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22 FOREST AVE - BUILDING INSPECTION (3) a7 I'he Commonwealth of MassilchllsCUS Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALGM Revised IGv 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Fun+ill D,rrllin.K This Section For Official se Onl Building Permit Number: ate r pplied: _ BuilJing OBicial(Print Nwne) Siytat pate SECTION 1: SITE 1 O ATION 1.1 Property Address: 1. sessors Map& Parcel Numbers X V-DREST Ave. I.I 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(sy It) Frontage(Il) 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 Lone? Municipal ❑ e disposal system ❑ Check it' cs❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 70 !fn/ !CA✓AMU6L'T -TAL-EM 10.3- O/97y N;m,e(Print) City.State,LIP I R R) ff-S T �LaUSpcciry: Nu.and Street TelephoneEmuil AddressSECTION 3: DESCRIPTION OF PROPOSED WORKt apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairations) ❑ Addition ❑cessory Bldg. ❑ Number of UnitsZ OthBrief Description of ProposedWork': . / r.ptf� ArV �oor-1nJC SECTION 4: ESTINIATED CONSTRUCTION COSTS Itcin Estimated Costs: Official Use Only (Labor and .\laterials) y I. Building S 1. Building Permit Fee: S Indicate how fee is determined: '. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 1 1, Plumbing S ' Other Fees: S 4. \lech;mical tlll'AC) S List:._ — � — S. ,Vshanicul tFirc -------------_-_--_ Su i,ressionl S Total All Fees: S_ Check No. Cheek:\mount: Cash Amount: 6, Total Project Cost: S ------ _- ... O ❑ Paid in Full ❑Outstanding Balance Due: c r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supen-isor License(C'SL) -�-1-=1-3 _{.•`�rf��-ff�f7-_ _1,�. a_._______— License Number Iivpiralion Dote Nameeoof ''SI. Holder _ List l'Si.1)pc Um hclutvl_ __ _- � L"s-�'' -I).� Description No�/ �k eet ��� Q U l4nrcstriercJ I Iluildin s ri l0 75,1100 cu. It.l _ Q� 9 6R Restricted 1&2 Famil DtcellinCit State.Z P M Masonry RC Roofing Onerin W'S Window and Siding _J7 p SF Solid Fuel Ilurning Appliances Lf) � ©Cj 1/ 1 Institution Nic hone [:mail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1 D,R9.5 3 8 ,28-/L 1 1'l/j TL I- IDrs �CIL✓.5'1 IZtJ��( E7 " �C IIIC Registration Number Expiration Date II IIC Company Name or I IIC' I!egtVG�islrunl Na...e �q "7tAJ 3 Ci 12 No._alid Street Email address City/Town.State,ZIP rcic hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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 Narne(Electronic Signature) Date SECTION 7b:OWNERI 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 Owner's or Nuthorizcd 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 Hume Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty fund under NLG.L.c. 142A.Other important information on the HIC Program can be found at ttww m:n. _;o% ,tc.i Information on the Construction Supervisor License can be found at k%ok%.m;nss 1; N Vh; _'. When substantial work is planned, provide the information below: Total floor area(sq. R.) (including garage, finished basement'attics,decks or porch) Gross living area(sq. tf.) _ Habitable room count .\Umber of fireplaces_ `'umber of bedrooms Number of bathrooms __ _ ___ Number ufhalf ho all 1)lie of heating s)stem _..._.. _ Number of decks, porches I)Pe ofcooling s)stem' -_.....-_ E ncloscil i. •Total Project Square Footage'nnay be substituted fir"Total Project Cost" CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT w•,. M:1 1':+MIN 1 n l \It11w 11C WAHa.\GIt iiaetr a 3n IS.N, hfti%.%t.ulit, I INJ17yC ll•.1. 77L.'ri•�i'IS • I°tx 9/MJrC•'+Y1A . liVurkers' Compensation Insurunce .