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7 GALLOWS HILL RD - BUILDING INSPECTION (2)
4 5p The Commonwealth of Massachusetts ' W OF Board of Building Regulations and Standards CITY M Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Ilse Only Building Permit Number: Dat Applied; W ' Building Official(Print Name) - Signature o e . SECTION 1:SITE INFORMATION rrt 1 1.1 Pro�perty Address: 1.2 Assessors Map&Parcel Numbers -i C�Gt t bi�S H> 11 P'd c )r L l a Is this an accepted street?yes r/ no Map Number Parcel Number W .m ,,!I 1.3 Zoning Information: 1.4 Property Dimensions: 'D cn. I V 1I Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) W 1.5 Building Setbacks(it) w -- 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ ' Check if yes❑ SECTION 2:,PROPERTY O.WNERSHIPr 2.1r Q��rr of ecer �� r m lX^ _ <' _�- , � r C)`ry Name(Print) . City,State,ZIP `-1• -1 &O.A O"3S 510-R ry-) 0(lx.mhn l oj, No.and Street Telephone J ail Address T SECTION 3:DESCRIPTION OF PROPOSED WORKz(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repatrs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work-2: r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fed:$ Indicate how fad is determined:2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project.Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees:.$ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 3�— ❑Paid in Full O Outstanding Balance Due: C S�,O • l M pit L s Q -t'� hA . p • Zg SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling Cityfrown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN 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 0 er's Name(Electronic ign ture) llate SECTION 7b: OWNERI OR AUTHORIZED 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. II � ( I � Print Owner's or Authorized Agent's a(Electronic Signature) - Date 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at ivww.m&%s."ov!oca Information on the Construction Supervisor License can be found at www.ma:sxov/dps 2. When substantial work is planned,provide the information below: Total 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 SALEM, MASSACHUSETB BUILDING DEPARTMENT 120 WASHINGTONSTREET,3" FLOOR TEL. (978)745-9595 KIMBERLEY DRISCOLL FAX(978)740-9846 MAYOR THOMAS STTPIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date Job Location Home Owner Address D ba-A a ,12 t—h Q_d(� , Present Mailing Address `� V Ol � IOVJn, t�i k 0 . The current exemption of"Homeowners"was extended to include owner-occupied,dwellings of two Units or less and to allow such homeowners to engage an individual for hire that does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one=or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official,on a form acceptable to the Building Official, that he/she be responsible for all such work performed under the Building Permit. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPECTOR The Commonwealth of Massachusetts Department of lndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia vivorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FH,ED WITH THE PERMITTING AUTHORITY. Aoolicant Information /-+ Please Print Legibly Name(Business/Organiz tion/Indi%idual): Siq2GCCt t Et/e-/Lfi OT eyed j "LoAft LC_C Address: 320 C luu ho hu.v�t ' City/State/Zip: Av-J+t-rr-1 N �f 63032 Phonek 60?--e, 2-Y—F389 Are you an employer?Cheek the ep ropriate box: Type of project(required): 1.{+y 1 am a erployer with employees(full and/or part-time).• 7. New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.E]1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.