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9 CROMBIE ST - BUILDING INSPECTION
` The Commonwealth of Massachusetts t " Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALERevised ar42011 U Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Dat lied: Building Building Official(Print Name) Signature SECTION 1: SITE INFO ti 1d Pro erty Address: 1.2 Assessors Map St Parcel Numbers t�s ti .Z s�- 1.1 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 ft) Frontage(ft) 1.5 Building Setbacks(Il) 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 yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) City,State,ZIP gCrca .4,t Sa 44is-54%- q&3Z No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑ Demolition Accessory Bldg.❑ Number of Units Other ❑ Specify: Br f Description of Proposed Workz: -- -sue d SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials F `. 1.Building $ & Y 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: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:$ Check No. _ Check Amount: Cash Amount: 6. Total Project Cost: $ J60 Paid in Full 0 Outstanding Balance Due: v SECTION 5:�CONSTRUCTION SERVICES k 5.1 Construction Supervisor License(CSL) l cf ( L -CS L License Number Expiration Date Name of CSL Holder List CSL Type(see below) 1� Croce S t . No.and Street Type I . Description �,�� U Unrestricted(Buildings u to 35,000 cu-ft.) IJ Restricted M2 Family Dwelling Ci /Town,Staatte,ZIP M Masonry /O�kCe` RC Roofing Covering 1... ` WS Window and Siding SF Solid Fuel Burning Appliances S�� JCS'(SbtFr] C(,"C,py—kG$G/'Ovt}rGL}-vg• nC I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) l UnST2 . 6h C�as, C .� '�l HIC Registration Number Expiration Date HIC Company Narryg or Registrant Name // Ct�C�SS L" No and Street " Email address Acue,rtN VGA -gay) 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 ........I,< No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize &R4- cw.. J to act on my be Calf,in all matters relative to work authorized by this building permit application. nt Owner's ame ectronic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this applicationis true and accurate to the best of my knowledge and understanding. nt C tV (— ) lint r?,/-7 /OD .Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 can be found at www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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 S.0 EN1, l LksSACHUSETTS • Bum mtG DEPARTNm,�1T 120 WASHNGTON STREET, Yo FLOOR TEL. (978) 745-9595 FAx(978) 740-9846 KIN jBERLEY DRISCOLL j% AYOR T HONUS ST.PMRRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Construction Debris Disposal Affidavit r, (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 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 111, S 150A. The debris will be transported� J � �bby: � � 6d�Nt /9 - C tj Up� — (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) signature of permit applicant =/3 date OP ID: DO ,4coiza CERTIFICATE OF LIABILITY INSURANCE O7118/2 Y 0 3 7/18/ 013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 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 policy(ies) must be endorsed. If SUBROGATION IS WAIVED, 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 endorsement(s). PRODUCER Phone:978-745-3300 NAMEACT John J Walsh Ins Agency,Inc Fax: 978-745-9557 PHONE FAX P O BOX 4407 AIC No Ext: A/C No): Salem,MA 01970-6407 - E-MAIL Mark W.Bettencourt PRODUCER CUSTOMER G,9CHAS01 INSURERS AFFORDING COVERAGE NAIC M INSURED Eric Chase dba INsuRERA.First Mercury Insurance Co. t, Chase Contracting&Project INSURER B:Commerce Insurance Company 34754 Management LLC INSURER C:Associated Employers Ins Co. 11 Cross Street Beverly, MA 01915 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 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. DD B POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY) (MMIDDNYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY NJCGL0000019695 10/22I2012 10/22/2013 PREMISES Ea accuEence $ 50,000 CLAIMS-MADE lxl OCCUR MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 . GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGO $ 23000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ B X SCHEDULED AUTOS RXQ123 05/04/2013 05/04/2014 PROPERTY DAMAGE X HIRED AUTOS (Peraccident) $ X NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY S C ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ N/A WCC-500-5012042-2013A 05/05/2013 05/05/2014 E.L.EACH ACCIDENT $ 13000,000 OFFICER/MEMBER EXCWDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EXPIRATIONTHE DATE THEREOF, City Of Salem ACCORDANCEWIfHTHEPOLICYPROVISIONISE WILL BE DELIVERED IN Attn: Building Inspector 93 Washington Street AUTHORIZED REPRESENTATIVE Salem, MA 01970 �' 'L✓(�'�/ .G�j. ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009/09) The ACORD name and 1090 are registered marks of ACORD aCITY OF S.ULE:Nt, i8v'L-kSSACHUSETTS BUILDIING DEPART E NT 120 WASHINGTON STREET.3aa FLOOR TEL (978) 745-9595 FAx(978) 740-9846 MIBRRT RY DRISCOLL MAYOR � TrIOMAs ST.PIERRS DIRECTOR OF Pt:BLIC PROPERTY/BUTLDCVG COM\11SSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ((''11 Please Print Legibly Name(BusinessOrganiratioNlndividual): Ir.t- a4sc Address: JI (fie tS 19 City/State/Zip: &AfAe Phone 1#: 9N'S 7$ Are you an employer?Check the appropriate box: Type of project(requireQ: I.J` I am a employer with :�z 4. 0 I am a general contractor and 1 6. ❑New construction employees(full and/or par-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its ]0 Electrical repairs or additions required,) officers have exercised the 3.❑ n 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have12.0 Roof repairs no insurance required.)t employees. [No workers' 13.0 Other comp. insurance required.) •Any applicant that chocks box#1 most also fill out the section below stowing their worker'compensation policy infutmadoa 'I fmtaowcrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a rcw affidavit indi®ting such ;Contractors that chock this boa moat attached an additional sheet showing the none of tho submmrctors and their worker•comp,policy information. I um an employer that is providing workers'compensation insurance for my employees. Below Is the policy and fob site information. Insurance Company Name: Wf4 S60-Sb►20 42• Z 01.1 rh— Policy 4 or Self-ins,Litt#: Expiration Date: OS I s•//y Job Site Address: S (or o.y.i, t SI— City/State/Zip: &/o.•.-. M fo Attach a copy of the workers'compensation Polley 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 S250.00 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. I do hereby certify�riderr i#e pains and penalties of perjury that the information provided above is true and correct. Silz t re: LN l Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offrciai City or Town: PermitfLicense# Issuing Authority(circle one): 1. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:— Phone#: