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6 FEDERAL CT - BUILDING INSPECTION (3) The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CIvIR Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demoli One or Two-Family Dwelling M Thts Section For Official Use,Ohly f y Building Permit Number Date'(spphed ' Y/ YZb ' Date Bull ding Official(Print Name) 5jgnature SECTIONISITEIiNFORMATION e_ 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers Q46- l.la 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: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system El Pubtic❑ Private❑ Check if yes[] - SECTION`2f.PROPERTY.OWNERSHIP'' 2.1 Owner'of Record:FEDE RR*L, ry�E M p l 8 6 7 MA-2Y 2icHkR.DS-?7� / Name(Print) %J0A-W VA- N• F�E►tB upl J I City,State,ZIP , st) PIUFvA-tom Ny9� '?87-1?Lg4 -f57&' No. and Street Telephone Email ddress rt SECTION 3:.DESCRIPTION OF PROPOSED WORK.(check all that apply) - New Construction ❑ Existing Build ng ❑ Owner-Occupied ❑ Repairs(s),X IAlteration(s) ❑ Addition ❑ Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work : R e o or LNI SECTION 4: ESTIMATEDAZONSTRUCTION COSTS . ` Estimated Costs: Official Use Ord y'i Item Labor and Materials)- 1. Building $ 1 Bwld hg Permtf Fee $ Indicate how fee is determined:, ❑ S tan dodd Ct ./Town Application Fee 2. Electrical $ / ❑t661Pi6je6t Cost4(Item.6).xmultip(lerc- x' 3. Plumbing $ 2 Other,Fees. 4. Mechanical (FIVAC) $ l List 5. Mechanical (Fire $ Total All Fees' S' Suppression) r� Check No. Check Amount Cash Amount. X6. Total Project Cost $ /�o ❑ Paid in.Full ❑ Outstanding Balance Due: _ SECTION 5: CONSTRUCTION SERVICES 5.1 Coustruction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No. and Sheet Type .Description U Unrestricted Buildin s u to 35,000 cu. It. R Restricted I&? FamilyDwellin Citylrown, State, ZIP R fvfasonRestricted r RC Root-in Coverin WS Window and Sirlin SF Solid Fuel Burning Appliances I Insulation "relz hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or I-IIC Registrant Name No.and Street Email address 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 [, as Owner of the subject property, hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW 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. Print OWnl.r's or e\uthonzed 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.inass.i)ov/oca Information on the Construction Supervisor License can be found at www.ntass.govd n 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) (including garage, finished basement/attics, necks or porch) Gross living area (sq. If.)_ Habitable roots count Number of fireplaces Number of bedrooms _ Number of bathrooms Number of halt/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" �. Office o onsumer A airs&B siness Regulation ' License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. 3f found return to: Registration �123313 Type: Office of Consumer Affairs and Business Regulation Expiration: 1127/2013 Private Corporation 10 Park Plaza-Suite 5170 —•q Boston,MA 0211 vER8RESTORATION/DEVEREAUX ENTERP. WALTER BEEBE CENTER' 789 WOBURN ST WOBURN,MA 01887,', rs. Undersecretary Not valid without signature Massachusetts- Department of Public S:Ifet) l Board of Building Re_ulations and Standards Construction Supervisor License License: CS 67041 WALTER D BEEBE-CENTER 789 WOBURN ST A t WILMINGTON, MA01887 o - �"�'- =s� Expiration: 10R8/2013 (onnoisvimier Tr#: 5770 ACORQR CERTIFICATE OF LIABILITY INSURANCE DATE IMWODIYYYY) 08/27/2012 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(les)must be endorsed. N 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 QT T Gwen Vos urgh _ Mason & Mason Insurance Agency, Inc. 791.447.5531 FA 781.447.7230 458 