The URL can be used to link to this page

131 DERBY ST - BPA-16-423 BATH REMODEL U4 The Commonwealth of Massachusetts 'RrCE er Board of Building Regulations and Standards P ECTIO RVIES Massachusetts State Building Code,780 CMR S Revised Mar 201I Building Permit Application To Construct,Repair,Renovate Or Demol i V028 A One-or Two-Famhl v Dwelling This Section For Official Use Only 211, Building Permit Number. I . I ,, Data#plied Signature,p� Da Building Official(Print Name) SECTION I:SITE INFORMATION X- I.J.Property Address: l.2 Assessors Map&Parcel Numbers A r Is this an accepted street?yes no Map Number Parcel Number _ 1.3 Zoning Infairmation: T t.4 Property Dimensions:% A, Zoning District Proposed Use Lot A=(q ft) Frontage(ft) 75—Bonding Setbacks(11) A Front Yard Side Yards Rear Yard Required T: Provid ed vided Required Provided Provided — e : 1.6 Water Supply;(M.01 c.40,§54) 1.7 Flood Zone Information:?'f 1.8 Sewage Disposal System; Public(R Private 13 zone: outside riorid Zen? Municipal ES On site dis system' 0 CheckifyoC POW , in t `SECTION 2: PROPERT'VOWNERSHM' 2,%woerof RZr, JL 0 0. 54 leko%. M A 0 061a game(Prira)j4 I L .%advr' City State,ZIP 112 l 617 yJ o to�4 UA0 Y No.and Street Telephone E7jQ Address SECTION 3:DESCRUMON OF PROPOSED.WORIO(check all that apply5, New Construction 0 E-xisting Building 0 Owner-Occupied 0 1 Repairs(s) C3 1 Alteration(s) 6 Addition 0 Demolition W Accessory Bldg.C3 Number of Units_ Other 13 Specify Brief Description of Proposed Work?: 'Ll SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: I � " Item Official Use Only A- _4 (Labor and Materials) 1.Building 1. Building Permit Fee:S Indicate howfee is determined- 0 Standard Citytl`6,�jn ApplicationFee �zC 2.tlwri�l $ d Total Project Cose—Jitern 6)x multiplier x Ire 3.Plumbing S pQ o0 2. Other Fees. $ "I 4.Mlechardcal WAC) S List: L 5.Mechanical (Fire Suppression) $ 4e Toitail All Fees:S Check No. Check Amount Cash Amount: 6.Total Project Cost: $ 466 0 Paid in Full ,, I ding Balance D-ue- 0 Outstan _ J AA L Tt) 'f-_VAW_0 5(l:=_) 4" 21 SECTION5: CONSTRUCTION SERVICES .. A 5.1 Construction Supervisor License(CSL) .-, . . , to c�D�4_ ��UCI _ License Number =ExpirafionDine , Nnme ofCSL Holder - i List CSL Type(see below) ' P No.and Street _ TXPa '.° t - �Dtscription U • - Unrestricted(Buildingsup to 35,000 cu.li Cityrrown,.Stale,ZIP - - Restricted 1&2 Fami. Dwelling "a. M Meso � tt RC Roofing.Covering - i - WS Window and Siding - ^ &Ao65r SF -Solid Fuel Burning Appliances 1 t a R Insulation r Telephone T' +, Email address I D .Demolition _ d 5.2 Registered home Impr ovemeot Contractor(HIC) 6seP�!/ �it,,cr 4 tso 137L13o II z" K M Company Name or FRCRcgistranl Name HiC RegiSuauonNvmber Expiration Date - ' �Ir P,�au Art✓ ; ` k>w �SI4hCoe5iau Tvrc Q�Masr• cT- ( and Sow r address K�tw'�e`' 1�1►9 e215/ /7-593 s Cityfrown,State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFfDAVfT(M.G.L.c.151.§25C(6)) Workers Compensation Insurance affidavit must be completed'.and submitted with this application. Failure to provide .t this affidavit will result in the denial of the tssuaric- of the building permit. ( ' Signed Affidavit Attached? Yes.......... No...........❑ - ' • ' ' _ I SECTION9a:OWNER AUTHORIZATION TOBE COMPLETED WHEN ` OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING ERMIP T s _ 1,as Owner ofthe subject property,hereby authorize 0&r%GN161 to act on my behalf,in all matters relative to work authorized by this building permit application. J�E K p (c, :P t Olen YS Nr�rire, lac is Si ) � r . ��e 9 to " • ..SECT I b:OWNER'OR AUTHORIZED AGE DECLARATION' 1 By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information t contained in this application is We and accurate to the best of my knowledge and understand{ Prim Owner's or Authorized Agent'sName(F„l"Ironic Signature) r NOTES: L An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor r (not registered-in the Home Improvement Contractor(BIC)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 z www mass.eov/oea.Informafionon the Construction Supervisor License can be found at avwrv.r sss.govldns' 2.. When substantial work is planned,provide the information.below: .