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18 FOSTER ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF o Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use=OIV, � fi Bu ding Per mt Number f Date Applied` t uddmg 0 ficiAl(Pnnt-Name) 5rgna .Date,' SECTION 1 SITE INFORMATION , 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 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(sq ft) Frontage(ft) 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: Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Public ❑ Private❑ Check if yes[] "SECTION2: PR 6000WNERSIILP' ' 2.1 �Ownerto Record: / rJ I �/ Name lint City,State,ZIP 7 No. and Street Telephone Email Address SECTION 3: DESCRIPTION'.OF PROPOSED WORK' (check all that apply) .. New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': a[ SECTI6N4: ESTIMATED.CONSTRUCTION COSTS .` " Estimated Costs: Official Ilse Only Item Labor and Materials x ' l. Building $ G / 1 13ulldmg Perinrt Fee $ 3 Indicate how fee'is determined: ❑ StandaLd City(' own Application Fee 2. Electrical $ ❑Total`Protedt Costa (Item 6)xntukiplie'r X 3. Plumbing $ 2.. Other Fees. 4. Mechanical (HVAC) $ List r S. Mechanical (Fire Total All Fees Suppression) Check'No. Check Amount Cash Amount 6. Total Project Cost: $ Paid` Full ❑ OutstandingB.alanceDue SECTIONS: CONSTRUCTION SERVICES rName truction Supervisor License(CSL) l / , License Number Expiration Date SL Holder Lis[CSL Type(see below) (/ eetDescription ' -L3 0 L 2 U Unrestricted(Buildings u p to 35,000 cu. ft.) City/Town,State,ZIP ' �a� /'��/'� R Restricted 1&2 Family Dwelling M Masonry � . RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances p�� 3/� / ,�� I Insulation 'I'ele hone Email address D I Demolition 5.2 Registered Home Impr//vement Contractor(H//IC) `� // 3 3 . ALe- �G� / >�/"ii' y� r j FIIC egistration Number Expira HIC Compas ame or HIC`R�pgi r/apt Name No. and Street 2 �e4� Email address Ci /Town, State, ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G:L. c. 152.;§ 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 Tar;OWNER AUTHORIZATION TO H .BE COMPLETED WEN 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 Name(Electronic Signature) Date SECTION-7bi-OWNER' OR AUTHOR[ZED_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 Authorized Agent' ame(Electronic Signature) Date NOTES: [2. 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 not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the H[C Program can be found at www.mass,,mv oca Information on the Construction Supervisor License can be found at www.mass.eov%dns When substantial work is planned, provide the information below: al floor 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 SM EMs MASSACHUSETTS BuiLDiNO,DEPARTJIENT S } t r 120 WASHLNGTON STREET, 3ie FLOOR TFf 978 745-9595 FAx(978) 740-9846 KI,,fBFRt FFY.DRISCOLL MAYORTliObtAS ST.FIF1tR8 DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CM12MISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Leeibiy Name(Busiiwss organizatianAndividual): Address: City/Statc/Zip: Phone #: Are yo an employer?Check the appropriate box: Type of project(required): i. 1 am a employer with_;;l, 4. 0 1 am a general contractor and 1 6. ❑New construction employees(hill and/or part-time).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner• listed on the attached sheet: 7. emadeling ship and have no employees These subcontractors have a. J] Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.) officers have exercised their l0.0 Electrical repairs or additions 3.0 I airs a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.[No workers'camp. C. 152, §1(4).and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' comp insurance required.] 13.0 Other •Any applicant that cltccks box ei must also rill out the section bulow showing thek wmkus'compensation policy information, t Ihweuwm"who suhmlt this affidavit indicating they am doing all work and then him outside co,lnu °n most Submit a now affidavit indicting such. _ :Cuntrautom that check this box meet attached on addidutual sheet showing the name of the aubaontraetom and their workers'ramp.policy information. t am an employer that Is providinir workers'compensation Insurance jor my employees. Below&ale policy and Job site iujormatlom /v f Insurance Company Name: z 4 Policy 4 or Seif=ins. Lic. H: Expiration Date: Job Site Address: 1 e- City/state/Zip: Sn! Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigmiotut of the DIA For insurance coverage verification. l do hereby certify fill a the puns and pe ,/fury t/rat the h1forthalon provided above is irae and correct Sicnuure' Ile /1Z.2SP 7 Phone Y• OJlic ial use ally. Oa not write in tbls urea to be cunrpleted by city ur town n/jlclaL City or"Town: Permlt/1.1cense N Issuing Authorily(circle one): v- 1. Board of Iicullh 2.Building Department 3.Cilytrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: .. . ._._._...__ Phone 4: CITY OF SAL.EM N'LuSACHUSETTS i BUEWNG DEPAR"MENT 1 30 WASHLNGTON STREET,34°F.00R T EL (978) 745-9595 t' F.*.Y(979) 740-9846 KiNfBFRT EY DRISCOLL AkYOR THOA(AS ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/BLUING COS(SItSSIONER 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 t t 1.5 Debris, and the provisions of i41GL c 40, S 54; Building Permit # 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 : A' e Cam/ _ (name of facility) '/ sal (address of tacit ity) signature of permit applicant /f date dcbns�L`J.w 12/05/2012 10: 18 9786833147 PAGE 01/01 Ql A DATE(MlODYWY) CERTIFICATE OF LIABILITY INSURANCE �5zo12A ya THIS CERTIFICATE IS I!3$UED 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 cenificate holder IS an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and CBntllUonll of the policy,certain policies may require an endorsement. A statement on this certificate does not Confer rights to the certificate hostler in lieu of such endorsement(s)- PRODUCER CONTACT NAME M P ROBERTS INS AGCY INC PHONE (978) 683-8073 ac Np.(97B)683-3147 1060 Osgood Street � robertsnsurance.com North Andover, MA 01845 -it;paula@Merobarta.inauranca.com i g1aURER(4) AFFCRpINa CCYEIIAaE NAILM INSVRERA:ATLANTIC CASUALTY INS CO INSURED STEVE :HADLEY CONTRACTING INSURE11.MERCHANTS INSURANCE STEVE ;BADLEY DBA INSURER C' 239 JE.FFERSON AVENUE INSURER D:LIBERTY MUTUAL INS CO SALEM, MA 01970 INSURER E INSURER R: COVERAGES CERTIFICATE NUMBER; 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. xsN a • POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INI p POLICY NUMBER JEMERINYYYL IMWDDrYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 LN X COMMERCIAL BErvERAL LIABILITY PREMISEE occunence $ 100,000 CLAIM MADE �OCCUR NED EXP(Any one person) $ 5,000 A L143002666 07/08/12 07/08/13 PERSONAL It ADv INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LINIT APPLIES PER: PRODUCTS-COMPIOP ASS $ 2,000,000 POLICY PRO F LOC F AUTOMOBILE LIABILITY Ee accident E 300,000 ANYAUTO BODILY INJURY IPer person) E $ ALL OWNED ,8 SCHEDULED MCA7014084 10/28/12 10/'28/13 AUTOS AUTOS ( )BODILY INJURY Per apddent $ IL HIRED AUTO NON-OWNED PROPERTY DAMAGE a ,}[ AUTOS (Pew xyldn � F F UMBRELLA IJAB OCCUR EACH OCCURRENCE T EXCESS LIAB CLAIMS-MADE AGGREGATE S -- UFO I I RETEI,TIONB $ WORKERS COMPENSATION WCBTATU- I OTH- AND EMPLOYERS'LIABILITY T RV LIMB ER D AN P OFFICEN MIBERwEKLLUEWE'ECUTIVE Y❑ NIA WC5-31S-329064-032 07/08/12 07/08/13 E.L.EACH ACCIDENT $ 500,000 IMuneNory In NNI E.L.DISEASE-U 11PwYEi$ 500,000 If yea deaprlbe under Ok8G�RIPTION OF OPEF ATIONS below E.L.DISEASE-POLICYLIMIT I F 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IAIISCn ACORD 101,Additional Remarks Scnedule,If more spade Is squired) *LIBERTY MUTUAL WILL ISSUE A CERTIFICATE OF INSURANCE TO YOU DIRECTLY* FAX: 978-740-9846 JOB: 18 FOSTER STREET, SALEM MA CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING INSPECTOR rHE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 120 WP.SHINGTON STREET ACCORDANCE WITH THE POLICY PROVISIONS, SALEM MA 01970 AUTHORIZED REPRESENTATIVE 1 ©1988.2010 ACO D CO PORATI ON. All rights reserved. ACORD25(2010/05) The ACORO name and logo are registered marks of ACORD