705-3 FARRELL CT - BUILDING INSPECTION Iaar�2 4*A4&-1— DHe,
$1521 `(W W .
,. , The Commonwealth of Massachusetts
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Department of Public Safety
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City of Salem
BuildingPermit Application for an Buildin other than a 1- or 2-Fa it
t rhis Section For Official Use Only)
OuJ.ting Permit Number: Date Applivd: Building Inspector:
SECTION 1: LOCATION (Please indicate Block a and Lot I for locations for which a street addnr s Ys not available)
.No. and Street Cih• /Town Zip Code Nameut Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here 0 or check all that apply in the two rows below
E.ai.ling Building❑ Repair Alteration ❑ Addition❑ Demulitiun O (Phase fill Out and submit Appendix 1)
ChangeolUse 0 Change of Occupancy O 1 Other O Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Peer Review required? Yes O No O
Brief Description of Proposed Work:
1as@s 3+t/f r.4ivS �t�lc4et> �'�vr'�eE.arE.v¢
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) 0
Existing UseGroup(s): Proposed Use Group(s): It
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluors/Stories(include basement levels)&Area Per Floor(sq.ft.) -
Total Area(sq. ft.)and Total Height(ft.)
SECTION S:USE GROUP(Check as applicable)
A: AssemblyA-1 0 A-2r ❑ A-2nc 0 A-3 0 A4 0 A-5 O B: Business 0 E: Educational O
F: Faeto F-1 1 F2 O H, HI Hazard H-1 ❑ H-2 O H-3 ❑ H-4 0 H-5 0
h Institutional 1-1 0 1-2❑ 1-3❑ 1-4 0 M. Msrtantils O R: Residential R-10 R-2 O R-3 0 R4 O
S: Storage S-1 0 S-2 O U: UtilityO Special Use O and lease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a Iicabls)
IA ❑ Ill ❑ IIA O fle O IIIA 0 1118 0 IV 0 VA O VB O
SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public ❑ Check if uutatdv 1:1 d Luna•❑ Indicate muroclpal ❑ A trench will not be Licensed Di.►w.d Site O
required Our trench or.pecd.v:
I'm ate❑ or rrtdentdy Zone: or on site,c.tem❑ permit t.vnclo. i Cl
Railroad right-of-way: Hazards to Air..Navigation: \I\ I Int• n, t •tnnn.•o n Itr. ,.. I•n
\ol \p)•hcable❑ I.Strum laze wnhtn aupurt eppn•.tch area' I.their rrva•lc annplrled.'
•a -,I,, it l•• Ignl.l encL•rd ❑ 1e,❑ nr Xn❑ 1'e.❑ \u Cl
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I-.Mnm ,q G,dc. L,v(0.niplo, rl peul Con.truclu-n. t)ccupanl Load per flour
I i ,,• the budding canLun.rtt Sprinkler;%stem' Special Shpulahun.:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Lhe
Pn, wrrttyOwner . //
ld (rw1,C�6/L fT 7/6jss 07/5r. O/97 O
Nu.and Stnrl Cily/ town zip ner l ontact Inturmauun:� ,+^�'�M'PI✓ TelephunrNu. (busmen.) rrlephunr�Vu. icell) a-madadafn�.ble, the property owner herebyauthorizes
.Name Stre t Address City/Town State Lip
the ro•erty owner'•behalf, m all matters relate e w work duthortzed by this buildin • ermtl a p nhca Cron.
SECTION !0:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If i•uddin is Ivs%thin 35,(M cu. Mot emiawJ space and/ur not under Col-truction Control then check hen Oand.Aup Sacttun 10.11
10.1 Re istered Professional Responsible for Construction Control
kf,jyf,— sf. 4ke4tlisc fs 17Y. -7,MY 73 7 N/WN. WSARcffi�
Name(Rr•istrent) - Telephone No. e-mail address Registration Number
ao 9 INN. D I'17o
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cumpan) Namr: r
iNiclfoL�+s 's.V�ofiS e 7tv 7
Name of Person Rreprmsiblr fur Construction .�� License No. and Type if pplicable
2 e0 /Ti K7r Sf //4"'^'�^' nl/l- 0
2 7tF ,
Street Address City/Town State Zip
sue_ zz:. 2zGq sa8 .9z2. zzG9
Telephone No. (business) Telephone No. cell e-mail address
SECTION 11:WO ANCE AFFIDAY11(M.G.I..c. 1S2.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 1L•CONSTAUCi70N COSTS AND PERM17•FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) -f
1. Building f ZO moo .o o Building Permit Fee-Total Construction Cost x_(insert here
2. Electrical f e r9m�•OO appropriate municipal factor) f
3. Plumbingf
4. Mechanical (HVAC) f Note: Minimum fee.f antact municipality)
5. Mechanical (Other) f Enclom check payable to
6. Total Cost f.. (contact municipality)and write check number here
SECTION 13-SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below. I herebv attest under the pains and penallies of perjury that all of the information contained in this
a pplicatiun is trur.ind accurate to the best of my knuwlealge and understanding.