%induvit: dul Iders/Con trac torW Cite frici ion Sit Plumbers t 18cant In unnaflo PI riot Le •hl V;IITIO I Iluulw.y Or;{anuAninrvindrr�duulC_�/)�L p/tj ddrr.c.v: Cily,S(arc.Ziff• Q I �7 Phone a: 1531 QS11 IAry 11 n employer:'Check the:glpreprialif box: 1.ETI:un a cmPluyur*ilk 4. 0 I ,un a general couuxtor and I I yPe orpro)eet(required): 2. mnpluycus(full mnl/ur parr little),• Iloilo hired IN suh•cun'raciure b' New construction ❑ I mil a solo prnpriumr,or panncr• listed on the anachcd sheet : 7• Cl Rennotleling +hip and have no mnpluycos These subcontractors have working Air me in any capacity, workers'comp. Insurance, e' Demolition I Na workers'sump. insurance 3. ❑ We are a col 9. ❑ OuiWing addition nyuiruJ.) pontion and its atllcers have txcnirud their 10.0 Electrical repairs or additions ❑ I ant a homeowner doing all work right of usunption Par hIQL 11.0 Plumbing rupuirs or additions myself.(Ko wnrkun'comp. c. 152.41(4),and we have no iluuranco required.) r employees. (No workers' 12.0 Ruufrupairs comp, insurance requirud.) 1 J.0 Otbrr •any..;rphcoe II,Ie ci:ucks bate eb mill'Alw till cent'hit Iellwo Lciuw anwule'heir wwtui euntraeyy(yw plaier„awlrwrfan 'It. who"Anivk that t IMa ar1w,n had.line They art Joins all wink and 111ce biro Vwai4o euwrlwlpe M"i.rhnif Ain"amd••in indicw;ne•wh. •C,mlelanwv ihl'rMcY Ihit tea mIW AllAehee an AdpiliwYl.l►vl dluadne Jim nAnM of IN 14.enraehns And show%urte/e' Mint.IN'Ifty It urn un culpleyer'het IF provldln11 tvrrrkers'cvinpenradon brserrrncr/l/r/ny tmp/uyepq Br/mv/x/ArP•r//y unJ/e1 lu`wrrtrur/rrn, InsttranccCompany Vatne: a, L1 A1g_ yfiq -1 Policy o or Suir•ins. Lic.n: Z}t(ft_ �7�{NJl�6�'1 d r E.apirmwn Darer--• / Iub SIIc �\{IIIfe SM:_ AV C City, � !� \ttach ifcnPy of Ilte workers'cumpensatiun pulley du019. cleratiun puke(showingrhelpalley nS�e and spllun�t Iialluro ru.ccuro co%crage as required uudcr Scoiun?JA u1'JIGL c. 132 eau lead to 1110 imposition oferiratinal pansities of a tine Ill)n1 S L 3n0.gq and/or ui Ih* viol. llnprisnnmun4 As wall us civil penu111cs in tho loan ora STOP WORK GIRDER and a fine i up to i130 rN1 i Jay.A for l the v6vcI'". lle adviacd 'hut a copy urihi%oulemcru may,be lurwardcd to the 011icu ut Iq V�All�allulb ill the UTA for nt.ur:u'Cu:r,�craqu tcriliwLun. /,lu h,•n•hy r rrli r linder the i;ninr,nrJ r nu6iec of perj b in arrnwdon qLi rry/ ut r/10 /• prvviJpll ubuw is/run urrd roncc4 2 7- Ir1j/Iriu/rr.tt an/y. Do nnI,rrirt in Nllr urea, ro Ae rv+ny/a•Itd by city ur rmvn a//kmL Pinnit/Lltenre x Itt uinq .\ulhorily (cirrlx noe): I. Ib,ard f IIvA6b !. Ihldding Ucp.uuoelli 6. 1)tber ill.'I'olln Clerk 4. llcctric.il luspcctur 3. Plumping Imycctor i I l'm Lrc I I't nw1; j i Information and Instructions 04, tatu .11 )crfg to tc euA t,)t their t r hu.,e :ncri Laws C . everyIwtson In therviet of another under ny cuntnctofhe' I`urnu.urttonts% n �dd is dcitteJ as , press ur Implied, oral or wruten." two partnership..tssoeiuwn,coryoratiun ur other legal cnnry,Orally s.r or rheurs No v,nplupvt n delincd as"an InJiviJuah p to in ce Joyce, However the t the t:,reguutg engaged In aJoint enterprise, Ind ittclati ny the legal reprose gy,employing a deceased "s uY' I eCCIVCf Jf lrA>,lee of .rt llldlvldral, pelmenhtp,Assactaioo or other legal entity,clap Y y ' p + rsons to do maintenance•curtsruetion or repair work on suchin9CT haute owner of a dwelling house having{not more than three apartments and who resides therein,ur the occupant dwelling .Iwclhng huuid of another who employ. {K or un the grounds or building appurtenant thereto Shull not because of such employment be JeemeJ w be m employer.' �IGI chapter 152, !