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7 FOSTER ST - BUILDING INSPECTION a fhe Commonwealth of Massachusetts 1 i Board Building Regulations and Standards CITY y j Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM Revised Jununry Building Permit Application To Construct, Repair, Renovate Or Demolish a (I One-or rwo-Fanyily Dwelling \IV}\ This Section or Official Use Onl 1 Building Permit Number: Date Applied: Signature: L �y Building C issioner/Ins!t1V Buildings Date FCTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers :7 t7&574I rL 5 t. I.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions. Zoning District Proposed Use La Area(sq 11) Frontage(It) 1.5 Building Setbacks(R) From Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: Nome(Print) Address for Service: Signature Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(check a8 that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 31 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work': S}2L1 ro I-i- m G lj e,(20A" S.t>c,7AG C -AL9E14, ) 1 0 Y9 S� _s r� y NSF SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: 0MC121 Use Only Labor and Materials I. Building S .ens tl�. �d 1• Building Permit Fee:f Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 1. Plumbing $ 2. Other Fees: S 4. Mechanical (tIVAC) S List: S. Mechanical (Fire S Su ression Total All Fees: f Check No. Check Amount: Cash Amount: 6. Total Project Cost: S C>U fJl� 0 Paid in Full 0 Outstanding Balance Due: SECTION 3: CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor(CSL) ,I"W454i I.icenx Number I:xpintiun Date Name of CSL- I IolJer 7 I.ist CSL Type(see below) U r IDescri tion :WJress �y /) U I llnreatricted(up to J5,000 Cu.Ft. R I Restricted 13I Famd Dwellin Siynmure y�— M M Onlya 9C -439 vI RC I Residential Rooting Covering rcicplume WS Residentiol Window and Siding SF Residential Solid Fuel Burning Applia c Installation D I Residential Demolition 6.2 Registered Home Improvement Contractor(HIC) / jam n S ��yNS l'/L rX�ft_Oti Registration Number I IIC Company Name ur HIC Registrant Name t�r�r'_mZ':', FrtS t�/! /��F/-�i3(7�;r /O —a?— / / Expiration Date stgna are Ala SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f 23C(6)) Workers Compensation Insurance affdavit 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 ..........IN 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. Siunature of Owner Dare SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I, S tt ilE Cf'i�, i•,T ,�[�S ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and behalf. , Print Name Signature off)yy er or Authorized Agent/17 Date Si unJe�he airs Died penalties of u NOTES: I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will-W 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 790 CMR Regulations I IO.R6 and I IO.RS, respectively. F2 When substantial work is planned,provide the information below: Total floors area ISq. Ft.) (including garage, finished basementlattics.decks or porch) LNumber ng area(Sq.Ft.) Habitable room count f fireplaces Number of bedrooms f bathrooms Number of half/balhs eating system Number of decks/porches ooling system Enclosed Open ). "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ,,IA1It H[.IiY!A(HCOLL \I�) ,a 12^,WASHING ION S7XELT• Six LEV1,MASsct osE rIS G197.^, fta_978- ti1i95 P:tx: 978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A i licant Information /1 Please Print Legibly Vame(Businccs/Organi>•atiottllndivicluul):���Ii s e Address: I 1�l�P .4 -1n.v�`r4i i�C City/Staid/.ip: jAfg amt)y MiQ 01970 Phone r'P: ` -27-1 O-S� ^�3 Are you an employer!Check the appropriate box: Type of project(required): tte�e I am a employer with a 6.4. ❑ 1 m a general contractor and 1 New construction 1.4y ❑ 1t employees full undlor an-tine).' have hired the sub-contractors ( P 7. ❑ Remodeling 2.❑ 1 ;un a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. worker' comp. insurance. 9, ❑ Building addition _ No workers' coat insurance 5. ❑ We are a corporation and its p• MCI Electrical repairs or additions required.] officers have exercised their exemption right of on per MGL 1 LEI Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work g P P' myself. [No workers' comp. C. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] -An•:1pplicaut that chocks box dl must also till out the section bclaw showing(heir workm'cumpenvttion policy information. r I Wmaowrwrs who uutmil this affidavit indicating they are doing all work and then him outside contractors rotor autmih a new al'rdavit indicating such. -Contmcwn that check this box must attached an additional Aecl showing the name of the subKontracturs and their workers'comp.policy information.. l ante un employer that it providing workers'compensation hisurauce fa•my employees. Below is the policy and job she irrfurutarion. T� Insurance Company Name:4P., t2z t)...._-.-..._ J'A'SC>.2.p ----- Policv or Self-ins. Lic. n � :—S -r C 9/ 7-54 Expiration Date: y'/D Job Site Address: —City/State/Zip: �SALG," /'?.Q• 0/ 920 Attach it copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ul-NIGL c. 152 can lead to the imposition of criminal penalties of a tint up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to S250.00 it day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ul'thc DIA for insurance coverage verification. l do,hereby certify under the pains and henulticv of perjury that the information provided above is true and correct. �icnauue' C_-� Datg I'hurt ��...v Q/jiciul rise only. Do not write in this urcu, to be completed by city or rown ojjiciul. CitvorTown: Permit/I.icensc4---_- _. .._____.. ._ ...-..__. _ . Issuing Aulhority(circle one): I. Board of Health 2. Building Department 3.City/'fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Ottier — - Contact Person: -.-- Phonc ti: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an empluree is defined as"...every person in the service of another under mIy contractor hire, express or implied, oral or written." ` 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:m individual, paimership,association or•other legal entity,employing employees. However the owner of a dwelling.house liaving 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." `1GL chapter 152, §25C(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_wlio hasrtot produced-a cepiali'le evidence of compliance with the insurance coverage required." .additionally, 2v1GL chapter 1'52; §25CM states'+Neither the commonwealth nor any of its political subdivisions'shall enter into any contract for the performance of public work until acceptable evidence otcuiupliunce 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) namc(s), address(es)and phone number(s)along with their certificate(s)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 date the affidavit. The affidavit should be remnied 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 you regarding the applicant. ['lease be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permiClicemw 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 for future permits or licenses. A new affidavit must be tilled 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. "I"he OI I ce of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. - The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-os www,mass.gov/dia DATE(MM ACORD CERTIFICATE OF LIABILITY INSURANCE 01/2 N 2010 o1/is/2o10 PRooucER (978) 745�6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rose Insurance - HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Boa 958 - Salem NFL 01970— INSURERS AFFORDING COVERAGE NAIC# INSURED INBURERab7ERCBANTS INSURANCE GROUP CY�„��ni�� z Constmuctlon INSURERB;GL—Td Insumance 21 Pocahontas- Drive INSURER C: INSURER O. MA 01960- INSURER 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. NMITrVE TAPE OF INSURANCE POLICYHUMBER O C(MMIEFUO V) PoDA Em mH LIYRB A GENERAL LIABILITY CM041643 - 11/08/2009 11/08/2010 EACHOCCURRENCE $ 500,000 g COYYERCULL GENERAL LIABILftY p EEMISES O�mDm.O® S 50,000 CUUMS MADE ❑OCCUR / ( ( ( MEDE(P(An on w...) S 5,000 PERSONAL B ADV INJURY 8 500,000 GENERALAGGREGATE S 1,000,000 GENLAGOREGATELULITAPPLIESPM PRODUCTS-COI,iP/OP AGG 8 500,000 POLICY .