*- Total floor area(sq.ft.) (including garage,finished.basemenUattics,decks or porch) t Gross living area(sq.:ft.) Habitable room count I ..Number of fireplaces _ Number of bedrooms .: Number of bathrooms _ Number of half/baths Type of heating System .` Number of deckst porches Type of cooling system " Enclosed' t I 3. "Total Project.Square Footage":may be substituted for"Total Project.Cost" r----- The Commonwealth of Massachusetts Department of Industrial Accidents ulkirkers' I Congress Street,Suite 100 Boston,MA 02I14-2017 www.mass.gov/dia Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Leaibiy t Name (Business/Organization/individual): AIDYtA S G t7G5ioiN ' Address: RIJ P46 0V& I City/State/Zip: AeyeNL M4 OZfStl Phone#: 6/7-593.9Z/5- Are you an employer?Check the appropriate box: Type of project(required): P I.R I am a employer with;?,q employees(full and/or part-Lune).- 7. ❑New construction 2.❑i am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I era a homeowner doing all work myself.[No workers'comp.insurance required.]t d 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property, I will ensure that all contractors either have workers'compensation insurance or are sole I I. Electrical repairs or additions proprietors with no employees. t 12.❑Plumbing repairs or additions i 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs t These sub-contractors have employees and have workers'comp.insurance.[ 1 6Q we are a corporation and its officers have exercised their right of exemption per MGL C. 14.❑Other P 152,¢1(4),and we have no employees.[No workers'comp.insurance required.] I ^Any applicant teat checks box#I must also fill out the seetion below showing their workers'compensation policy information, e Homeowners who subttut this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such. tContmemrs that check this box must attached an additional sheet showing the name of die sub-contractors and state whether or not those entities have j employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: 7,_5 HLYA41 lloldepzwwemc,� d4 Policy#or Self-ins.Lic.#: WC 100 JO 320 y Expiration Date: � t4 t> Job Site Address: I_:31 pen AA ST ota City/State/Zip: Attach a copy of the workers'compe sation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificati l do hereby eerti nder the ain t penalties ofperjury that the information provided hov e 's true and correct Signal Phone Z Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: NORTSHO-02 SBOYER CERTIFICATE OF LIABILITY INSURANCE DA4/27/2016 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 endomement(s). PRODUCER CONTACT NAME: Welsh&Parker Insurance Agency,Inc./Hardy Office PHONE 57 Putnam Street (617)846-0731 Fa/c No),(617)846-0732 A/C No EM Winthrop,MA 02152 ADDRESS: INSURER(S)AFFORDING COVERAGE NAICO INSURER A:Merchants Mutual 23329 INSURED INSURERS:Independence Casualty North Shore Design,Inc. INSURER C: 211 Park Avenue INSURER D: Ravens,MA 02151 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 ADDLSUB POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICYNUMBER MMMIVY YY MM/DD/YYYY A X COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE T OCCUR BOP1076063 09/1712015 09/17/2016 PREMISES Eaocrudence $ 500,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ Included GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑jEa LOG PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident) A ANY AUTO MCA7015797 0911712016 0911712016 BODILY INJURY(Par Person) $ ALL OWNED )( SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NAONO WNED PPROPPEERd^DAMAGE 5 UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY B ANY PROPRIETORIPARTNERIEXECUTIVE Y❑ NIA WC100103804 0911912015 0911912016 E,L.EACHACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NK) EL DISEASE-EA EMPLOYEE $ 500,000 If yes,deecdbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,006 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE5(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Re: bathroom remodel CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Dean and Heidi Liebber THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 131 Derby Street,Unit M4 ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA 01970 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety Board of Building Regulations and Standards Cons[rucdnn Sup' n isnr License. Cs-058791 ,SEPHFRUCIA$O,JR- - 211 PARK AV, REVERE MA 02, Expiration 0711012016 Commissioner Office of Consumer Affairs&B �U1li�t�at�r�, /s110ME IMP NT CONTRACTOR Regulation License or registration valid for individul use only ROVEME RACTOR a _ y2egistratior 137430 before fke expiration date. if found return to: EEx iration TYPe: Office of Consumer P 11/12/2016 Affairs and Business Regulation Private Corporatio 10 Park Plaza-Suite 5170 NORTH SHORE DESIGN Boston,MA 02116 JOSEPH FRUCIANO _. 211 PARK AVE. REVERE, MA 02151 Undersecretary — j--�- Not valid wit out signature 150" 19,6 76 " — 499" ' USF3 6 USF37 IBATH.POD.HAR w J> � I1[)0 ml'u m co f - B.DOOR-F B.DOOR-F B.DOOR-F r N W N - A V O \, VAN330-L VAN330-R TOIL.STD T iI 1091, 41" P 150" Boston ntclln�na Sales Agreement EANDesigns 215 South Main Street Sales order# 7708 Middleton, MA 01949 Job/Tag# Liedberg-GM-104 Phone 978-750-1403 Date 4/19/2016 Fax 978-642-9595 Bill To Ship To Heidi&Dean Liedberg Heidi&Dean Liedberg 131 Derby Street,Unit 4 131 Durby Street,Unit 4 Salem, MA 01970 Salem,MA 01970 617.785.5581 617.785.5581 Designer GM-0 Store Loc 104 Terms C.O.D. Ln.# Qty. Item Mfr. Model &Description Rate Amount Cabinet ultracraft bathroom door style raised,cherry wood,stain 6,41 1.00 6,41 LOOT chock uk, for vanity,tub panels,tall cabinet A rn gE/Z Tile dal bathroom floor yacht club 6x24 YC01 325.00 325.00T Tile Litz bathroom shower and tub wall,anatolia 12x24 1,280.00 1,280.00T ottomano ivory polished Tile fitz bathroom shower ceillingl2x12 ottomano ivory 230.00 230.00T polished Tile fitz shower floor anatolia bliss stone and pebbled flat 195.00 195.00T mosaic color forest Tile thin set,grout,metal corners,water proofing 865.00 865.00T Misc tub deck,thustholds,niches,shelving in the tub 1,755.00 1,755.00T area color venatino Misc shelving in the tub area color venatino 18"wide 20 4,560.00 4,560.00T "deep 48"high with top and bottom piece and 2 shelves with a full back installed Installation construction as per agreement 54,242.00 54,242.00 Delivery delivery of material 580.00 580.00 payment terms deposit$6,000 deposit on older 4-19-2016$14,000 2 days after the job start$15,000 on rough inspection$15,000 on the installation$15,000 on shower door installation$5, 00 on completion $1,419.31 We Appreciate Your Business! subtotal $70,443.00 Sales Tax(6.25... $976.31 wWla.bostonkilchen.coml Total $71,419.31 CITY OF SM E:NI, ti'LasSACHUSETTS • BL'II.DIING DEPARTMENT • 130 W.tsHLNGTON STREET, 3'O FLOOR TEL (978) 745-9595 Fax(978) 740-9846 KI-gB Rr F.Y DRISCOLL ,ML AYOR THomtsST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BuninNG co% IISSIONER 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 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 by: JM NIL 42457'e— (name of hauler) The debris will be disposed of in : (name of facility) L%Q0leIDA) t+1SS . (address of facility) 77LJ' 17(�7 signature of permit applicant date debrisaf Am Thursday, April 28, 2016 City of Salem Inspectional Services 120 Washington Street 3rd Floor Salem, MA 01970 To Whom It May Concern: I am a Trustee of the Renaissance Condominium at 131 Derby Street Trust, residing at 131 Derby Street Rear, Unit 5, Salem MA 01970. As Trustee representing Building II as described in the Master Deed and Declaration of Trust recorded with the Essex South District Registry of Deeds at Book 24338, Page 134 and Book 24338, Page 147, respectively and as Owner of the Unit appurtenant to the subject property, hereby acknowledge and agree to the work authorized by the building permit application submitted by, or behalf of, the Unit Owners of Building II, Unit 4. Res ectfully Charlotte B. Fitzpatrick, Trustee CC: Tim Maxton, Trustee Judith Miller, Trustee