�?SC(b) also slates that"every state or 1CC3111censlagt Ayeaey shall ommu d the Issuance for May or renewal of a license or permit d ope rate a huslnea or to construct buildlnys In the cammoowealtb for Si, +SC 7)sates"Neither the commonwealth not any of its political subdivisions shall Aypllcant who has not produced acceptable evidence of cumpUlaee with the Insurance coverage %JJitiunAlly, %IGL eltupter 1 _ S- i ureter into any contract for the perfor an C,enteJblo the Contract y authority." of cwuyliarlCe with the insurance requiremens of this chapter have been p' Applicants ing the boxes that apply to your situation and,if compensation atNdavit camp-and phone nutnber(s)along with thou certi8cute(s)other of Please Ii1i nut the workers' amp aJdresslos)and P necessary supply sub-Conttacwc(s)n une(q, ed Liability insurance. Limited Liability Companies(LLCworketi Limiteompensa oe insurance'(if an)LLC or LLP does have than e members ur pone••, rn not required to carry enspinyeao a Partpoliners, is requited Be advised that ths of Industrial �l�be sore to rl�a and Jule he ufildavlt ttt7110 agirJav t should permit or license is being requested,not the ty,patment of \CCidenu for contlrmation of ithat th eo coverage' liAdothe low ur ii you are required to obtain a workers' he remitted to the city or town that the upplicatii ofns regarding Industrial Accidents. Should you have any q compensation policy, picas•call the Department st the number listed below. Self-insured companies should enter rhea sclf•insurancs license number on the appropriate line, city or'rowa Officials The Department has provided a space at the bottom lieant. please be sure that the affidavit is complete and printed legibly.Inv Itcant of the Affidavit for you to till out in the event the ORtee of Investigations has to contact you regarding the app hcatiens in anygiven cot,need only submit one utiidavit indicating curreu' I'I:usu be sure to till in the permit/license number which will be used as A refere reference nurnher. In addition,an app that must submit multiple penniu'iicatue app ' policy informati,if he uniJavi�hat has been oftle ally tamcss" the appliped or marrkedlb i tile City Or nay beprovided to theiuns in y y y Y tuwnl." %coPY permits or licenses. A new affidavit must be gilled nut eoch applicant as Proof that a valid Affidavit is on rite for tLttue pIt year. ear Where 1e ens• a uwner to burn Ieavesobtaining ai i g J Pecs nos permit required to complete this cAffidav tmmercial venture I hu I Mice of Investigations ,vuulJ het W dank you in adva^cc fat your cooperation and should you hate Any yuesuoas, please do not hesitate to give us A Call. fhe U p,uuncnt's aJdrers, rcicphund and The COmmOnwealth of Mamchuselts Department of industrial Accidents OtHee of Isvestigadons 600 Washington Street Boston, MA 02111 'fag. # 617.727-4900 ext 406 or 1.877-MASSAFE Fax M 617-727-7749 <.If, www.mau.gov/dire CITY OF S.�t.&Nfj >�L�SS.