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Municipal Inspector to fill out this section upon application approval:
Name I Lur
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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r.u: MI r 1 • �,.. �� I:C�t'.�J MW..�w)1'..rr .i\I I N,\tAK\I W .1 �..:1'r':
\I .,. . 111: '�'/-:14•lYIS .1'�\:'l1�•i JJ'111M
Construction Debris Disposal A111davit
(nryuired I'ur all demolition:Irxl renovation work)
ith the sixth edition of the Slate Building Code, 730 CMR section 111.5
In tccunl ux a w
Debris. and the provisions of MGL c 40,is S is4; MGL e
srued with the condition that the debris resultingm
Ouildinl{ Permit N 4ce>txd was disposal facility as defined by
this work shall he disposed of in a properly
ll1. S 150A.
dtb Tansprted by:
The debris wi Ie4nWu:f�ha0mL14r)E
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Ncja1G/eH>7L
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'I•he debris will be disposed of in :
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41 o , IOO La UANui� 11UNihALLLN6 Flilr P . Ovi5111)08
CERTIFICATE OF LIABILITY INSURANCE 8i26i2009)
'y PRODUCER (617) 964-5340 FAX: (617) 965-1843 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Marketing Associates Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
150 Wells Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Newton MA 02459 INSURERS AFFORDING COVERAGE NAIC p
INSURED INSURER g Mae sachusette Bay Insurance 22306
DANDIS CONTRACTING, INC. INSURERB'Hanover 22292
42 CHARLES ST. INSURER C:
INSURER D.
HYDE PARK MA 02136 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER1001NOICATEO.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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INT. DD' POLICYNUNBER POLICY EFFECTIVE POLICY EYPIRATXJN LIMIT6
GENERAL LIABILITY EACH OCCURRENCE E 11000,000
x COMMERCIAL GENERAL LABILITY S 300,000
A CLAIMS MADE x❑OCCUR =396311067 5/29/2009 5/29/2010 MED EIv(my one NEOI) s 5 000
X Deductible $1,000 PERSONAL 6 ADV INJURY 6 L,(L0,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LNIT APPLIES PM PRODUCTS.COWJ0P AGO 22 O00 000
X POLICY PRO-JITCT LOC
AUTOMOG)LEU MUTY COMBINED SINGLE LIMIT
ANY AUTO (ES acmart) S 1,000,000
B ALL OWNED AUTOS 8311366 5/29/2009 5/29/2020 BODILY INJURY
X 9CHMUtFDAUros ("M pere ) f
X HIREDAUTOS BODILY INJURY
X NON-OWNED AUTOS (PM eo:ment)
PROPERTYOAMAGE E
(PN xdeo0 o
... GARAGE UABIDTY�� ..- .. ,.. ..._ .AUTO ONLY.EA 4CtIDEM- Y _
ANY AUTO OTHER THAN EA ACC f
AUTO ONLY: qGG f
EIOESS I UMBRELLAUADILITY EACH OCCURRENCE $ 10 000;000
X OCCUR CLAIMS LADE AGGREGATE f 10 000,000,
S
B DEDUCTffiLE UNN8316171 5/29/2009 5/29/2010 s
RETENTION S
E
WORKERS COMPENSATION ill be Rent under WC 6TA TEIRY Tu OTM-
AND EMPLOYERS'LIABILIfV
ANY PROPREfORIPARTNERW.CUTNE YO sparsts cover E.L.EACH ACCIDENT f
OFFICEIRLMEMSER EXCLUDED?
(MwaEm y M NH) EL DISEASE•EA EMPLOY S _
S AL P Oe ISIO EL DISEASE.POLICY LIMIT f
SPECIAL PROVSIONS Ellow
OTHER
OESCRIPTICN P--YINS I LOCATIONS IVFD" S I EXCISIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
tJhe
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIEB BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAW 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.007 FAILURE TO DO SO SHAH
IMPOSE NO OBUGATION OR UA09UTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE J
Michael Susco/DAWN
ACORD 25(2009101) 01988-2009 ACORD CORPORATION. All rights reserved.