¢lT LOC AUTOMOBILE WIBIIDY / ( ( / COMBINED SINGLE LIMIT (Ee accYelA) S ANYAUTO ALLOWNEDAUTOS ( / ( / SODILYINJURV 8 (Per parson) SCHEDULED AUTOS HIREDAUTCS / / ( / BODILYINJURY S (Par arspe,rt) NON-0WNED AlfT05 PROPERTY DAMAGE _ a (PeraaMer10 GARAGE LIABILITY AUTOONLY-EAACCIDENT 8 ANYAUTO - / / OTHER THAN EAACC 8 AUTO ONLY. AGG S EXCESSNMBRELLA LWBILRY / / / / EACH OCCURRENCE 8 OCCUR ❑CLAIMSMAUE AGGREGATE S a DEDUCTIBLE RETENTION S - S 08/04/2009 OB/04(2010 g srAru OR g WORMERS COMPBJSATmM AND Si 917044 TORT LIMITS TM IN&LOVEW UNBILITY 100,000 ANY EL EACH ACCIDENT S OFACERMEMBER EXCLUDED) / / / / EL DISEASE-FA EMPLO S 100,000 HYaa.4evO0e,vWar EL.DIBEA6£-POLlCYL%MT It 500,000 SPECIAL PROVISIONS aMRN OESCRBRION OF OPERATiON31LOCATIONSNEHICLESIE%CLUSMNS ADOM BY ENDORSEMENTISPECULL PROVISIONS - CERTIRCATE HOLDER CANCELLATION _ ) - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE T)IE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 GAYS WRITTEN NOTICE TO THE C£RTFICATE HOLDER HAM£D TO THE LEFT.BUT 14 FAILURE TO OO SO SHALL IMPOSE NO OBYOATIOH OR LIABILITY OF ANY NINO UPDN THE ' -INSURER,ITS AGENTS OR REpR65BlTATNES. AUTHORIZED ESENTATVE ACORD-25(2001108) ©ACORD CORPORATION�1988 INS026(010e).06 CITY OF SALEM =r r h; PUBLIC PROPRERTY " ;;K -" DEPARTMENT ll] '."N.S 11 :j r 0 S.\1 I'\t, \f.\'i\1 :l! '1'1:1: 7,,4.749:Hy5 1'.\Y:'1%8.'a:'984,i Construction Debris Disposal Affidavit (required for all denholition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CN1R section 111.5 Debris, and the provisions of MGL c 40, S 54; ,Building Permit it _ is issued with the condition that the debris resulting from di this work shall be sposed of in a properly licensed waste disposal facility as defined by MGL c I 11, S I50A. The debris will be transported by: (name of hauler) I he debris will be disposed of in (name of facility) (address ,,f facility) ignatnrc of pannit applicant Y " l0 date -- dchii.aa d,. _r �//Z2 T0091Y/J[O'RfUCQN/� gyp✓ /A/oeuo. Office of consumer Affairs&Business Regulation - HOME IMPROVEMENT CONTRACTOR _ Registration:'•.140576 Expiration: 16/2712011 Tr# 289061 - Type. ;DBA CUMMINGS CONSTRUCTION STEPHEN CUMMINGS g—=— _ 21 Pocahontas Peabody,MA 01960i Undersecretary . . y NI n+acbusetts- 1)ep tilment of Public S Ife,N . Bou'dut"BuddingReaLuiati0nl .mdStsnxi;u-ds . Construction Supervisor License License: C3¢83956 Restricted Co: 00 STEPHEN D-CUMMINGS 21 POCAHONTAS.DR " PEABODY.,'MA 01960 Expiration: 10/1/2010 - - - Tr.--: 5512 <'unuui9iona•i - 1, IMnvDDnri'r) ACORD CERTWICATE OF LIABILITY INSURANCE 08/0412010DATE PR (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rose Insurance HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 Salem MA 01970- "77 DING COVERAGE NAIL 71 INSURED NTS INSURANCE GROUP Cummings Construction Insurance 21 Pocahontas Drive Peabod MA 01960- INEURERE'. COVERAGES THE POLICIES OFINSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OILER 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 CF SUCH POLICIES. AGGREGATE LIMITS SHCWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- 183RADDt POLIE(MMDCY CTNE;PDATE(NLICY PDONY)II LIMITS LTR INSRD TYPEOFRISURANCE POLICY NUMBER DALE(MNVDDM'I ' DATE IMMIDDf/YI A GENERAL LIABILITY CCP1041643 11/08/2009 11/08/2010 EACH U:CURRENCE E 500,000 DAMAGE TO RENTED S 50,000 X COMMEROIALGENERALLIABILITY PREMISES Ea accnPlnce CLAIMS MADE ❑CCCL'R MEO EXP(Any one person) S Q00 PERSONALB ADV INJURY 5 500,000 GENERA'_AGGREGATE S 1,000,U00 GENt AGGREGATE LIMIT APPLES PER: PROOUCTSCOMPIOF AGG 5 SOQ,O00 POLICY JRT LOG AUTOMOBILE LIABILITY / / / / - COMBINED SINGLE LIMB S (Ea acciiem) ANYAUTO ALLOWNEDAUTOS / / / / BODILY)NJUR"! $ (Par person) SCHEDJLED ALTOS ERED AUTOS / / / / BODILY INJURY �S NON-OWIJED AUTOS -ROPERTY DAMAGE S I (Per a¢Meup GARAGE LIABILITY AUTOONLY-EA ACCIDENT $ ANY AU-0 / / / / OTHER THAN EA ACC S AUTO ONLY: AGO S EXCESSNMBRIILALIABILRY / / / / EACH O_CURRENCE S OCCUR CLAIMS MADE AGGREGATE S I S DEDUCTIBLE *EACHACCIDENT S RETENTION & _ S B Oe/04/2010 08/04/2011 �ER WORKERS COMPENSATwn AND S'197C734307 EMPLOYERS'UABILITY S 100 r 0QQ ANY FROPRIETORIPARTNERIEXECUTIV E 1Q D r QQQ CFFICERMEMBER EX^_LUDEC? / / / / PLOYEE 5Ilyee,4escrP6vnCer . . CY LIMIT S 500,000 SPECIAL PROVIS IONS Me OTHER DESCRIPTIONOFOPERATIONSILOCATONS ENICLESIEXCLUVCHSADDEDBYENDORSEMENTISPECMLPRONSIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL-DO BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT City Of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR REPRESENTATIVES, AUTHORIZED ES NTATIVE � JJ l'd h6££9£98L6 U0Ipna)suoC) S6UIWLUnp e0q:90 O6 SO 6ny