�CHL'SETTS EILLmLNG DEPARTN NT 110 W.u1iLNGTON STREET, Y°FLOOR ` Tom. (978) 745-9595 FAX(978) 740-9846 KI\®ERLBY DRWOLL MAYOR THowu ST.Pmu DIRECTOR OP PLauc PROPERTY/lIUMOLNG COMMISSIONER 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 a 40, S 54; Building Permit N is issued with the condition that the dcbris resulting from this work shall be disposed of in a properly licensed waste disposal facility as dcfincd by b1GL c 111. S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : L. / iV4,1 l'li(& r (name of fatality) (address of facility) signature of permit applicant 9--2 -7- ! / date Jail y I Sr�2_. ' Melo's Construction LLC 13 34 Jennings Circle Peabody, MA 01960 Telephone: 978-531-0811 - E-mail: gaustinoMelo(almsn coin NIBMBiR Faustino Melo,General Manager Unrestricted Mass Builders license No. 80393 Contractors Registration No. 108953 SubmittedProposal to: jrl�one Address: — 8 O 5— $ — City,State,and F Code Job Description: Job Lacation: �19• e I . / Job Phone: we a�MMy W�m material,aid 16.. Awl t _ -/ o®plaoe m aooudaeae win me epecisc.bm.&aned below,far me even oF. Installation of Payments. �/' .�� do0°" (s D ®o Pavn eats will be paid in thuds.The fast installment will be paid before the job begins.The wood payment will be obtained in the of the jab.The last payment will be obtained after the Job is..pWt d. middle Note:This propoasl may be widilrawn by m if not accepted within 20 days. Authorized Signature: .> Date:_ e 1larery a ape�ryam Sad E.etvW la'. THE INSTALLATION OF ANEW ROOF To protect the homeownees property,Blue Tarps win be used to cover the siding,bushes end An of the layers of roofing will be stripped,and Bra during PPin6• will then be installed at the bottom of an edges,around �.screws,and/or staples will be removed. lee and water shield Fifteen(I 5)Pounds of felt cb and into an van Paper will be insta0ed onto all other areas of the roofleek. The 8"alumimmt dripedge will then be installed to all roof edges. Any existing Pipes will be covered with new rubber flanges. The roofing material to be used will be d % The homeowner is responsible for the selection f the roof color. Also,the homeowner nmy select ether hand or nnmmaKe &M for the O°d All the debris will be n8 application of the new roof. Your property. of on a 1w basis.Magnetic brooms will be used to extract an nails from We will protect you Prop"as best as we can,however,some foilage matting,b accept resPonsibihy for Possessions inside of the house,or debris '°r° ng could occur. We cannot rReplace customern6 into attic arras. Wo ra w t sa a o nos added Rotted Roof ioards NRepairs e a ve pnce O GN F•lnn Gutter R ad Chimney(s) �uCyUO€0 [nsteU g ems) Remove Aluminum Siding lace Facia Boards Remove Old/Rotted Wood all Ridgevent Repot coney Install Garage Roof Install Roof Louvers — Install Azek Board Install Insulation Install Window Trim Install Aluminum Gutter Install Tyvek Paper Install Aluminum Downspouts k atdl Shutters Cover Aluminum Windows Remove Vinyl Siding Install chimney cap Porch Repairs Repair Vinyl Siding Additional Not": Rebuild Chimney AMM Total Amount for Additional Work: Warranty by manufacturer to be free of defects f ir3Q yens, see manufitcarrves under'his contract shall be of good quality and fee from defects not inherent in the required details. A11 labor Performed of r cs years. This warranty excludes remedy for p spitted fora period maitenimm,improper 8e or defect caused by abuse,modification,improper or insnn�cent P Per operation,or normal wear and tear under nnorn al usage. This warranty shell be Ihrtited to the work Performed an electselds Construction,LLC and limited to either repair or replacement by Melds Construction,LLC at its sole descretion and election. Any and all clainis are waived unless made in writing to Melds Construction,LLC within 21 days after the law occurrence of the event giving rise to such claim. This warranty shall no extend beyond any limits huposed by applicable Payment and Penalties,Upon substantial completion of an work under this within 3 days-make the fiYou agree