[:]I am a homeowner and will be hiring contractors to condom all work on my property. I will ensure that all contractors either have wmkms'compensation insurance or arc sole 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5,M 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers'camp.insurance.: &M We are a corporation and its officers have exemiscd their right of exemption per MGL c. M er 152,§1(4),and we have no employees.INo workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sh"t showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. + t net an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. LL Insurance Company Name: Policy#or Self-ins Lic.#: `ts W�Q Q L( ' Expiration Date: 4 13� 16 Job Site Address: 7 Cio((ows Wit City/State/Zip: Silib-- t MA- O (4-10 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby terrify under the pains and penaltles of perjury utm the information provided above is true and correct Signature: AIL a/W a t Dt : 7 3 /S fr 3 9-1 OKicial use only. Do not write In this area,to be completed by city or town ojjiclaL City or Town: Permit/License# Issuing Authority(circle one): t.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Certificate of Flame Resistance REGISTERED ISSUED BY Date of Manufacture FABRIC JOHNSON OUTDOORS INC. NUMBER BINGHAMTON,NEW YORK 13902 MARCH 2O09 F-140.01 Manufacturers of the Finest Tent Products Described Herein This is to certify that the products herein have been manufactured from material inherently flame retardant as here after specified by the material supplier. NAME: SPECIAL EVENTS OF NEW ENGLAND CITY: MANCHESTER,NH Certification is hereby made that: The articles described on this certificate have been manufactured with an approved flame retardant chemical in compliance with California State Fire Marshal Code, NFPA-701', Underwriters Laboratory of Canada, and have been tested in accordance with the Federal Test Method Specifications and meet or exceed the Military Flame Specifications of MIL-C-43006G. Type,color and weight of material 13 OZ.WBO Description of item certifies ELITE PC 20 X 40 WBO HDF Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric Snyder Manufacturing, Inc. 1 Manufacturer of Flame Retardant VInvi Laminates TENT DEPARTMENT,JOHNSON OUT ORS IN . 'Large Scale SPECIEVE21 ACORD,M INSURANCE BINDER 04123/15 TE THIS _BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. PRODUCER---------- _-PHONE COMPANY - -- — - -'BINDER 8 ----------- A/C.No En: 888-489-7165 FAX LC-H�Ia_ 888 489 7105 Hanford Fire Insurance Company _ 145UUNQY9665_______ ._____---_.---___-__. USI Rental Specialties DATE EFFECTIVE TIME DATEXPIRATION TIME 1616 Smith Road,Suite D X AM I X'I'f2:o'AM 04/27/15 12:01 i Temperance,MI 48182-TX _ PM NOON 106/27/15 THIS BINDER 15 ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY CODE: SUB CODE: PER EXPIRING POLICY#: AGENCY 862907 DESCRIPTION OF OPERATIONSIVEHICLES/PROPERTY(including Location) CUSTOMER ID: INSURED Special Events of New England, Pkg/Auto Policy#45UUNQY9665 LLC Umbrella Policy#45HHUQY9727 PO Box 5203 Manchester, NH 03108-5203 COVERAGES LIMITS TYPE OF INSURANCE COVERAGEIFORMS DEDUCTIBLE COINS% AMOUNT PROPERTY CAUSES OF LOSS Blanket Business Personal Property $1,000 N/A $150,000 BASF BROAD 'A SPEC Blanket Business Income(Value) N/A NIA 1$453,000 ''. See Spec.Conditions/Other Coverages GENERAL LIABILITY 45UUNQY9665 EACIi OCCURRENCE 'S1,000,000 DAMAGEIO X i COMMERCIAL GENERAL yLIABILITY RENTUp,pF;EMIS S _,._,... S 300,090 CLAIMS MADE OCCUR MED EXP Any one person) $10,000 PERSONAL&ADV INJURY $1000,000 GENERAL AGGREGATE s2,000,000 ........-- __.-.-.-. FETED DATE FOR CLAIMS MADE: PRODUCTS-COIMPIOP AGO s2,000,000 AUTOMOBILE LIABILITY 45UUNQY9665 COMBINED SINGLE LIMIT s 1,000,000 ANY AUTO BODILY INJURY_(Per person) is ALL OWNED AUTOS BODILY INJURY(Per accident) IS SCHEDULEDAUI'OS PROPERTY DAMAGE is X HIREDAUTOS MED CAL F_AYMENTS S_ X NON-OWNED AUTOS PERSONAL INJURY PROT-- ',,$ UNINSURED MOTORIST '7s $ AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES X SCHEDULED VEHICLES X ACTUAL CASH VALUE X COLLISION: .