17 FORRESTER ST - BUILDING INSPECTION (2) The Connnonwcalth of Massachusetts —�— —
t y Board of 131,11ding Regulations and Standards ft IIL
Massachusetts State Building Code. 7SO I AIR. 7"' edition � \II NIt 'll' \III 1
O I3uilJing Permit Application To Construct. Repair. Reno%atr Or I)elnuliah a R, I",./ 4mrr.11 r
One- of rner-Vamilr Durl/Ing 1. _rot\'
V —
" is Sec in For Official use Only —'
Budding Permit Numb'r: Date Applied: —i
Si_nalwe: /y-/
Budding Col nnsuueri II specs i r mgs Dale
'TION I: SITE 1.\'F'ORM:1'I'ION
1.1 Pic erI (ddress:�u 1.2 :\s:;essars .Ylup ,t, Parcel Numbers -------- - --
1.1 t Is this an accepted street:'yes no Map Nunth"r
I1.3 Zoning Information- 11 : Property Dirncnsi:Ts: --�
i
E15
g Drstricl Proposed use Lot Area (sq IU
Building Setbacks (ft)
Fnml Yn
Side Yards --- Rear Y:ud
Required ywrcd Pnrv;JeJ Re mrrd—_
4 PnrrJrJ
J
.6 Water Supply: ( od Zone Information: 1.8 Sewage Disposal System: �
Pubi" ❑ Private _ Outside FhntJ Zone? I
Check it yes❑ I Municipal ❑ On site disposal sysem ❑
_ SECTION 3: PROPERTY OWNERSHIP'
2.1- Ow ner'of Record: —
Nawc I prints Address (or Service:
S;gncture Telepinme -
- SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Lunn_traction ❑ Existing BuilJi ng ❑ Owner-Occupied ❑ Repa us(s) Aher,!hon(s) ❑ I ,1JJiurm ❑�
Demolition ❑ Acress;.rry Bldg. ❑ i Numoer of Units Other ❑ Spcclty ---
Briel Description of Proposed Work2 -- —
� d i
SECTION 4: ESTIhiA'rED CONSTRUCTION COSTS
I(em
Estimated Costs:
(Lahur and Materials Official Use Only
I
- - y J
I. IiwlJing I g - 1 1. Building Per:rr: Fee: $ Indicate how tee a Jelerl nrned.
—
_'. Electrical ---TS ❑ Standard City/Ta•sn Application Fee
1. Plumbing 1 ❑ foial Pnect Cost' (Item 6) x multiplier r
5 _. Other Fees: K
-I. .Mechanical N VAC1 5 i List:
5. :blechanieal (Fire _----- ------ I
I Suppraswn) ti i .Lgal
('heck No. _CheOl Am,wril: Cash \ntoune �.;r total Project Cost s �� �� _-
/ "l /( )O v ❑ Paw in Full ❑ Outstanding Balance Due
f:
{1 i
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSI.)
License .Nu mhrr I
N an1r of CSL- Holder I.ut C,51_ Ts lie Ufe hClo�s 1 -
h,. i, Drscri soon
\ddies> l- t'nr-Sit JC(Cd iLill to
R Rewaacd 13c_' Fanul\ Uo rllme
Seen:cure V1 masons Unlr
RC Residential Rur1linc
\\'S Resdential \\1 nJa�, .inJ Sitliw,
relephonr —._--—.
SF Re Jeuu,il Soli) I uel 1L
ISunuue \ � li.uie: lu.i.d Lniai 1i
D 1e,,I&nllal Deinuhlwn _----{
5.2 Registered Home Improvement Cuntructor (IIIC)
Re6 istiatiun Number
Con 'an Name or HIC cg stra Nanrc-
HIC [a ,./.�I� /'try l.%n�n�/l�l � --
addres>� /,I C� / /�d7J/ `-'On dff_-_�lo—J11'- Fxpiratwn Uat:
"relephonr
Signature
SECTION 6: WORKERS' C N PENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pooide
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 COh1PLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
to act on my behalf, in all marten
authorize
i
relative to v:.:�k authorized by this building permit application.
Darn ------- .--
Si nature of Owner
SECTION 7n: OWNER( OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
I,
ue and accurate, to the best of my knowledge and
that the statements and information on the foregoing application are tr
I behalf.
2
Pont Name ✓IAr,, , �_Jgaa rF'/Jl�
N Signature of O
Date
(signed und
NOTES: —
I. An Owner who obtains a building permit to do his/her own work. ortn o\vner who hires an ume�asterad .untru�wr—{
(not registered in the Home ild ment Contractor (HIC.) Program). will no! have access to the aihin:uiun
program or guaranty fund under M.G.L. c. L1'_A. Other important information on the HIC Progr:tin and
Construction Supervisor Licensing (CSLI can be tound in 780 Cb1R Regulations I IQ.R6 :mil 110.R9, respecuseh`
When substantial work is planned. provide the informa^`rludlnr/garage. finished basernentJalncs. decks or nrehi
g b I
Total floors area 1Sq. Ft.I Habitable room count -- ---
Gross living area (Sy. Ft I Number of hedrnum, --- '--...