to nal and fun Payment of the contract Price.Any and all unpaid balances d ain asxxue wrath interest�1-interest per soma. Of an amount you owe under this an court costs scconta iCollection expenses incurred by Melo's Construction,LLC in the collection amount you ntract,includirng and without any limitation of reasonable attorney fires. Acceptance of the PropoaaL• The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified,Payment will be made as outlined above. Payments are to made as per requisittion and or invoice. The Proposal may be withdrawn within 20 days. Date of Acceptance: ! ; // - %1 /' AC10 CERTIFICATE OF LIABILITY INSURANCE. DATE /l/2oio) THIS CER I if.-ATE 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(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 endorsements . PRODUCER NAME: Lauren Goldman G B.R. McCarthy Insurance Agency, Inc. PHONE . (978)532-5445 FA/XC No• 1918)5]2-2211 10 Centennial Drive A"OpAgILIIS,lgoldma @crossagency.com West Entrance PRODUMFC n tlCER 00080022 Peabody MA 01960 INSURERS AFFORDING COVERAGE NAICS INSURED INSURERA:Main Street America Assur. 129939 INsunRB:National Grange Mutual Ins Co 14788 MELOS CONSTRUCTION LLC C/O FAUSTINO MELD INSURER C:Travelers indemnity of America 25666 34 JENNINGS CIR INSURERD: ICI 34 Jennings Circle INSURER E: PEABODY MA 01960-3568 1 INSURER COVERAGES CERTIFICATE NUMBER:CL1012139423 - 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 TYPE OF INSURANCE W POLICY NUMBER MMIDYYVY ADD[gUffiliT POLICY EFF MM/DO CY EXP LTR LIMITS ! GENERAL LIABILITY i EACH OCCURRENCE $ 110001A00 TO RE [ X I co,RIE.RCIAL GENERAL LIABILITY P EAaE ISES Ea occurrence $ 500,000 A I CLAIMS-MA9E X OCCUR j PH23862 11/26/201011/26/2011 MED EXP(An one person) $ - 10�,000 I I PERSONAL$ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 . I GENL AGGREGATE LOAIT APPLIES PER I PRODUCTS-COMPIOPAGG $ _2,000,000 I X i POLICY 1 ' is O I LOC $ I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea acc and) ANY AUTO BODILY INJURY(Per person) $ B j ALL OWNED AUTOS 9H43926 9/21/2010 /21/2011 _ .BODILY INJURY per accident) $ X 1 SCHEDULED AU'ICS PROPERTY DAMAGE S X 1 HIRED AUTOS (Per accidem) X I NON-0P.NED AUTOS 'SAOS $ Uninsured motunat 81 SPIN limit $ 20,000 I I UMBRELLA LIAR I i OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MA i AGGREGATE' $ %DEDUCTIBLE $ R%TENTION < $ L. WORKERS COMPENSATION I 12/4/2009 12/4/2 010 - -I AND EMPLOYRSLIABI1JTY YIN, _ 1.AN FRG 3 0?:PAPTNER IE<ECUTIVE❑ - E.L.EACH ACCIDENT S__1 000 000 NIA OFFIC Rh - R EXCLUOEOI HOH7S14M46510 2/4/2010 12/4/2011 (MBndalefY in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,cNSu to ender OE SCRiPTION OF OPERAi10�NS below E.L.DISEASE-POLICY LIMIT $ 11000,000 I DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (ANach ACORD 101,Additional Remado,Schedule,8 more space Is mqulmd) Refer to policy for exclusionary endorsements and special provisions. 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. For Insured's Purposes AUTHORIZED REPRESENTATIVE �--_,0 Timothy Tramonte/LG4 ACORD 26(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD !Nl [tsitchusetts- Department of Public SafetN Board of Building Regulations and Standards Construction Supervisor License License: CS" 80393 FAUSTINO N MELO 34 JENNINGS CIRCLE ✓yyy PEABODY, MA 01960 Expiration: 3/1/2013 I I r mho C ucr Si"Z'.rc� t `�tir'�"SBu a eou a�.n ,. ,�_L 'R�CVEP.9ENT CONTRACTOR Type. F MKS i=;raa. an. ,€i08953 '-�„ , E", anon A,7282012 Lid Liability Ccrpo S ii-7 �j �� dy NIA 01980`� i Undersecretary GK C�oty — fhe