21 FORRESTER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
ry '� Massachusetts State Building Code, 780 CMR, 7'h edition OF SALEM
Revised Jannary
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tsvo-Fumdy. elhng
This Section Fo ffic I Use Only
Building Permit Number: �f Date lied:
Signature: 7r✓- ��
Building Commissioner/Inspect of Buildings Date
SECTION 1:SITE INFORMATION
1.l Propecrty Address: \ e 1.2 Assessors Map& Parcel Numbers
L` 'T6drGSt'Gf
I.Ia 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(it)
I.S Building Setbacks(R)
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 E3/ Private❑ Zone: _ Outside Flood Zone? Municipal WOn site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record„ _
t'Pt.0 a n✓5 F._ --k 170 V`R.t.C( 1t✓l �r �R�N'1 M q
t
Name(Pr Address for Service:
-7-4 s- G`fQ -7
Signature Telephone
SECTION 3: DESCRIPTI N OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building Owner-Occupied 13rf Repairs(s) <Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work'': �, q.
5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S�j' c'/ O O I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
` 4A,1
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSII:I folder r List CSL Type(see below)
Description
T
re Unrestricted(up to 35,000 Cu. Ft.
Restricted 1&2 Family Dwelling
Sig lure O M Mason Only
.
— t 5'r7 D RC Residential Roofing Covering
relephone WS Residential Window and Siding
SF Residential Solid Fuel Bummij Appliance Installation
D Residential Demolition
5.2 Registered Home ImRrovemeot Contractor C. 1 61�/6VO
5¢.wW ocJ i. .S C� CO wSrt C6
I IIC Company Name or IIIC Registrant Name Registration Number
JAdds .�Cck-( 5.��- sp' lion Date
elephone
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 a building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
tD t--N R f3 ttw as Owner of the subject property hereby
authorize sz cxn�,n _ LC, to act on my behalf,in all matters
relative to work authorized by this building permit application.
s
(i �--�1� T� N�� I S 0 11
Aignature of Owner at
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
,as Owner Aul ' ed 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 a
(-16.1 L(�1 � 1 2--
Si ature of rized Agent Date
(Si er the pains and nalties of r'u
NOTES:
1. 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 rro have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I I0.115, respectively.
2 When substantial work is planned,provide the information below:
Total floors 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"
CITY OF S.U..&N19 AxSSACHL:SEM
SL aDL)G DEP.\RTMENT
120 WASHINGTON STREET. )sa FLOOR
TEL (978) 745-9595
F.%x(978) 74&96"
\CSEAFY DR)SCOLL THOMASST.PMRRS
MAYOR DIRECTOR OF PLSLIC PROPERTY/gVILEILNGCM0111510NER
Wurkers' Comp risatloa Insurance AMdavit: guilders/Contractors/Electr(clanWPlumbers
>nnlicant Information Please Print Leesibht
VaIne 11)ur,ne+r0fW,zanonln,Lv,duall: c_ = .�SSyt,.f c— _ Y�-� �0..•-+� ., ` o .
Address: LL-C C4r • 4 �S EN-ery,
Cily/State/Zip: k Met -b 1Q0 ne#. W( 6 i d'S
Are you as employe!Cheek Rho appropriate box- Type of project(required):
I.❑ 1 am•anploye with 4. ❑ 1 am a IDeneral cattrerbt and 1 E ❑New an
employees(full and/or past-time).• have hired the sub•ea tractors
2.Q 1 am 113012 propriemr or partnef- listed on the atracMd.heat : 7• emaksling
ship wool have no employee Them sub-comraemre haw M. Q Demolition
working ror me in any capacity. Workers'comp.insurance. 9. Q Building addition
1 No worken'comp insurance S. Q We are a corporation and its
requireL]
ofters have exercised their 10.0 Electrical repairs or additions
1.Q 1 am a homeowner doing all work right of exemption par MGL I I.Q Plumbing repain or addlNoro
myself.(Na workers'comp. c. 152.f 1(4),and we haw no 12.Q Roof resin
insurance required] ► emplayem.LNo wakes'
comp,insurance requited.] I S.❑Othe
-nny apyuaaw its chants boa II mssa awns ti0,sw tM asuae belw atoaiq,heir wwskew•rvnpwerhrs oulisy inbrasadoi
't I,sne,wwrase the subme age aledvil i„dlering they as Jain/all wart and than him outside erprsras ssrs suhwt a new amdsa indicriss wr►
T,mlrsrora,M chst,hie iwaa,m.r sashed as addwwwl ahsa dwsrine da nelN of red wAsassraawe saa,Irk wwhae•raaw Rowley iaeanraaa
/ear ew txrphyer that 4 providbrR workers'compemdee infatmwm for ny employees Below is red pWAM&Jodi*&Sft
informal"
Insurance Company Name'
Policy 0 or Self•ins. Lie. M: 1J U 3C7 Z3 Expiranioo Dab: 20 1
Job Sire Address: rem S CityJSlawzip: 310 fe'-n ry,-4
-%Crack a Copy of the workers'compensation policy deelo/xtloa pap(ahowing the policy somber and etplrxtloa drde).