-.$1 a00____.- -_ STATED AMOUNT is X I OTHER THAN COL:_$1,Q00_ __ C"(HER GARAGE LIABILITY AUTO ONLY-EA ACCIDENT ANY AUTO OTHER THAN AUTO ONLY EACH ACCIDENT is AGGREGATE EXCESS LIABILITY 45HHUQY9727 EACH OCCURRENCE is 1,000,000 _X_ UMBRELLA FORM -AGGREGATE -___-':$1,000,000______ OTHER THAN UMDRELIA FORM RETRO DATE FOR CLAIM115 MADE: SELF-INSURED RETENTION j$10,000 WC STATUTORY LIMITS WORKER'S COMPENSATION E.L.EACH ACCIDENT_ Is AND E.L. - EMPLOYEE 5 EMPLOYER'S LIABILITY DISEASE EA EM ------- E L.DISEASE-POLICY LIMIT I Is SPECIAL Location: 1 FEES is O HER NDITIONS' 320 Rockingham Rd,Suite 2,Auburn, NH 03032 TAXESOT __ COVERAGES (See attached Spec Conditions/Other Covs page.) ESTIMATED TOTAL PREMIUM S NAME&ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN# A71ZEDREPRESENTATIV E ACORD 75(2001/01)1 of 3 #489604 NOTE: IMPORTANT STATE INFORMATION ON REVERSE SIDE JXJAH © ACORD CORPORATION 1993 CONDITIONS This Company binds the kind(s) of insurance stipulated on the reverse side. The Insurance is subject to the terms, conditions and limitations of the policy(ies)in current use by the Company. This binder may be cancelled by the Insured by surrender of this binder or by written notice to the Company stating when cancellation will be effective. This binder may be cancelled by the Company by notice to the Insured in accordance with the policy conditions. This binder is cancelled when replaced by a policy. If this binder is not replaced by a policy, the Company is entitled to charge a premium for the binder according to the Rules and Rates in use by the Company. Applicable in California When this form is used to provide insurance in the amount of one million dollars ($1,000,000) or more, the title of the form is changed from"Insurance Binder"to"Cover Note'. Applicable in Delaware The mortgagee or Obligee of any mortgage or other instrument given for the purpose of creating a lien on real property shall accept as evidence of insurance a written binder issued by an authorized insurer or its agent if the binder includes or is accompanied by: the name and address of the borrower; the name and address of the lender as loss payee; a description of the insured real property; a provision that the binder may not be canceled within the term of the binder unless the lender and the insured borrower receive written notice of the cancel- lation at least ten (10) days prior to the cancellation; except in the case of a renewal of a policy subsequent to the closing of the loan, a paid receipt of the full amount of the applicable premium, and the amount of insurance coverage. Chapter 21 Title 25 Paragraph 2119 Applicable in Florida Except for Auto Insurance coverage, no notice of cancellation or nonrenewal of a binder is required unless the duration of the binder exceeds 60 days. For auto insurance, the insurer must give 5 days prior notice, unless the binder is replaced by a policy or another binder in the same company. Applicable in Nevada Any person who refuses to accept a binder which provides coverage of less than $1,000,000.00 when proof is required: (A) Shall be fined not more than $500.00, and (B) is liable to the party presenting the binder as proof of insurance for actual damages sustained therefrom. ACORD 75(2001101)2 of 3 #489604 SPECIAL CONDITIONS/OTHER COVERAGES (Cont. from page 1) •Building Limit : $541, 100 w/$1, 000 Deductible Business Personal Property Limit : $100, 000 w/$1, 000 Deductible Business Income Limit : $151, 000 Location: 2 248 Old Candia Rd, Auburn, NH 03032 Business Personal Property Limit : $50 , 000 w/$1, 000 Deductible Business Income Limit : $302 , 000 Inland Marine Equipment Floater Blanket Limit : $2 , 000, 000 w/$1 , 000 Deductible Any one item/In Transit Limit : $100, 000 AMs 7sA(zoomi 3 of 3 #489604