Commonwealth of MassacllLISCUS - -- } Board of Building Regulations and Standards CI'I'1'OF 1 i9 Massachusctts State Building Code, 780 CMR SALEM �J ?L��N Revised.11ur'lll l �O Building Permit Application To Construct, Repair, Renovate Or Den a One-or Two-Fuadlr Du ellin,q This Section F fficiai Use Onl Building Permit Number: Date.4ppli _ Building Official(Print N:une) Sig, ore put SECTION 1: SITE INFOR ATIO LI operty dress: 1.2 Assesso ap Parcel Numbers W 0.7 I.la Is this an accepted street?yes no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed LJsc Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided �.�. 1.6 Water Supply:(M.G.I.e.10.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yesO Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owners of Record: :Nuc(Print) City.State,LIP Lull and Street Telephone Email Address SECTION J: DESCRIPTION OF PROPOSED WORK=(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': r (( �(vy(_ ✓La_yriL SECTION a: ESTINIATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only ILabor and \laterials) y I. Building $ 1. Building Permit Fee: S Indicate how fee is determined: 2. f'lectrical S t> Ld ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier ___x 7. Plumbing S 2- r 2. Other Fees: S 4-Mechanical ill\':\(') List:__ 5. \leehanieal 1 Fire - --_-------__— tiu'I rrasionl S lGy 740 Total All Fees: S _ ChakNo. ('heck :\mount: _ _ C;uh:lmoum: 6. Total Project Cost: S (Q ❑ Pail in Full ❑Outstanding Balance Due: -----. ..- -, ��r+•f e o w� � G r SECTION 5: CONSTRUCTION SERVICES / 5.1 Construct' upervisor License(C'SL) )3 /9 / /2— License Number Ifspirauo t Dntc � , List CST. I)PC Isce below)__ _ �✓ ""--- - -- - TN Description " No. and Sir"t I etri ted J I Ilui Family gs li i 35,11110 cu. tl.l d``/1 --' /'l R Restricted Lt:2 Famil- Dticllin Cityifuwn.State.ZIP M Nfasonry RC Roofing Cmerin -_ - WS Window and Siding SF Solid Fuel Burning Appliances I Insulation 'felt hone ['mail address D Demolition 5,2 Regt red Ike Improvement Contractor(HIC) /2 / �� IIIC Registration Number lispvat' n Uatc I IIC comps Nani o�C' Registrant Name !!CC of colt/ No. ai1J Street '�n,r ��qy.� S�S��.12C_ y! Email address Et/Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... O 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 to act on my behalf,in all platters 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 containe ' this application is true and accurate to the best of my knowledge and understanding. iA, �� y' 0 e' Print 1 wner's or:\pthorizcd Agent' Name(Electronic Signatures DaW NOTES: I. An Owner who obtains a building permit to To his/her own work,or an owner who hires an unregistered contractor snot registered in the Hume Improvement Contractor(HIC) Program),will tart have access to the arbitration program or guaranty fund under NI.G.L.c. U?A.Other important information on the HIC Program can be tiland at nau,.�;o% oc.I Information on the Construction Supervisor License can be found at�%%�tt_.mase Jp, 2. When substantial work is planned, provide the information below: Total fluor area(sy. ft.) (including garage, finished basentent'attics,decks or porch) Gross living area I sq. tt.I Habitable room count Number of fireplaces_ Number of bedrooms Number of hathrooms Number of half haths l, Ise of heating s)stem .__ .. ._ Number of decks, porches _- I)peofCnolulg :)itenl 1?11closed Open 3. 