S445StC*=
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 111.5
Debris,and the provisions of MGL a 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
111,S 150A
The debris will be transported by;
Renewal by Andersen
(name ofhau w)
The debris will be disposed of in
Renewal by Andersen
(name or facility)
30 Forbes Rd, Northborough, MA 01532
(address of facility)
signature of permit applicant
data
debriadCdw
The t^.otseneoawveale(r ofMoavachasdti(s
Deparaatant aJ'Indvab>id At�denRw
QW606OfInva gadens
600 WaWnSIM Sb W
Boston,HA 92111
Work 'Compsmadc m Imuranee Affidavit g die
Workers'
APa1G:ant Info ntannC� bsIe(ans/Plambers
p1�Je Pllat .odhly
Name i; RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
. NORTHBORO.MA 01632 Phone# 508-MI-2214
Are You an emP)oY'e11 Check The appropriate boat
1.O I am a employer with 30 4. 0 I am a genwal cont ache and Ir7.
dProl�( :
employees(6h11 and/orPart time).• have hired the s NaW Co>t�uction
2.❑ I am a sole pmprbeOr orpaMar- hdod on the attw&ad Sheet �rmg
ship and have m employers These eab-conhaetote have Damo)itga
Woridag forme in any capacity. amployaosandhaveworkora'[No workers'comp.i�oe comp,ksuraace t addilioa
3.❑ requirail 5• ❑ We aro a caspmation and its 1 1?teobtcal mPece or additions
I am a homeowner dotog a0 work officers bows mteroin d their 11,❑B6*ing or mysa[No wcdmrs'amp. right Of exam onparMOL ❑ �® atom
e rogairal]t c.15$61(4),and we have no 12' Roof
employees.[No workers' 1313 Omer
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Insurance Company N me: OLD REPUBLIC INSURANCE COMPANY
Policy#or Salf-ios.lac.#: MWC30823100
Bxpaadon Dms: 10/01/2017
Job SiteAddteer 25 Cresent Drive
��,mpy��� ,����Policy dachriatlast atya em MA01970
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bmhlg An0mrlty(drde one):
L Boar of Heilth L liopdi�Depsrtmaat 3,City/fown Clerk 4.Eleeuteal Impactor S.
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ANDECOR-01 SALWAWV
`..� CERTIFICATE OF LIABILITY INSURANCE DA'E""MoA'yM
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CERTIFICATE 18 ISSUED AS A NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.9/3=016
TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONBTRUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORLMD
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30 Fmbos Road
Northborough.MA 01532 PURJFIER O:
INSURER E:
COVERAGES RBURer P
CERTIFICATE NUMBER: RIN1910N NUMBER:
THIS M TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEEJL43UED7DTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDMoN OF ANY CONTRACTOR OTHER DOCUMIXTWTIH 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 POLICES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LM TYPE Or MOUPANCE POLICY NIAmlR
A X comaRGAL sanrAL UABany LasTa
cIAIIB-HALE [X OCCUR W2Y 308284 EACH 0tuR� $ 1100010
10/0U2018 10101/1M7 S 500,00
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RMAOBREGATEUMIT.APPUES PER I PBt30NALBAPINJURY S 1,000,000
X Po�❑JECrpp ❑LOC I AL AGGREGATE S 4,000,00
OTHER PPDDJCre-COMM-ArXi s- 4000,00
AUTUMMLE LIMILnY =
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DESCRIPTION OF OF OPEAATIDNB oelen I EL DISEASE-PA BAPL 3 1,000,000
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DESCRIPTION Or 0pMTIONBILOCATMNE/YEIeCIa3(ACORD 101,Adtl "Renmb adws'N'„ ,be VbebeeBmme spear m*drad)
CERTIFICATE HOLDER
*ANCELLATIONN
OF THE ABOVE DEWMagD POLICHES BE CANCELLED 804MM
ION DATE THEREOF. NOTICEWILLBEDELNERED 01 WITH THE POLICY PRWISIDNB.EBBRAnnalrrwrence a
ACORD 25(2014ro1) 41988.2014 ACORD CORPORATION. All rights reserved.
The ACORD nano and logo are registered marks of ACORD
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Construction Supervisor
JAHAE L MOFtIN Y
80 GARDINER STLYNN MA ("ON
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RENEWAL BY AN
JAIME MORIN
30 FORBES RD
NORTHBOROUGH,MA 01532 Uadereeerctary
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