INS025(2oomi) The ACORD name and logo are registered marks of ACORD
it iO vO QIIJQIJVJI UANUIS LUNIHALIiNU ilfll P. UU i/Upy
4CORQ CERTIFICATE OF LIA51LITY INtiu HAIVVt 07/14/2009
PRODUCER TMIS CERTIFICATE IS 183UEO AS A MATTER OF INFORMATION ONLY AMC
Applied Risk Insurance services, Inc. CONFERS NO RIGHTS UPON THE CERTIFICATE HOPER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
/i 10825 Old Mill HIS AFFORDED BY THE POLICIES BELOW.
Omaha, HIS 6816E-0446
(077)334-4410 INSURERS AFFORDING COVERAGE NAICa
INSURED INSURER IA Continental IAdaMnity CO. 2 6 2 5 8
Dandle Contracting, IAD. INSURER B: _
dha Dandle Contracting, Inc. IN RERC:
E2 Charles at
Hyde park, MA 0313E-1602 INSURER D.-
L 3,A73 46556§ INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
No,
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 OESCRI13ED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TR TYPE PCLIRAMLE POLICY NUM DFFE LOOS
GENElUI LIABILITY EACH OCCURRENCE S
PREM111 NTED
COMMERCIAL GENERAL UAWUtt PREMI�FS(Ee oecurrenn, E
CLAMS MADE❑OCCUR MED E%P IA^ are Personl S
PERSONAL L ADV INJURY S
GENERAL AGGREGATE $
OENL AGGREGATE LIMIT APPLIES PER; PROOUCTS COMP/ AGG S 1
PRO•
Poucr JECT LOC '
AUTOMOBILE LIABILITY COMBINED SINGLE UMIT
S
ANV AUTO ma AcGiduAl)
ALL OWNED AUTOS BODILY INJURY I
SCHEDULED AUTOS (Pa fHrtonl
i
PROPERTY DAMAGE I
(PSI SPOONS)
NDN40LNNED aUros (Per aaciaenj
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT P
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY; AGG S
ETCES4NMOAE"LIABILITY EACH OCCURRENCE I '.
OCCUR F-�CWMSMAOE AGGREGATE
S
DEDUCTIBLE L
RETENTION E i
WORMERS COMPENSATION AND r TORYUII F.R
ENPLOYFRa LABIIITY 1 , 0 0 0 , O O O .
AN YPROPRIETOiVPMTNERIENECVnVE e6-016397-01-01 07/21/09 07/271lO E.L EACH ACCIDENT f
OFFM;ERAfEMBER EXCLUDED?
II ypi.EOK,De PIIOY E.L USEAM EA EMPLOYEE I 1, O O O, O 0 0 I
SPECIAL PfgVISION$EebM E.L=ASE POLICY LIMIT 1 , O O O , O O 0
OTHER
DESCRIPTION OF OPERATIONS LOCATIONS VEMGLEa I EICLUAON6 AOOm BY EMDORBEMENTI SPECIAL PROVISIONS 1
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCHOED POLICIES BE CANCEilID BEFORE THE
Dandia Contracting, Inc. EXPIRATION DATE THEREOF,TH6 ISSUING INSURER WILENDEAVOR TO wa
63 Charles Bt DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFr—,KT
PAd1URE TO 00 90 SMALL IMPOSE NO OBLIGATION OR UA8SJTY OF AMY CNO UPON
Hyde park, MA 02136-1602 THE UBUBER AGENTS R REPRESENTATIVES
AUTHOIBTtc REPRESS!
AttAll project Manogur 1783116 J�
ACORD 25(2DOI/06) ®ACORD CORPORATION 1968
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Board of Building Reg aCtons and �ar
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
4 Home Improvemept Contractor Registration
s Registration: 16075ti !
U Tvpe: DRA
Expiration: WWO10 Tr# 273235
DANDIS CONSTRACTING INC
PARTHENA DANDIS
42 CHARLES ST
HYDE PARK, MA 02136 --- ... -- -- — -- ---- -----
Update Address and return card.Mark reason for ebange.
rJ Address Renewal Employment O [.oat Card
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Construction Supervisor License
License: CS 71627
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NICHOLAS GIANIOTIS
200 BURT ST �a
TAUNTON, MA 02780 r
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Expiration: 7/31/2011
Tr#: 19"7
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