'Total Project Square footage'Ina) be Substituted filr"Total Project Cost" CITY OF SALEM {' PUBLIC PROPRERTY - -W DEPARTMENT I+m: a:r r:ralN,1I r 11C\VAttaAt:tt).k,lISCL•T • Snu•.w,M.tu.u.rn u I nJI�17: l*"' 'gR711vS'/S shax Y7N•NC•naM Workers' Compensation Insurunce .undavit: liuilders/Cuntrectur3/Electriciane/Plumbers \ I Illunt In(urmalion r—_ PI a+ Prinf le 'AI V;IITeillua;k�it)r;yanvitimvindn�duulC_ /On. �/t/�/j�/(y Address: t 5 37 �6 M—� Ciry,Srarc.%ip _ /sY' w Phunerl:_ Are i' n employer?Check the approprime box: I I. 1 am a em lei cr wish 4. l')M orprq)uct(required): P Y ❑ 1 um a general coulractor and 1 mnpluyccx(1'u11 and/or part-time).• have hired the sub-cumraciors ('' Nc nslructiun 2•❑ 1;mt a sold prnpretior or partner. listed on the attached shed 7• Remodeling ship and h ve no cmpluyuc's These subcontractors have S. Demolition working lots and in any capacity. wvrkera'comp, Insurance. I Nn workers'comp. iosurance S. ❑ We are a corporation and its 9. ❑ Building addition ).❑ nquircd.) Mytcers have c.rersised their IO.Q Electrical repairs or additions 1 ant a hntndnwner doling all work right of exemption per NML 11.0 Plumbing repairs or Jtlditions nyxlf.(No workers'cunlp. C. 152,¢I(3),and we hnvd no insurance required.) r - employees. (No workers' 12.0 Ruul'repain comp, insunncumquircd.) 13.0Other 'q n),n,phcur IhW chcchs cal el muei alau till,ae the acoon Wake,darwlna Mr wwhwi rumptetcaiun policy udwmwiws 'I tonwrow,wn whe uarmit this arlldwit indiulinx Ihry au doing poll.vure and sham Ain twnids etenrnenn mwl.ut"if a iaai wrctt •r.mlrJcrtec'her chvck this toms mtw Jnachad an additiu hvn n,d+ aw,wina Ihr nanlg u/the cubrc mnctars and Thee wu new alnaarit indhun'coop.ptdtey i ,namantn olen toun entployrr/tour If prveid/nx rvarAers'rutnpmrrnrlon haturvnee/br rey emp/uyraa Br/ors lr tAe pis/&y arse/ub sire %II`drer/rWf416 Inauraucc C'unipany Name: I'olicy is ur Sclr•ins. Cic.to: - ' - _ � Enpirmwn Dare: lob Sole hddre.cs: C'uyr5late/ZIp; Attach it copy of the workers'cumpenaatlan pulley JeclurrNun page(showing the policy number and espl►atlun date). I+allure Ito+ccun coverage as required uoJcr Section 2JA ul'`6IOL c. 152 taut lead 10 file imposition of criminal penalties of a ILw up nr S I.SnO.()n Jntl/ur uoe-year imprisonment,N well Js civil penullru in this r'unn or'a STOP 1YORK ORDER and a fine nl up rn i'SO.r)n a Jay aguinat the vi-A f le Ile advi.ced thul a copy urfhis.,luldmcnt may be lurwitdcd la the Orlicc uC IaY�alhJllnlls ul';hd 1)1,\ IOr IINIIf:ICee GtiY efa�e 1e11heJIlUn, /du hert•by certify under the pains Intl paudrier ufprr/nry their 1/10 in/bnnurlon prvriJatl ubuw is true filed carrera �I�:I:wIIJ I�!/leiu/inn only. /)u"tn/Irrire jet rhLr Ore m, ru beeooty/rrrd by city of to a//J,iul Cfly or I'mrn: Pcnnittl.leen+e 1_ (+vuing.\whurily (circle )oel: II. IlafrJ of IlcJlfh 1. Ihnlllin. ncpartmc"I I. t:il);Tourt Clerk a. C•'leclrica) lotpccrur ;• plualbinll (P. In+ycctor . Ofhv nun: I'hunc 1: Information and Instructions loon in the service of another Miller:sly contract of hire, \1.Us.ichusetls IaCOCfJI Laws chapter i j2 regWfe3 all eltiployers to provide workers' eJl"W"tMln y hell ct1of hire, e3• PMnu:un to Iivs.latute, an emplrrrre is defined as"...every pc ,.press or Implied, oral or written." An employer is dctincd as"an Individual, Partnership.association.corporation Mr oil of 3 er legal eased or any two r the more a the I'oregomg engaged Ina joint enterprise,and including he Icgal represmuativeslo in evmvlo ees employer,or he ant of the ieemver Jr trustee ul'.tn individual, peamersh+p,asaoe spar or oiler legal 4111011Y,resides a therein. Y a ' D owner of a dwelling house having not more than three apartments and who resides herein•or the