South Ave. E*IUL ADDRESS, Whitman, MA 02382 PRODUCER Gwen Vosburgh INSURE S)AFFORDING COVERAGE NAICC INSURED INSURER A: NGM Insurance Company 14788 Devereux Enterprises Inc, INSURERS: Continental Indemnity 0282S8 dba Essex Restoration INSURERC: _ 789 Woburn St Unit /3 INSURERD: Wilmington, MA 01887 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 12/13 GV built ' 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. INSmR AD SUB POLICY EFF POLICY EXP tlM� TYPE OF INSURANCE I POLICY NUMBER /YYYY GENERAL LIABILITY MST8864 07/2612012 07/26/2013 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY PRE ISE Me old $ SO OO CLAIMS-MADE �OCCUR MEDEXP(Arryarepemnn) $ 10,0 A PERSONALBADV INJURY $ 1,000,00 GENERA-AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 2,000,00 JPRO- POLICY LOG $ AUTOMOBILE LNSDAY 1119S2680 12114/2011 12f14/2012 COMBINED SINGLE UNIT $ (Ea acOdere) _ 1,000,000 ANY AUTO BODILY INJURY(Per Pereon) $ ALLOWNEDAUTOS BODILY INJURY(Per acadenU $ A X SCHEDULED AUTOS PROPERTY DAMAGE X HIREDAVTOS (Peracciderd) $ X NON-OWNEDAUTCS $ $ UMBRELLA UAS OCCUR EACH OCCURRENCE $ EXCESS LIAS CWMS_MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WOIMRS COMPENSATION 468424380101 08129/2012 W2912013 WC STATU OTH- EEL AND EMPLOYERS'LIABILITY YIN IMITS ER B MYPROMEMBERE%CNERE4ECUTNE❑ NfA E.L.EACH ACCIDENT S 500,00 (Menda"In NH) OFFICER IS INCLUDEE E.L.DISEASE-BA EMPLOYEE $ S00,00 rc yee.deacdbe under E.L DISEASE-POLICY UMR $ S00 00 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPEMTIONB f LOCATONS/VENICI.ES PVMCN ACORD d01,ACditlwlel Ranarka SclNdrN,Nmore epos N reyWred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Devereux Enterprises Inc Essex Restoration AUTHORED REPRESENTATIVE 789 Woburn St Unit i3 Wilmington, MA 01887 Philip Mason ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD ACORQ. AGENCY CUSTOMER 10: LOC S: ADDITIONAL REMARKS SCHEDULE page of — AGENCY NAMED INSURED - Mason & Mason Insurance Agency, Inc. Devereun Enterprises Inc POLICY NUMBER 789 Woburn St Unit i3 Wilmington, MA 01887 CARRIER NAIL CODE EFFECTIVE OAIE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORMNUMBER: _ FORMTITLE: ACORD Certificate of Liability Insurance Garpapggee Liability YEFECTIVE pqq LRWSRD POICYNUMBER DAIEMFEVOD'YY) OATEMW MnYj LIMITS AUTO ONLY EA ACCIDENT E ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO E Autgqoppmyo�bile Liability RpTIpN ILTSRR NS)1A POLICY NUMBER P�M ODM'1 PDOATCEYMMI00/YY) A Excess/Umbrella Liability PIER ADM POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MMIDOW11 DATE(NIMMOM) LIMITS E UOther Liability ppL��y FF��Try pLICy E�-p�Rp L,TR POLICY NUMBER DATE(MYIOMYj PDlll¢(MwomYT( LIMITS ACORD 101(Z008l01) (D 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD � t . wtJ'\ 14, Salem Historical Commission 120 WASHING T ON STREET, SALEM, MASSACHUSETTS 01970 (978) 619-5685 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABII I TY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ 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 Cours Name of Record Owner: Latina N. Peabody & Mary F Richards TTFs Ced raI Comb RQu ty Trot Description of Work Proposed: Repair fmni. moor (restore dock and latch to full function) to replicate existing. No changes in color, nrater•Lal, (ICS7g17, locaiiOn or outs-yard appearance. Non.applicable due to being in kind rr2aintencu7ce/r•eplacenaeni. Temporarily board up door while ivork, is being ccmapleled. Dated: September IT 2012 SA I _ CAL COMMISSION By: The homeowner has the option not to commence the wort: (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. TI-ITS IS NOT A BUILDING PERMIT. Please lie sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work rl