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11 FOWLER ST - BUILDING INSPECTION S a The Commonwealth of Massachusetts t Board of Building Regulations and Standards CITY / m OFSALEM Massachusetts State Building Code, 780 CMR, 7 edition Revised Jaruarry Building Permit Applicatio To Construct Repair.Renovate Or Demolish a On te- r rwo-Famiiv ruing This Section F Official Use Only Building Permit Number Date Applied: n, Signature: L Buildin Commissioner/Ins (dings Date S CT ON 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map At Parcel Numbers .1 w yLe2 ST I.la Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Propo ed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(it) 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? Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owne t of Record: 2 OS,,,rL & yi-s-,/(; // f�/-.z Si Name(Pri Address for Service: 5,'z e b-- er,,.f-L✓t T 9 If--f 77-3 3 " Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) QP I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work'': SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OMcial Use Only Labor and Materials I. Building S Fd-OV - rz I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost (Item 6)x multiplier 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: / y 5. Mechanical (Fire S Total All Fees:S Su ression Check No._Check Amount: Cash Amount:_ 6.Total Project Cost: S �t�eV vr, 0 Paid in Full 0 Outstanding Balance Due: ! i SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) / 9685-° f -/-iz -AA,4/aleM?tf, p License Number Expiration Dute Name ol'C'SL-I(older l �^ /i, LiuC'SL'fypetseebelow) N/J' iJ F �;iviD2� J / /✓j/f/7S ////� .rvDc Description A _ � " /f U Unrestricted(up to 35.000 Cu.Ft. Signature R Restricted IR2 FamilyDwelling i It ;7 C> f M MasonryOnly RC Residential Rooting Covering Telephone WS Residential Window and Sidin SF Residential Solid Fuel Bumin A liance Installation D Residential Demolition 5.2 A egistered Home Improvement�int/rector(HIC) /t�A) o M Caw /?Y HIC Compan Name or II1C Registrant ;umc Registration Number �6 �iv.4/LT AJ r��N � ✓Ce / - DoL; lj Expiration Date Signature � Telephone 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 the building permit. Signed Affidavit Attached? Yes ..........,H" No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 2Ls v Z Ll Xs/y16IC hS/y S/' as Owner of the subject property hereby authoriz to act on my behalf,in all matters relative to work authorized by this building permit application. r- Signature of Owner Date //�� SECTION 7b:OWNEEW OR AUTHORIZED AGENT DECLARATION 1, &1Z�L x k - 0�� `®/6 r:s//G i .�f,as Owner Authorized he y declare that the statements and information on the forego' g application arc we and accurat , o tmy knowledge and beh Prin ne Signature of Owner or Authorized Agcjh Date Si ned under the pains and penalties ofperjury) NOTES: I. 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 W have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115,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" -iCE. OIr&) a22-61'2U .l - r W QW111Rb q ��3 Sc � nor -< RECT fly. i p hE}K':7�EUHG itll P..o. i. o,k Phone: . . . . . . . . . . . . . . o"nees im"ne / v `% mac / :�C. +(e�� /✓l..Lily �.ui!'.!'L. . . . . ,il2t ��. A'? . . . . . . . State Zin . . . . . . . . . .. . . . . Cr . . . . .. . .. .- . ,S DINC1. v � . (,f�11l�cly � ..-�/ ar- U��✓'h` r rt r �i. . . . . . . r br SrrAu r r.Oe• �'� U 1 . . . . I / 7 o � di ceervw 7z7 � Area, rn Lc (bale, din Hou, . . . / _. 'orchcs . . /__ !�� mas 1'tne•r Ct�/. . . . . .. . . . �� _.� TJn Color t"�:-.�L.,l..'. . . . . r'rim rt• be lone / I. . . . . -,. 4Ilrminum tnm co.tcr .is Casings siYl�l.'%?.<. �2-:L •L > �_,sd' <. / //.C<. r� 4 !- r :'�'1✓4/'T. .G 71. n, vutlur5 aiw y>i;_r ks C,�. Yes CJ rJu (.,;��C'. / - LLL 7. .,uurfcr D Yes kRy No . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. Windows and Jnols . . . . .. . . .. . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . colol. . . . . . . . . . ... . . . . . . Ara" to be clone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Remove cust;c . olinpbcs �s No 15 M. Ielt . .. 'llcial Edging. . . . . . . . . .. Lcr "hrn my and. Gt±ts •tc. o. ZI . . . .. . .. . . . . . . . . . . . . . . . . . .. rr labor fn cost as follons rYlatcrial mrd $. ../.. .L'. .. �� 7<able �— �/ YC S` a is r 'rmr lair t.iti d<. JI,aid e:url in m;a vorl uahip nurnner 1 o r r r tt camel rbis S'�.'muv r "CAI; lost.re,r ! - o:: r r r r owl) ,,tile, rhdn d an adreu of be seller, rrh n.rcu v be Iris mare Me or brut r 'uercol A osrded You n rl I s t r n "Ohl r 'ns i o ..c or bowl) by ordinary mail Pasted, by teliagmin sent at by delivery, nor later than nuanight (b the third bume,s bl ab.rv<irg the s o.