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183R FEDERAL ST - BUILDING INSPECTION (3) I The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards a� Massachusetts State Building Code. 780 CMR, Te edition Building Dept Building Permit Application To Construct. Repair. Renovate Or Demolish a tlkM One- or Tito-Pun Duelling This Sectio or 0 tctal Use O 1 But Wing Permit Num r: D e A Signature: 3 in Building ommnstoner/I tar of Buildings Date SECTION I: E 14FORMATION 1.1 Pyoysr �4dre /_ /f 1.2 Assessors Mop i Parcel Numbers ih-55 M —Number Parcel Number I.1a Is this an accepted street'!yes no 13 Zoning Information: 1.4 property Dimensions. Zoning District Proposed Use Lot Area(sq R) Frontage 1 R) 13 Building Setbacks(R) Front Yard Side Yet& Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L e.e0,sae) 1.7 Flood Zone Information: 1.11 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal O On site disposal system El Public O Private D Check (yesO SECTION3: PROPERTY OWNERSHIP' 2.1 t.J ' f Record;...�54 ✓1 G Name PSEC Addraa for Service:Signs Telephone N 7: DESCRIPTION OF PROPOSED WORK'(chock all Thal apply) New Cting BuildingD Owner-Occupied D Repairs(s) O Altention(s) O Addition O Demolessory Bldg.O Number of Unity_ Other O Speeiry Brief Description of Proposed Work': SECTION d:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Offlcld Use Only Item Labor and Materials I. Building f �� I. Building Permit Fee: S Indicate how fee is determined: O Standard City/Town Application Fee I Electrical S O Total Project Cost'(Item 6)s multiplier e 3 Plumbing f 2. Other Fees: S 4—Mechamol IHVAC) S List: s Nechantcal (Fire S Total All Fees:S Su resston y Check No. _Check Amount: Cash Amount:_ 6 Total Projeel Cost S �2� ❑ Paid m Full ❑Ouuundmg Balance Due SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Consrrucllo upenisoi ICSL) i. L,cense.umber Espiruuon Date Ntroe ul l 54 Lr.t CSL Type(Av Alow) AJJre T Description U re Unstricted u to 35,000 Cu. A Sgiui re / R Renricred IR2 Family Dwelling N Masonry Only Res ii'r F l7 ii" bbb RC Residential Roofing Covering Telephone wS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 9.2 Regl tee Home Imp/ re Contractor(HIC) 4 Orr HIC Coln any or,HIC Registrant N Registration Number Addiesa /✓o M„� Expiration Date Signature Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2./ 2SC(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 AOldavitAttachriP Yes..........67 No.. —.....O SECTION Its:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, J�k-1 �§ , as Owner of the subject property hereby authorize A l 0 to act on my behalf,in all matters relatXtauthorized by this building permit application. Sier Date SECTION 7 •OWNER'OR AUTHORIZED U NORIlED AGENT DECLARATION 1, /% z);` ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing/application are true and accurate,to the best of my knowledge and behalf. Print Name �A2 Signature of Owner or Authorized Agent Date Si ned under the ins and penalties of NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contraclor (not registered in the Home Improvement Contractor I HIC)Program),will W have access to the arbitration program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and 110 R5,respectively. 2. When substantial work is planned,provide the information below, Total floors area(Sq. Ft.) (including garage, finished basementlanics,decks or porch) Gross living area ISq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of hallbaths Type of heating system Number of decks/porches Type of cooling system Enclowd . Open 1 "Tool Protect Square Footage"may he suh,tituied for 'Total Prolat Cost" The Commonwealth oflVldgiiA% efts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 l www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Indivi dual): G Address: /`J7 -zw 4 City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees.(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I 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 10.0 Electrical repairs or additions ` 3.❑ I am a homeowner doing all work �� officers have exercised their I L❑Plumbing repairs or additions . myself. [No workers' coi#p. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such tContiactors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the poliey and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: b�rZ����z Expiration Date: lob Site Address: ' �5�--` � City/State/Zip: `v�� 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$250.00 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 cerh;fy under the ains and penaltie perjury that the information provided above is true and correct Signature � Dater —yam Phone# �OSS — 5 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#: 02-16-'10 12:39 FROM- T-915 P002/009 F-665 GRANITE STATE INSURANCE COMPANY 0092241-oo WC 007-42-6452 13102 ^^�013-66-0309-00� r tPQ PARSON BUILDERS INC © �009 0d� Member Companies of 1 0 R WINONA ST q P ABODY Y. MA 01960-0000 �J�AR O American International Group F► EXECUTIVE OFFICES: 70 PINE STREET. NEW YORK N.Y. 10270 SEE EXTENSION OF REM 1,OF THE INFORMATION PAGE -WC990610 - LON r IFRS. RICHARD S ASSOCIATES INS INC WORKERS COMPENSATION AND EMPLOYERSMAPLE ST LIABILITY POLICY INFORMATION PAGE 102 QANV MA 0 2 -0000 POLICY C RP RATION RENNEWAL N 0 82668 7 2 M"fif WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PACE—WC990610 M512 POLICY PERIOD t"t AM mandord tinro m iho lnsu a -, m eing address mom 03/17/09 TO 03/17/10 Hula A. Workers Compensation Insurance: Part One of the Policy appllea to the Workers Compensation LOW of the states listed here MA B. Employers Liability Insura cet Pert TWO Of the Policy applies to the work In each state listed in item 3A The limits of our liability under Part Two are - Soddy Injury try Accident S _ .100.000 ' each acCldarrt Bodily Injury by Disease g 500.000 Polley Unlit Bodily Injury by Disease S 100_,000 each employee C. Other States Insurance Pm Throe Of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC200306A D. This policy includes these ' SEE EXTENSION OF ITEM 3.0. OF THE INFORMATION PAGE-WC990612 ITEM a The premium for this policy will be determined by Our Manuals of Rules, ClassitiCations, Rates and Rating Plans. All Information required beiety is subject to verwicauon and change by audit Estlmawd To\el Raft Por 0nmated ... RemYaafitlne Annual 3 Ye9r premium ClasslliGlione Coda NYm01, O ❑ 3,0 e f a, © ❑ x _ Ano"i 3 TPM SEE EXTENSION OF ITEM d.. OF THE INFORMATION PAGE—WC7756 TAXES/ASSESSMENTS/SURCHARGES $188 EXPENSE CONVANT(EXCEPT WHERE APPLICABLE an CrA7E1 18 MA MINIMUM PREMIUM S5OO MA TCRALMMIATED PREMIUM I 11 Indicated below.MIGNm adiustmanm or oMmiUM Mall be made: semi-Annutlq ountedy Monthly OEPOSR PREMIUM 03/24/09 ASSIGNED RISK 66 Issue Dole IraWttp 011lee Awhodsod ReptlnrJllatWe YID 00 00 01 399a7(Rov'd 0448) PEARSON BUILDERS General Cofactor - Warren A. Pearson 150 R.Winona St. Phone&Fax 978-535-6555 W.Peabody,MA 01960 Cell 978-758-2938 Massachusetts-Department of Public Safety. Board of Building Regulations and Standard's' Gdhsttu�'ir?n Supervisor License ,J'.tnense:.CS ' 40996 :s_ FWARRE PFJi'fi0 ,a1.50R ''VV �/�� P09 Expiration: 4/122011 Tr#: 13734 . � .� . - board o(Buddmg'Regulah ns and'Standards HOME IMPROVEMENT 60NTRACV0 ' Registra,ge ,107999 Ex .� h'on—'1112010 ra . W+yA, LKEN A P W erren.PeaT50n it 15DRWinbgaSt. � ~. T ` AiiH`rmr5t3a r 0dy h A01960 CITY OF SALEM j PUBLIC PROPRERTY DEPARTMENT '14 I'C�t'a,nl]o;,,N$rRLET •5.urs1, Sta :u ul a 1...Pr l F1 978.743: 395 I'.\x:978.740.9846 Construction Debris Disposal Affidavit (required I'ur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.3 Debris, and the provisions of MGL c 40, S 54; Building Permit p is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I 11. S 150A. The debris will be transported by: (tame of hauler) The debris will be disposed of in : (name of facility) (address of lixility) signature of penmt applicant date 0 mrle Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT 311 FAX (978) 740-0404 CERTIFICATE OF APPROPRIATENESS 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 will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property 1 R3 Rear#? F deral Street Name of Record Owner: John & Monica Zisa Description of Work Proposed: Replacement ofsix windows in violation on second and third floor with Brosco, wood, single glaze, double hung true divided light windows to match existing windows on house, painted to match existing Replacement,of'roo/'with 3-tab, Certainteed Seal King roof with option for color to be either Star White to match existing, or to be black or charcoal grey. Dated: February 4 2010 SALEM HISTORICAL COMMISSION The homeowner has the option not to commence the work (unless it relates to resolving an outstafiding 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.