Failure to secure coverage y required under Section 25A of MGL C. 152 can lead to the imposition of criminal penalties ors
fine up to S 1.300.00 and/or one-year imprisonment-as wall m civil penalties in the farm of a STOP WORK ORDER and a floe
of up to S230.00 a day aysinst the violator. Ile adviwd that a mpy of this statement may be rurwarded to the Mice of
Invc.ugariuns ofd,e niA far' /nee coveralp won.ticatioa.
1,10 hereby C and t slow and ptnelNts 010er t inforwaden providtd above is true end Carnes
0flTC;M)'V30q4 Do nor write in this erre,for bt urnpind by 4 by or town o//ir'%!
City or ruwn: _ . eermica.lctnse 0
hsuing Aulhurwty (circle une):
I. Iluard ui Ilealtb 2. fluildlnu 0eparrmcni J. Cityfrown Clerk J. Electrical Inspector S. Plumbing Impactor
6. tither _
l ,ntacr Person: ._ _.. Phones:
�A CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
I'.16NII1 'MIv.H1
\I •I'M t!C�.1+111\I. ,!V llMkrr �)•111)1, �t.�+<.11 I11 y 1
Construction Debris Disposal Affidavit
(required lur 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 c 40, S 54;
Building Permit N 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
111. S 150A.
The debris will be transported by:
t name of hauler)
'I'he debris will be disposed of in :
(nartle ut7a�lty�,
(address of farsh,Y)
.Irnat rc nt I v � plica t
20 ('�-
date
Id. ..n s.
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MWOD/YVYY)
10/12/2012
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 950
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:ESSEX INSURANCE COMPANY
J Serven and Son INSURER B:
14 Griffen Terrace - INSURERC:
INSURER M
Lynn MA 01902- INSURER 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.
INSR ADUL POLICY EFFIE POLICY EXPIRATION
LT INSRD TYPE OF INSURANCE POLICY NUMBER DATE MMID DATE MWO LIMITS
A GENERAL LIABILITY 3DG3923 01/19/2012 01/19/2013 EACHOCCURRENCE a 10000000 _
X COMMERCIAL GENERAL LIABILITY P REMISES I.DAMAGE TORE
ence a lOOOOOO
ocwn
CLAIMS MADE 7 OCCUR / / / / MED EXP Wy one n 6 5000
PERSONAL B ADV INJURY 8 10000000
GENERAL AGGREGATE $ 20000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO a 20000000
POLICY MaLOC / / / / HOB
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS / / / / BODILY INJURY
SCHEDULEDAUTOS (Per pe ) a
HIRED AUTOS / / / / BODILY INJURY
NON-OWNED AUTOS (Per accident) e
PROPERTY DAMAGE
(PWacadent) 6
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT e
ANY AUTO / / / / OTHER THAN EAACC $
AUTO ONLY: AGO 8
EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE e
OCCUR CLAIMS MADE AGGREGATE 6
8
DEDUCTIBLE
RETENTION S WC g 7µ 6
WORKERS COMPENSATION AND / / / / TORV LIAAIRS OER EMPLOYERT LUURLITY
ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $
If Ym,d scribe ER EXCLUDED? E.L.DISEASE-FA EMPLOYEE $
d yes,deSGibe uMer
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMB I s
OTHER
DESCRIPTION OF OPERATIONSILOCATONSIVEMCLESO(CLUMONS ADDED BY ENDORSEMENTISPECW.PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
servenconst@aol.com EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRRTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
ED S DOROTHY KEENAN INSURER,ITS AGENTS OR REPRESENTATIVES.
21 FORRESTER STREET Aurlrrueu neraraenran _
SALEM MA 01970-
ACORD 25(2001108) ®ACORD CORPORATION 1988
INS025(DIOB).DB Page 1 of 2
t� Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supen'isur
License: CS-074086
JOHN K SERVEN= �-
14 GREFFIN TERR =_
LYNN MA 01901:
Expiration
commissioner 11/08/2014
Office o onsumer airs mess egu a ion
�. FRegIstratIqk,, ,j6'q"5Q'70�
H OME IMPRO0VNESMFENT CON*T-R`ACTOAR
—
tion77Expira DB
NANDSON
. TY6e.
COn
JOHN SERVEN t- 1t�.-
14 GRIFFIN TERRE "
LYNN, MA 01902 Undersecretary
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