Loading...
12 FORRESTER ST - BUILDING INSPECTION --- The ('onunum+catch ul Massachusetts I I Y Ht } „ Guam of Budding RegulotionS Mid Standards ,i, \II Nit, II' \l ll l- t ,a Nlassachu settS State Building Code. 780 CNIR, 7 edition I SI. i Building Permit ,Application To Construct. Repair. Renovate Or Denlolish a /d 1, rJ hnnl„ Oiw- ut' Tit o-I,tmili' Dur/line /. 'on,\' I' Section For Official (/se Only —1 Building Permit Numh• : Date Applied: — Si��n:uure: Z�.�U—t7---- - - ------- i• I-of 131' ¢s U;ue llnunl„ n. DUI I - 13w mq( I SECTION I: SI'TF. INFOR:\IA'1'ION 1.1 Properly Address: 1.2 Assessors Slap l Parcel Numbers - I-LtFarnw }-en 5a Ll kn _ LI is. to t^is all uc.eptrJ >,leet" cep ✓ nu \taP N'uulbe; I'::rei Nun;in:. _ � _ 1.4 1^rrpe•'t 7rtme v.. t ------ "J I it)1 ;a I un c,:r I ❑ Pnapo,ed (ae I _I 1 .- :,c; u-I III Building Setbacks (ft) F front Yard Site Yards Rear Yard !I Reyuircd Required Provided Kayo ucd I�—P I... &d 1 1.6 Water Supply: tM G.L r. 10. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone:' \.tunic al On rite die w•;a! s• ,lem ❑ Fuhlic Private ❑ _Check ii yes❑ P' SECTION 2: PROPERTY OWNERSHIP' of Record: — — 2.1 Owner N.uw, I Prino Addrese tar Seri,ice: Signawrc Telephone SECTION 3: DESCRIPTION OF PROPOSED WC3RK-(check all that apply) ?Jew Crmstructiun ❑ Existing Buildinj80 Owner-Occupied ❑ Rep.u;: `I��r:ItinNs) ❑ •\dJilin ❑ Demolition ❑ Accessory Bldg Number of Units Other _G S)<<:iy: Ell ief escri uon of Proposed Work-: _-- — --- r�oc���s+ — SECTION J: ESTIMATED CONSTRUCTION COSTS I Item Estimated Cysts: Official Use Only (Labor and Materials) L Building S oo D I. Building Permit Fee: 3 Indicate huu fee a Jetcrnuncd: ❑ Standard City/Town Application Fee ?. Electrical 5 ❑'Total Project Cost' (Item G) s multiplier .a _ 3. Plwnbulg '� ©('� '. Other Fees: 5_ Fi4. Mechanical IHVAC) 'SList:'vtechamcal (Fire SCoral :\II Fees: S t rossion) Check No.1�G 'heck Amount: _ ('ash Amount - I, Total Project Cost N 2�l 00C 0 Paid In Full 0 Outslanding Balance Due:----- SECTION 5: CONSTRUCTION SERVICES S.1 Licensed Construction Supervisor (C'SL) m -L r /} _7 I_Irrnse Numher I;ynewnn Daw Namc tit CSl.- ILdder ����7_ � Lul CSI. 7\pe Leo helur% _ - (U ,1�--y�'`-'^ 1\' e Desire pion �J lddres> / 2i 6 ��} U //Y Qii` C llursvi.IrJ iu i to j5.IN111( u. I l --_ -- R Regoocd L@_' F.mul\ Dsselhnc Si naluo. NI Nl:uonn lhlh V V RC Rc>id:nual Ituuhne (t"Cnmg - fClephunc \\'S R:.idcuo.d \\l nduo .,red Sidin_ i 7 V SF Re'I&II11.11 .Suhd I'uei Bwunl_e \I Id i,inc: Iml.ill ins ii 5.2 Registered Home Im rovemr)t Contractor (11110 HIC 01111pall mC htllC�Re i (rant Name Reeutratimi N'umbci Address �' / , n �17 - 72N PLA F%pualwn Dale Signature elephot SECTION 6: WORKERS' COMPV4ATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Fall ore it, pro%Ide 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 nutters i relative to wotk authorized by this building permit application. Si nature utOwner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1 , 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. k Name ture of Owner or Authorized Agent Date d under the ams and enalties of rfu 1NOTESn Owner who obtains a building permit to do his/her own work, or ❑n owner who hires ;m unreglsteled C0nnra�l,)1 not registered in the Home Improvement Contractor(HIC) Pr(igram). will not have access to the at hitr:vimi program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing (C•SL)can he found in 780 CNIR Regulations 1 10 R6 and I 10 R5. respes:ii . ' When substantial work is planned, provide the information below Total flours area(Sy. Ft.) Iincluding garage, finished basementHutics, decks ur porch, ! Gross living area ISy. Ft.) Habitable room count _- Number of fireplaces Number of hcdrooms Number of hathnx,ms Number or h•dl/h:uhs - -------_---. ._ l\pe of heating system -- - Number of decks/ p,,tC hes Type of cnolin„ system Lnaoeed _ _ _Open 3. -Total Project Square Footage' may he substituted tier 'folal Project C•o+t" CITY OF SALEM �A PUBLIC PROPRERTY :. DEPART'NIENT Ill v'B-Vi-'lj'S • I \s. 