}rd of 1 „y L Ic.mCrll All work perlbrmcd by !hc conrp9m n fully hP u cd. 1 IN M!)l'NI_MS 7 r ICR1:h1, rile mimes b, r. hereunto signed (ilea uznres this -.. y+ C ��-� P r' 't CITY OF SM-E.`Q, NWS.-kCHUSEM 19 BL DLNO DEP.SATIE%T I_0 W.+imiNG-rom STREET. 3'°FLOOR TEL (978) 143-9599 F.%x(978) 740-9846 Kf»EX"Y DRlSCOLL TUObW ST.PIF.RRA HAYOR DIRECTOR OP Pt aLIC PROPERTY/flt:lLDLNc CO-%L%nS510v ER Workers' Compensation Insurance Affidavit: Builders/ContractorlElectrlclansiFlumbert a t Ilcant Infnrmatlan Please Print Leaibh NarnG Iamtmes.Oryarsuarior►IreLvdtnll: !man ��,/ .,, 9;., (_ �<.�/u i Address: / N-Ati� CityiStatrjzip: //.s4tc f2s 7f - 721/-o,2-SS Are yaw an employs!Cheek the appropriate beat Type of project(required): 1.❑ 1 am a employs with 4. ❑ I am a gancral continue and 1 6. ❑Now construction employee(full and/or pan-time).• have hired the m&cara race rs 1. lam a soli proprietor ex partner- listed an the attached sheot.t 7. ❑Reniadeling .hip and have no employee Them sub-cont some have s. Q Dunolition working rar me in any capacity. workers'comp.insurance. 9. Q Building addition INo workers'camp insurance 5. Cl We are a corporation and is IO.Q Electrical repair or additions!nquiral l officers have exercised their 2.❑ 1 am a homeowner doing all work risk of exemption per MOL I I.Q Plumbing repair a additions myself.(No workm'comp. c. 152.41(41 and we have no 12.0 Roof repairs insurance required.)t employee.LNo wa lime, 1).Q1j�Orbs comp insurance required.] _T •Any appacar the rearso bag el more ale*na mr tar MINN tale.dtrai.e le'le oars..'ownpwadrt policy instmuda. 't lovimmnaa who sub"arts aAlevr idlotins May as Jose an work am thm him curie eotreesre mat aMk.raw d"devk fndiaiq ML l.,etncaew dar'baek this bee mYa artaltat as.wNtiwtet char dewing der Moe of ea a ll."ceRlmr ad,hair warhrra'come,policy ieaenw ilea. /am eve ewp/eye►char b yreri/hrE tvorhers'cow/errader fnsrnwn js aq tarp/ryaax Sehnr h rM pa/fq er//oI sfb injwa►wtaa // _ Insurance Company Name: U/t/9rvi�'P Sis7e - Policy M ur Self•ins. Lie #: WC 7 124F-PZ/ Expirtioo Doter G/" /6J�i�o Job Sirir Address: // �raie2 Ss/ Cityistatdzip: sy`ry+ /// , 2Vy11210 attack a copy of the worttars'compenanon policy declaration pap(showing the porky member and esplrsdor drite} Failure to secure coverage L required under Section 25A of%IOL c. 152 can lead to the impoeition of criminal penalties of a fen'up to S 1,500.00 and/or one-year imprisonmam,as well as civil penalties in the form of a STOP WORK ORDER and a floe Of up to 5250.00 a Jay against the violator. Ile advisal that a copy of this statement may be rurwardcd to the Office of Iovc is,gatiuns of ilia MA for insurance coverage verirwaliaL /de hereby rertij under the pains and pemolds al perjury then the injernadow provided above is true and a arreca C6 offl iol ure an//c Do mar Write to this area,to be rWnplad by city or rewn a/ffrial I City orruwn: ecrmio.1cense0__ Issuint Authonly (circle une): I. Ifuard of Ilvulik 1. nuildlnll Department ). Citytrown Clerk 4. Electrical inspector 5. Plumbing, Impactor 6.Other L onlid Pcnon: _ . _ Phone e: . —�...�,, vlr.1� 1 u Ivy 1 $_ v1 KILEYSR 1 06/22 09 rPROOUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dan, 1urley Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Chestnut Green, Suite 24 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Seven Federal Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Danvers MA 01923-3620 Phone: 978-777-9394 Fax:978-777-3306 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Preferred Mutual 15024 aley Brothers Construction INSURERS: Granite State Bart KileyDBA INSURER C. a Conant Street eet Danvers MA 01923 INSURER O: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITFISTANDING 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. - RSIT LTR rGENA. F INSURANCE POLICY NUMBER PDATE MMID DATE MM/DDIYYN LIMITS ITY EACH OCCURRENCE $300000 NTW AL GENERAL LIABILITY CPP0160564252 10/16/08 10/16/09 PREMISES E E mnw) $100000 y MADE X❑OCCUR MED EXP(Arty one person) $S 0OO PERSONAL&ADV INJURY s300000 GENERAL AGGREGATE $ 600000 TE LIMB APPLIES PER: PRODUCTS-COMP/OP AGG $ 600000 PRO- JECT OC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMB $ (Ea accident) ALL OWNED AUTOS BODILY SCHEDULED AUTOS (Per $ HIRED AUTOS BODILY INJUcleat) $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLALIABIUW EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMBS ER EMPLOYERS'LIABILITY B ANY PROPRIETORIPARTNERIEXECUTN WC7426631 O62OE / /09 06/20/10 E.L.EACH ACCIDENT $ 100000 OFFICER/MEMBER EXCLUDED? SEE ATTACHED NOTE E.L.DISEASE-EA EMPLOYEE $ 100000 IT Yes,describe under SPECIAL PROVISIONS below E.L DISEASE-POLICY LIMIT s500000 OTHER )ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS As per policies. :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE �'c AL'.:a. Daniel J Hurley ,_ `te i /f WORD 25(2001/08) - ©ACORD CORPORATION 1988