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6 FEDERAL CT - BUILDING INSPECTION (2) t LA- I S(ob ��2z The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date lied: Building Official(Print Name) Signal= JkDa4t, _ SECTION 1:SITE INFORMATION _ 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 6 FE�EaR�. Le�oRT 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(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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes[] SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: MARY RIt;1+rtRDS (TAJST-EEOF R2 '4t> n)(T HA ol86 Name(Print) FfipfatAL Ce,)&-r 94LN -F vTTI City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK Z(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 0, 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work : R061P, REPI•ALf_ Cl. P&ARcS I - IcI1-1Tj oc� Ra AlZ OtrJ(r of—' HooSE . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials - i 1.Building $ 1 a 00 0 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 0 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ v Suppression) Total All Fees:$ 6.Total Project Cost: $ 1 2 0 0 a Check No. Check Amount: Cash Amount: ❑Paid in Full ❑Outstanding Balance Due: 01 - 4z 3— 0323 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) D67 n q 1 10 1 g 1 S y)R 1.-ra- 66 a f- (�F f3-1 12 License Number Expuatton Date Name of CSL Holder t) J� List CSL Type(see below) 7 B'o� r^)mQ, No.and Street Type Description 11,• r�•-7 U Unrestricted(Buildings u to 35,000 cu.ft. t'1 In1(rTOny I-( /} 01 t�U R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) I z3313 I -r 11 7� wgl.ryR HIC Registration Number xpr ron Date HIC Company N,�me or HIC Registrant Name WalSo2� S r • wgtTEfZ� 6SS>r�RES oRArArJ.co No.and Street Email address la,t,wr�c--Toa 04 o18g7 q�8 Hz� a3�3 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 .......... ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize W A 1_Tlo— E6 E- or t3tf-1Q— to act on my behalf,in all matters relative to work authorized by this building permit application. Mw Alcoos T,mc 1-1 I1 Print Owner's Name(Electronic Signature) ate 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 application is true and accurate to the best of my knowledge and understanding. l�kl-TrG2 gr✓EgE- CS�n1-t"�� q n I Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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.eov/oca Information on the Construction Supervisor License can be found at www.mass. oe v/dos 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" r-Y-- Massaxhusetts_Department of Public Safety �l Board of Building Regulations and Standards Construction Supervisor License:CS-087061('A .. WALTERDBEEB-;E-C 789 WOBURN sT;if3 1 WILMINGTON MA Oj 92—mod/. „ ,r la„r Expiration Corrseissioner 10/18/2015 eN Vltn tRo�/r-)Raft[/Xpl��O�Ci�%/LO1N[C�[!JE/.(i . Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Wfe,gigtraticm: �123313 Type: Office of Consumer Affairs and Business Regulation iration:a 9f27/2015• Private Corporatic 1 10 Park Plaza-Suite 5170 '?5+ - g - 71 Boston,MA 02116 ESSEX RESTORATION/DEVEREAUX ENTERP. -t WALTER BEEBE-CENTER 789 WOBURN ST N3 �. WOBURN,MA 01887 - -- Undersecretary Not valid without signature CITY OF S.1 XINI, AL SSACHUSMS 31:I1.1)LItGDEPAR`17 E[&iT 120 WASHLNGTON STREET', 3w FLOOR 'I FL (978) 745-9595 Fix(978) 740-9846 ICI\tBERLEY DRISCOLL MAYOR THows ST.Pmms DIRECTOR OF PUBLIC PROPERTY/BUUMNG CONJIMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /^ y l Please Print Legibly G Name (Bus)ness/Organization/individual): sSe �Qs-lIOI�}-I10(1 Address: Itel Will bUr•I1 S� -A3 City/State/Zip: ' 1V1j A ALA 6 f?3 Phone #:_ Are you an employer? Check thtrappropriate box: Type of project (required): 1.dam a employer with_I,)— _ 4. ❑ I am a general contractor and 1 employees (full and/or part-time). have hired the sub-contractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, Demolition working for me in any capacity. employees and have workers 9. ❑ Building addition [No workers' comp. insurance comp. insurance,: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] ' C. 152, §1(4), and we have no 3.❑ Other employees. [No workers' comp. insurance required.] •Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the time of the subcontractors and state whether or not those entities have employees If the sub-contractors have employees,they most provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and%ob site information - 'f Insurance Company Name: GDt1 Thetl-+,1,( Atle MA LAI Policy # or Self-ins.. Lic. #: t42 41 B 0l G I Expiration Date: 2 Job Site Address: 6 r�DEr1tq L Co a2Y Ciry/State/Zip: Sq LfW M t4 C)%9-?0 Attach a copy of the workers' compensation policy 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 $1,500.00 and/or one-year imprisonment, as well as civil penalties In the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance co erage verification. I do hereb c rt Ueer the gins a nalties ofperjua that the in ormation provided above is true and correct. Signature: Date 17 I Phone : g7t,-423-a323 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#i r CITY OF SM E.N1, XWSACHUSETTS a BuMDLNG DEP.4aniENT ro 130 WASHNGTON STREET, 3r FLOOP T FL. (978) 745-9595 FAX(978) 740-9846 KIJIBERLEY DRISCOLL MAYOR T HomAs ST.Pmm DIRECTOR OF PLBLIC PROPERTY/BUMDLNG CONMUSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: CAS6L LA wqV-16- (name of hauler) The debris will be disposed of in CA WC,t-4 cJgSr� (name of facility) (address of facility) V- signature of perri(Wapplicant �i-t/ I� date �-1 DEVEENT-01 BOUQUET CERTIFICATE OF LIABILITY INSURANCE DA91121201BI 4Yn THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),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 CONTACT NAME: Mason&Mason Insurance Agency,Inc. �NNa Ed:(781)447-5531 ac No):(781)447-7230 458 South Ave. E-rM11L Whitman,MA 02382 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC d INSURER A:NGM Insurance Company 14788 INSURED INSURER 8:Continental Indemnity Company 28258 Devereux Enterprises,Inc. INSURER C: dba Essex Restoration 789 Woburn St Unit 3 INSURER D: Wilmington,MA 01887 INSURERE: 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 ADDL SUM POLICY EFF PODCY E%P LIMITS TYPE OF INSURANCE POLICY NUMBER MMm MMA) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 AIMS-MADE T OCCUR MST8864E 0712612014 07126/2015 PREMISES Ea occurrence $ 50,00 CLAIMS-MADE MED EXP(Any one person) $ 10,00 PERSONAL B ADV INJURY $ 1,000,00 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY❑PET LOC PRODUCTS-COMPIOPAGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 (Ea actldenl A ANYAUTO M9S26807 12/14/2013 12f1412014 BODILY INJURY(Per pereon) $ 20,00 ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 40,00 AUTOS AUTOS X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per aaidard $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ I$ WORKERS COMPENSATION X PER OTH- ANDEMPLOYERTIJABILITY STATUTE ER B ANY PROPRIETORIPARTNERIEXECUHVE YIN NIA 468424380103 0812912014 0812912015 eL.EACHACCIDENT $ 500,00 OFFICEMMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 500,00 00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ SOO,O DESCRIPTION OF OPERATIONS I LOCATIONS[VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Devereux Enterprises,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN rP ACCORDANCE WITH THE POLICY PROVISIONS. DBA Essex Restoration 789 Woburn St Unit 3 Wilmington,MA 01887 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 6 i• Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978)619-5685 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving ❑ Reconstruction ❑ Alteration ❑ Demolition j& Painting ❑ Signage 1�L Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property: 6 Federal Court Name of Record Owner: Joanna Peabody & Mary Richards Trustees Federal Court Realty Trust Description of Work Proposed: Repair/replace clapboards on rear wing of the house. There will be no change to the color, material, or design. Repaint with existing colors. Dated: September 24, 2014 SALEM HISTORICAL COMMISSION By,Aa� The homeowner has the option not to commence the work(unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals)prior to commencing work.