Numbcrotfireplaces Nwnberodh.Jt/h.uh, —
I Number or hathnronr' Number tit decks/ ponnccs
Tcpe pit heanng systcm --
Type oI cnolm_ ,}stem
3. Total Project Square Footage" may be substllulyd for "total Project (osh
.4C0RD_ CERTIFICATE OF LIABILITY INSURANCE OPID C DATE(MMIDDNYY)
SE14URPH 05 27 08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Thomas Gregory Associates Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
601 Edgewater Drive S235 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Wakefield MA 01880
Phone: 781-914-1000 rax:781-246-2601 INSURERS AFFORDING COVERAGE NAIC 0
INSURED INSURER Arbella Protection Ina. (A)
INSURER 8:
BP Murphy Plumbing & Heating, INSURER C:
Inc &Browns Kitchen & Bath Inc
72 Holten Street INSURER D�
Danvers MA 01923
INSlA2ER e
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY NUMBER DATE RAMCCIYYTDATE MMIOD LIMITS
L.NQ TYPE OF INSURANCE
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
A X COMMERCIAL GENERAL LIABRITr 8500025389 06/OS/08 06/0
1
/09 FREMIses(Ea eccuMxe)
$300000
CLAIMS WDE X�OCCUR MED EXP(any one person) $5000
PERSONAL L ADV INJURY $ 1000000
GENERAL AGGREGATE s2000000
GEM AGGREGATE LIMIT APPLIES PER PRODUCTS-COWIOPAGG $2000000
POLICY PRO- Loc Ben. 1000000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
A ANY AUTO 99770400002 06/01/08 06/01/09 (Eee Odwl)
ALL OVYNED AUTOS BODILY INJURY
X SCHEDULED ADIOS (Per person) $
X HIREOAUTOS BODILY INJURY $
X NONOVVNED AUTOS (Per ecdderd)
PROPERTY DAMAGE $
(Per evader$)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S 1000000
A X O CUR ❑a-AIMs MADE 4600025390 06/01/08 06/01/09 AGGREGATE 41000000
s
DEDUCTIBLE $
X RETENTION $10000 S
WORKERS COMPENSATION AND X TORY LIMITS ER
A EMPLOYERS'LABILITY 909SO20607 06/01/08 06/01/09 E.L.EACH ACCIDENT $500000
ANY PRWRIETOR,PARTNEMEXECUTIVE
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500000
If M.describe under
SPECIAL PROVISIONS W. E.L.DISEASE-POLICY LIMIT 11500000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
TO Whom it May Concern IMPOSE NO OBLIGATION OR LIABILITY OF ANY MO UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZE SENTA
ACORD 25(2001108) - - ®ACORD CORPORATION 1988
—� CITY OF SALEM
PUBLIC PROPRERTY
DEPART'NIENT
N nrkers' Compensation Insurance .\Ilidacit: Builders/ContractorsiElectriciansiPlumbers
\ ) )lic.lnl Information Please Print Lreibly
+
`,IIIId: ,11v.u7lr.. l lr_.u``liaeel n''m hi.hd:dual i'. &/) n S / ✓N-nA 'ten
Addless
D-1rD1/114S Phone97c4 -77N �33 3�
('It) State,Zip: 0JIT23
\re you an employer:' Check the appropriate bus: r%pE;�
project(required):
4. ❑ 1 airs a general contractor and I o. ew construction
I I am a enlploycr w ith
unpluyers(full Jnd'ur part-unle l.' have hire) the sub-contractors
?.❑ I am J sole proprietor or partner-
listed untie anuclied';heet. 7. .� emodeling
,hlp and have no employees 1 hese sub contractors hale 8. ❑ Demolition
working for me in any capacity workers' comp. Insurance. y, ❑ Building addition
No wurkers' cons 5. ❑ We are a curporution and its
P insurance officers have exercised their IU.❑ Electrical repairs or additions
reyuircd.i 1 I. Plumbing repairs or additions
{.❑ I am a homeowner cluing all work right of exemption per h16L ❑ B P"
myself. [No workers' comp. c. 152. S 1(4), and we have no 1 2.❑ Roof repairs
insurance required] r employees. [No workers' 13 ❑ Other
comp. insurance required.[
•:\try applicant Ihat checks box 41 mu>n also till out the section below..hawing their workers compensation policy information.
' I lUmeUwners a'hu>Uhmit Ihi5 atridavlr Indicating they are doing all work and then hire outside contractors must)ubmlt d new affidavit Indicating such.
:c a t aors that check this box mint attached an addmonal sheen+hawing the name of the sub-contractors and their workers'comp.policy information.
