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7 FOREST AVE - BUILDING INSPECTION (2) CX- azt(o S The Commonwealth of Massachusetts RE fil� °t9a. Board of Building Regulations and Standards YSPECI t 11M-S Massachusetts State Building Code,780 CMR SALRevised Mar 2011 ill Building Permit Application To Construct, Repair,Renovate Or Dei,$*41AY 18 A 11: 54 ^� C'D N)O O One-or Two-Family Dwelling L 1 This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) - Signature - Date _ 'SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers —1 a219cT � l Lin 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 11) 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❑ C1�E14 of Rec �,. SECTION2: PROFkRTYOWNERSHIP' 2.1 Owner' ord: I.C�R-`N t, r. —[" TnPe.V- Si1lEM � S C11Cf �� Name(Print) City,State, —► Fob ,mt S� NV L sag No.and Street _T\ _ T Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORTO(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work: Wn d 4 PA56 d SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee:$ indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(ltem 6)x multiplier - x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List:. . 5.Mechanical (Fire $ Total All Fees:$ Suppression) Check No. Cheek Amount: Cash Amount: 6.Total Project Cost: $ Iqm6o° ❑Paid in Full ❑Outstanding Balance Due: _i....�_ N�—�"O IIJ3 iN �—O $tG' N� y.�(C • -- 7�M11 tt_l.'-L� C©NTH 5 ,1c` tV�VV VI�C�'a t_ A�IZ-O s' SECTION 5: CONSTRUCTION SERVICES 51 c,ConstruMton Supervisor License(CSL) Lta —09Q r4 E uao ` �� q. C;! ` 6 ` �� xp n Date Nameof,CSLHolder r,„ ..�� Hrr1, ''y'I,,,"1 0 1 , List CSL Type(see below) `egnr tt In` � Type . y Descaiption No.and Street `- �� I11 � �� U Unrestricted(Buildings u to 35,000 cu.ft. P1 R Restricted 1&2 Family Dwelling City/town,State,ZIP M Masonry Roofing Covering Window l V WS Window andnd Siding SF Solid Fuel Burning Appliances �� )�, ld(j�{ I Insulation Tele hone mad address D Demolition 5.2t�Registered Ho`mAe(Improvement Contractor(HIC) ►/ery iE+ — YT V44 U 4 HIC Registration Number xp atioa Date HI Co any Name or HIC Regis ant Name No.�d t� �Q�� /� !�dS r "Hi�/ ✓1r1Y�1 .e & Q` �� _^� 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........... O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,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 7bOWNER'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. 94rP I Prin�err5 or Authorized 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 wlvw:mass.govloca Information on the Construction Supervisor License can be found at www.masa�.tov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,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" Jt V The Commonwealth of-mms"Auseds Depatfinent ojlndissir alAccidents I CougressStre4 Suite.100 B.oslo^MA 01I14-20I7 www.mamgov/dia Workers'Compensation Insurance Affidavit:Builders/Con&aefora/Eleddeians/Phm*tm. TO BE FILED WITH THE PERWgTr]NG AUTHORM. Aeollcantlnformaflon Please Print Ledbly Name(Basmesseizanizetion4nmviduat): J5211qtLt S9 E.1✓ �.�'�i . Address: �e6 Cityl tate/Zip: 149:92 Phone#: T79�7W. 7 Are yaa m employer?Cbmk the appreprWe bm: Type of project(reyair}d): l.�l am a employer wei,%-� .eambyeer(fill md/mpmt-taffi).e- 7. Tlew construction 2.Qlaaeaoh:pmpriemrorpartocshy®dbave no empbypo wo{$log fnrmem 8: Q]Z,EnWeling my�ry Mimi, -,Soaaaoce mquhed.I 1PIMahec�r�detal.��(No,�r•emp: .e�It 9. OD >roon ., ; ,.•. Io p sir�dmg aaditwn. 4.❑Iema homeow andmlbebk*cmtradosmcmdwtanwodrmmyproperty. IwiH . etmee that all oomiaams etlherhave workem'cDmpe�on iasmance orare sole I I.Q Electrical repairs or additions pmyastpta With no empbygs.. - t phunbipg tepags oridditioba S.Ej Ism a aeneml commam add l have 6fied&e subxoaQaetme lilted as the wed stet - 13. Roof 7mWmb-c v-1Dmhaveemployeesandhavew0dom 'comp.museum:- - repairs Id(x.c. 14.0Other 6.❑Weareacorpomtimaoddsoiri shaveeserciwdthehrikofeaempli-per ls2.il(4),and wehaeno 6WOYees.