'i'%.'a_.984o Construction Debris Disposal Affidavit (required l'or all denwlition and renovation work) In accordance \\ith the sixth edition of the State Building Code, 780 Cb'IR section I 1 1.5 Debris, and the prowisions of'v1GL c 40, S 54; - BUilding permit it is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal racility as defined by MGL c l 11, S 150A. The debris will be transported by: �(�LL✓� 1S � r� � /JG� // ) -- (name of hauler) I he debris will be disposed of in (name of facility) tnddress of Iacllinl _ leer urc of ptnnit apphcm\t - ACORy_ CERTIFICATE OF LIABILITY INSURANCE DP ID C 0ATE(MMIDOR'YYY) BFMUAPH 05 27 08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Thomas oratory Associates Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POL 601 Edgeooater Drive 3235 I ES BELOW. Wakefield MA 01880 Phone: 781-914-1000 Lrax:781-246-2601 INSURERS AFFORDING COVERAGE NAIC i INSURED INSURER AtEe11A Protection Ins. (A) INSURER e'. BF Murphy Plumbing S Heating, INSURER C: Inc &Browns KitchBn i Bath Inc 72 Holten Street INsuRERD'. Danvers MA 01923 .. INSIfRER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L. NZA TYPE OF INSURANCE POLICY NUMBER DATE DATE MMO LAMB GENERAL LweILm EACH OCCURRENCE i 1000000 A X CCMMERCWGEMERALLIASRITY 8500025389 06/01/08 06/01/09 PREMISES Eaoccvence) 4300000 aA.MS MADE a OCCUR M€D EXP(MY Wo Peron) $50 00 PERSO &ADV INJURY $1000000 GENERAL AGGREGATE s2000000 GEM AGGREGATE L IMT LIES PER: PRODUCTS-COFPgP AGG 52000000 APPLIES POLICYF-j PJERC°T LOC I mmpBen. 1000000 AUTOMOSILE LMIRUTY COMBINED SINGLE LIMT $ 1,000,000 A ANYAUTO 99770400002 06/01/09 06/01/09 (Ese deM) ALL OWNED AUTOS BODILY INJURY S (PM Person) X SCEMEDAITOS X HIRED AUTOS BODILY INJURY : (Per ecdderi) X NON-OWNED AUTOS PROPERTY DAMAGE $ (Per ecdderS) GARAGE LIABLDY AUTO ONLY-EAA IDENT S ANYAfT(1 OTHER THAN EA ACC S AUTOONLY'. AGG S EACESSAAMBRELLA LMBSRY EACH OCCURRENCE $ 1000000 A X-1 OCCUR ❑CLaMSmADE 4600025390 06/01/08 06/01/09 AGGREGATE $ 1000000 S DEDUCTIBLE S X RETENTION $10000 S WORKERS COMPENSATION AND X TORYLPADS I ER A EMPLOYERS'LIABILITY 9095020607 06/01/08 06/01/09 E.L.EACHACCIDENT $S00000 ANY PROPRIETOR,PARTNERIENECUTIVE OFFIGERIENBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500000 It yes.descdw wrier E.L.DISEASE-POLICY LIMIT $ 500000 SPECIAL PROVISIONS M9wv OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROWSIONS CERTIFICATE HOLDER CANCELLATION 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL _ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FALURE TO DO SO SHALL To Whom it May Concern IMPOSE NO OBLIGATION OR UABILRY OF ANY KIT®UPON THE INSURER IT'S AGENTS OR REPRESENTATIVES. AUMORIS-0 SEMA ACORD 25(2001109) ®ACORD CORPORATION 1988 CITY OF SALEM ' S' PUBLIC PROPRERTY DEPARTMENT .I UL;g f t'1"JIt KG ni l \I�n In C?CW,wfu.�(:n>�Srxttur � $ntr s(,b1.\�*�ctn ir:tn ut97� fart. 979-745-95`6 • f.sx. 979-7410L1846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers . Please Print Le ihiv A ) ylicant Information L/ t ✓ 2 Narnd lBu:inessit)rganiratinNlndry utualif C�Li /7 �� 7L) atldreSS: 72-� 'G� l�eA r�lli7! l/S Me City,State,Zip: Ulf/ Z3 Phone r'.': "I7k, 27 '— :\ 'rc you an eu Type of project(required): yrloyerl Check the appropriate box: - i 1 :tin employer with 4. ❑ 1 ain a general contractor and 1 G. ❑ New construction i en listed tV yccs(lull anur part-time have hired the sub-contractors part-time).' have ❑ Remodeling r.❑ 1 and a sole proprietor or partner- listed on the attached sheet. : ship:md have no employees These sub-contractors have 8. ❑ Demolition working lilt in any capacity. \workers' comp. insurance. 9, ❑ Building addition 5, ❑ We;ire a corporation and its 10.❑ Electrical repairs or additions required.) workers' comp. ituurance officers (lave exercised their required.] I 1. Plumbin� It. .tirs or additions 3.❑ 1 unit a homeowner doing all work right of exemption per N1GIL ❑ b .p. ce c. 152, 51(4),and we have no 12.