I urn on employer that is providing workers'compensation insurance for troy employees. Below is the policy and job site
information. y�
Insurance Company Name: �/ J
Policy q or Self-ins. Lic. q: 9 Oq S0 20 I0 07 Expiration Dater&p�L l IO q
Job Site AJJrcss; 17 E0 f c4) City,State/Zip:
.\ttach a copy of the workers' compensation policy declaration page (showing the policy number an&expiration date).
failure to secure coserage as required under Section 25A of hIGL c. 152 can (cad to the imposition of criminal penalties
tine up to Sl.ioomo :uld.'or one-veer imprisonment. as well as cis11 penalties in the firm ofa STOP WORK ORDER and aline -
,,I up to S 25tl.rill a day aeain,t the s iolator. Ile ads iscd that a copy of this siatclllent IoJy' he for\Carded to the Office of
I on c,u C.0 lon5 of line DIA fir insur.ulce colcrage scrlticanon.
l do hereby rertift tinder the pairr.ss andd penalties uJ perjury that the ur/unnunon prat riled ubo/d a A true mod c arre,t
Dare
�iyl lLtinrd. _ V
F
ono• Do wet krill in this area. nr he rwisplefed by cityor town fi fro rut
n: -. - - __ 1'ennittl.icrnseqhurih- (circle suet:Health 2. Building Department 1. ('ity, fawnleek J. F:Icctriral Imprctor S. 1'Iwnbing Inspector
_rson: --.-----.___- Phone q: _-------
Information and Instructions
Y
%
\LL,.L4u,ct, licnrral l .I vv, :Lapter l 1,quue, .111 cmplovcr, to pro%ide workers congvcu,alion for (Iliit cnlplovees.
I'•,u,uant to (Ills aaftlic. .ut rutphnee I,-Jcl*.Xcd as ' cv cn per,orl ul the ,cIN lie ofanother midcr my :ontrict of hire.
:y,ic„ Or lnphcd, oral or tvlincii
vnp/mer Is Jc tined .Is ...ul uldry:,I Iva I. p.0 n:cr,hi p. .I„o.Llnon, a 1Porat on or of her !cgal crow, or .utv Ball or more
, t 1hr G,I:_omg cngagoJ :it a fault cutelpn,c. and in.ludmg the Ic_al Icprc,entanv e, of� Jr:ea,eJ cmpl, er. or the
.�.cn er or it of.lit mdI%IJua1. p.0 Mier,l t Ill. a„o.IJ n on or other Icgal cti my, enyllo Ing emplovees. I lovvever the
, •.v tier of a k%vIIulg house Having not :more than three aparrincnrs anJ %%ho reside, tlicrem, or the o.:upant of the
,hvciang hou,c oI another who eluplov, per,on, to do m.nntellan.e. con.drucnon or rcpatr Mork on ,kwh dwelling house
,•r „n the _.wounds or hoddoig .Ippullc:I.I111 lhelclo ,11.111 not hc:.w,e of,uch cngllo5 nlcnt he decrlled for he an cntplo5er.'.
\Il II_ chapter I>_'. 'SC(b) also dote, that "dery .fate or local licensing agency ,hall 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 wilh the insurance coverage required."
\ddrtionally. MOL chapter 152, ,,]5l'1-I ,tates Neither the conunonwcalth nor any of Its political ,uhdn t,lons ,hall
cuter Into any contract for the perhnnlance of public work until acceptable ev tdence ol'winpliance with the Insurance
rcymle111CIlls Ut this chapter ha\-c been presented N the.ontracting authority."
k
1pplicallls 5
['lease till out the workers' compensation affidavit completely. by checking the boxes that apply to your situation and, if
necessary• supply sub-contractorls) namels). addressles)and phone number(s) along with their certificate(s) of
insurance. Limited Liability Cumpanies (LLC)or Limited Liability Partnerships l LLP) with no employees other than the
members or partners, are not required to cant' workers' compensation insurance. If an LLC or LLP dues 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 date the affidavit. The affidavit should
Ile 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 Town 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 fill out in the event the Office of Investigations has to contact yoti regarding the applicant.
Please he sure to till in the permit,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 infi)rmation (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
lovv n).•' A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
.Ipplicant as proof that a valid affidavit is on tile fill future permits or licenses. A new affidavit must be tilled out each
Near. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(I e. a Jog license or permit to burn leaves etc.),aid person is NOT required to complete this affidavit.
I he (mice of Im e, orations would like w thank wu in advance for sour cooperation and should you have any questions,
p1c.1,e Jo not he,talc m glue us a :all.
the I)epaltutcut•, .Iddress, telephone.Ind tax nunther:
-The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investlgetlons
600 Washington Street
Boston, MA 021 1 1
Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE
.ol
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
4y 1 '
DEPARTMENT
t r r • S.\t i m, \I.t.;
Construction Debris Disposal Affidavit
(rctluired lix all demolition and renovation work)
In accordance \�ith the sixth edition of the State Building Code, 780 Ch9R section 111.5
Debris, and the provisions of NIGL 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 facility as defined by MGL c
111, S 150A.
The debris will be transported by:
- _ (name of hauler)
The debris will be disposed of in
(naimnee of facility)
tadtIress of taciltly)
_Si nature of permit applicant
0/3 1
dale