[NO woikem bmjL'*eameeregimed.] .eAnY appliraM ffiat ebecks boa:dl must SIM 6014"the apebOn bdvW*mWhW,d1eh woilcae mo pohry r Homeowms abo submit nit af6dava iadig they olio doing all wall thedh��e outmde a must euLah 6mvaffidav&;odinmg nx•R. ICoummeen that cbeA thisbet mug amiched araditamal awd&Nowmg♦in name of&c mb-coovsdom and sate wheMam no gw eww"have employees_Ifthe sub-moactua have.empl-oyw4 ftymostpaovdet= workm'-samp pohcymmib? lao+agemp/oYerthatisprovrdingwoikers'compeMmloninrifrence.TortnyempJpyea. J;ellawisthepoHryandfabstte - � injofa. Insurance Company Name: Policy N or Self-ins.I*.# Expiration Dates Job Site Address: iP Attach a copy of the workers,compensation policy declaradon page(showhtg the policy number and exph-adon date). FAure to some coverage as iequired Imder IvIM c: 152,§25A is a tamiina]violation punishable by a Sue up to$1,500.00 and/or one-year imprisonment,as wen as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the vioLuor.A copy of"araten.=t may be forwarded to the Office of Inveatigaticros of the.DIA far bmumm coverage verification. I do hereby ewtt ry under thepains and penaties ojperjary that the information provided above it true and^eomect i>c ., Doe, IeLg-U \ O�' :....e ..a. q_a D Ph a• Ofi7cia/ase only. Do not write in this area,to be eowtplemed by dry or town ooteini City or Town: PeradUL leense 0 Issuing Authority(circle one): I.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone M > i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, express or implied,oral or wnttM ' An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(t7 also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)narne(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(11Y)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and data the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate lime. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the parmt/licemse number which will be used as a reference number. In addition,an applicant that inert submit multiple pemrit/licemse applications in any given year,need only submit one affidavit indicating current policy information(if necesssary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a d9B license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017- Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia rm:1111b Internationail0:DIK Coif Salem sheet For city or saiem 10:41 8b/19/16 LI Pg 3-3 Client#: 149839 SALEMSHEET ACORD , CERTIFICATE OF LIABILITY INSURANCE DATE(MNUDD/YYYY) 5/19/2016 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 pollcy(les)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 NAME: HUB Int'I New England(NORSB) PAHtO NE 600 Longwater Drive ILEM: - AC o 978-988-0038 ADDRESS' Norwell,MA 02061 INSURER(S)AFFORDING COVERAGE NAILtl 781 792-3200 INSURERA:Commerce Insurance CO 34754 INSURED Salem Sheet Metal Inc. INSURER B:Hartford Casualty Ins Co INSURER C: Roger Petit 89 Russell Street INSURER D: Peabody,MA 01960 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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 ADD SUBR POLICY EFF POLICY EXP LTR INSR MD POLICY NUMBER IMMIDDNYYYI IMMIDD/YYYNILIMITS A GENERAL LIABILITY HHN900 1012912015 10/29/201 EACH OCCURRENCE $1 o0O 000 X COMMERCIAL GENERAL LIABILITY qCl j RENTED IAI anccurrence $100000 CLAIMS MADE ❑OCCUR MED EXP(Any one perwn) $5 000 PERSONAL S ADV INJURY $1000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000000 POLICY JECT F LOD S A AUTOMOBILE LIABILITY 15MMBBLXBV 3131/2015 03/311201 Eaacc,identSINGLELIMIT) $1,000,000 TXXI"rive Y AUTO BODILY INJURY(Per person) $ L OWNED X SCHEDULED BODILY INJURY(Per eccitlent $ TOS AUTOS ) ED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per scadent Om Car $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEO I I RETENTION$ $ B WORKERS COMPENSATION 08WECAA8678 D710712015 07/071201 we sTATu- orH- ANDEMPLOYERS'LIABIUTY YIN ANY PROPRIETORIPARTNEPJEXECULVE E L EACH ACCIDENT s500 OOO OFF:CER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.I.DISEASE-EA EMPLOYEE $500000 It yes,descobe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Scherlule,If more space Is mqufreC) CERTIFICATE HOLDER CANCELLATION City of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W Attn:Purchasing Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St.,3rd Floor Salem,MA 01970-0000 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1613311/M1515631 DKO04