❑ Roof repairs myself. [NO workers' comp. c. (No workers' insurance required.] r Other comp. insurance requircd.J ---- •n�ry:ytphcant that checks box It muff aliU ill our IIK fiction tnaUw showing IIKIr workeni'cunlpcn,afio l hulicy intiartwtiun. '11,Im<uwtan who xabant this affidavit indicating they arc doing all work and then him outside cwtt'-eW s"'air auhm"a new atrdavit indiwbng a,wh. {' ! nth I 'heck this tax m\ur auwhwl an additional 'h a•t h.wing the nano of the sub-contractors and their svurkms m'cop.policy infonnanun. l am wr einployer that is providing workers'coutpea.vadon insurance fur )icy enrployec.s. Below is the policy and/ob site infuriation. Irourancc Contpuny V:une: U r_ ( _2..- 0 Kr U '__ Expiration Date: Poll" is or Sclf-ins. Lic. h: - A Job tide :\tldress: I `I 1—�d—% -f. --' C'ity;StateiZip: G1T1,�:�/.1 c Attach at copy of tine workers'compcnsatiun policy declaration page (showinJI the policy number and expiration date). Failure to secure coverage as required under Section 25A ul'.%IGL c. 152 can lead to the imposition of criminal penalties of:' fine up to SI SOQ I)0 and/or erne-)car imprisomncnt,as \well as civil pcnaitics tit the I'orrn of a STOP WORK ORDER and a fine of up to S250.00 a day ;Igainst the violator. Iic advi.scd that a copy u(this statement may be forwarded to the Office o1 Invcsngutinns of tire DIA or in<w'at:ce average Icri ticaLun. lilt,hereby cerfifi'render the pains and penoltrev of perjury that the urfonnation provided above is true«tic!c orrect __ DAtkr _ O/Jiciul rise only. Da nor write in this area, to he couipleled by city or town officiaL City or'1'ovvn: Issuing.\ullturity (circle one): I. Board of Ilcalth ?. Iluild ' n incp:lrunent 3. Cilyi 1'ovvo Clerk 4. Electrical luspector 5. Plumbing Inspector b. Other Phone N: Contact Pcrsou: Information and Instructions ,Vassarhu,etts General Laws chapter I52 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an empluree is defined its "_.every person in the service of another under any contract of hire, cypress or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more oI the foregoing engaged in ajoint 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 cnaptcr 152, g25C(6) 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 ofpuhlic 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-contractor(s) nume(s), address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) 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 may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and dale 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 line. City or'rown Officials Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. PlI ase be cure to till in the pennit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) 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 proof that a valid affidavit is on file t'or future permits or licenses. A new affidavit must be tilled oat each Year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he I)Ilice of lnvc5ngatnon5 would like to thank you in advance fur your cooperation and should you have any questions, please do nut hesitate to give us a call. The Depau nncnt's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Otflce of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE It:viscd ;_,n.o5 Fax # 617-727-7749 www.mass.gov/dia ---------- ---------- 34" - - -24"-___ ' -.__-27"1.. 8', 33" 12" —L. - -47 27"-T s 33 -.--- - --- V3Ofl'Iz 'p[rt3 _ _ 3D2 COMBOW B27 `ra �or _2 - sb 'pfy er I n' d Above Qnbs above) -- Mi 9 m - - ^^ i In N 20„ ° ° F R a % TRJ3384�/ 1� 432R83213R W3015 V93K 69 lx.M;- e -------- --- ------ - ---- — -_zz—_ i Ot j 3 � a^� All dimensions size designations given are d" K This is an original design and must not be Designed:5n12008 subject to verification on job site and race owc es released or copied unless applicable fm Printed: 5/72008 adjustment to fit job conditions. has been paid or job order placed. Fitst Fl left I All Drawing# I 9 , rr 35—" _ 15 , rr I nm M Z e m w TOILET-1 1" cV 4 . tl ` /O/y�u e'.f W W .-IN 3 W N _a It -------34'_�- Shower stall CO f' I R s gf All dimensions size designations given are 2O' `0 i This ism original design and must not be Designed:5/7/2008 subject to verification on job site and �o�Y released or copied unless applicable fee Printed:5/7/2008 adjustment to fit job conditions has has been paid or job order placed. Designl All Dot#: I