occupant awvlling house of another who employs ficrionthereto shulllnotnbecause of such employment be deemed tocbe a house n employer." or un rile grounds or building appurtenant MCL chapter 152. If:SC(6) also states that"every state airlocal Ilcens buildinlag aueaey had withhold alth for any Issuance or renewal are license ur permit to operate a business or to construct ItIs a insurance in Ill*commonweea :+ppiicant Nllo has not Pror u51 §15C(7)sthle a esrNeither hit commonwealth alth ur any of its poli calgtubdivisions'ihsll �dditionully, �IGL chapter l S_, a- vncer into any contract for the perfornan is onedbto the eon�ract i+crluthoreryvidence ofcontpliurlcewith the ulsurancc requirements of Ihis chapter have been p' •' a' Applicants pp to our situation and,if as and hone number(a)along with thew certiflcnte(s)of Please fill out the workers' compensation atltdavit completely,by checking Ilia boxes that apply Y necessary, supply sub-contructor(s)name(s).addreLimited Liability) P with insurance. Limited Liability Companies(LLCwo fees, com pensa oe uuurance.(If an)LLC orLLP does have than a al members or partners, are not required o carry employees,u policy is required Be advised that this affidavit may be sta ad d to the the Department The of affidavit be Accidents for chae confirmation town insurance ce co canon for the pane orolicensenis being requested, he Uapartmant of Industriul Accidents. Should you have any questions regarding the low or if you era required to o u workers' es should enter their s co+npensatiun policy, please call the Department'it the number listed below. Self-insured companies self-insurance license number on the appropriate line. City or Town Officials I+canL please he sure that the affidavit is complete :u+d printed legibly. The Department has provided u space at the tom Of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the app ' \rmit/licensc numM:r which will be used as a reference number. In addition,an applicant I'I:use be arc to fill in he p Lit or that must submit multiple Pennit'licaitse applications in any given year,need only rewrite uric affidavit indicating Curren of the necessary) it but has been officially stamped or marked by the city or town inay be provided to he Policy inl'ormucion(if necessary)and Midst"Job Site Address"the applicant should write"ill lucutiuns in y town)."A copy applicant as proof that uffide a valid affidavit is on file for future permits or licenses. A new afNdavit n+u31 be Illled out each venture t not ye`r.a Where ens or permitOwner to burro leaves cte)aid pers license NOTlrequired o complete this al'frdav tto any business r mmereial venttrrs I he I slice ui ou in advance fur your cooperation and should you have:Iny 4unuons, luve.tigatiuns would like to hank y lcuse Jo nut hesimto to give us a call. p f he Ucparnnenc's address. telephone and C number: of Massachusetts Department of Industrial Accidents Off ce of lavelsdgadoes 600 Washington Street Boston, MA 02111 'fei. p 617.727.4900 ext 406 of 1-877-MASSAFE Fax N 617-7I7-7749 www.maw.gov/dia CITY OF SaULEM, , L�SS.�CHL'SETTS BLImLNG DEPARTMENT 110 WASHLNGTON STRM, 3iO FLOOR T IRL (978) 745-9595 FAX(978) 740-9844 KINMERUY DRISCOLL .MAYOR Tho.+ua sT.PM"A DIRECTOR OF PLBLIC PROPERTY/BCILDLNG CONNISSIONER 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 I 11.5 Debris, and the provisions of MGL c 40, S 54; Building Permit N 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 l 11. S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) Sig acute of permitap licantt dace