11 GARDNER ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Budding Regulations and Standards �w
Massachusetts State Building Code, 780 CMR, 7'6 edition Budding Dept
Building Perron Application To Construct, Repair. Renovate Or Demolish a
One. tar Two-funuh•Dtrclf/ng
This Secuo for Official Use Onl
Building Permit Number: Date Applied:
Signature: )ZI Z9�7
Building ommissioner/In i uildtngs Due
T
ECTION 1: SITE INFORMATION
1.1 Property Address: 1 1.2 Assessors Map 6 Parcel Numbers
11 �✓ ✓c�N�✓ �l
M Number Parcel Number
I.1 a Is this an ace ted streeC'Yes no Map
Ili Zoning Information: 1.4 Property Dimeasions:
Zoning District Proposed Use Lot Area(sq 0) Frontage ii
1.5 Building Setbacks(n)
Front Yard Side Yards Rew Yard
Required Provided Required pYovided Required Provided '
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flaod Zone Informatloo: t.g Sewap DIsposal System:
Zone: _ Outside Flood Zonal Municipal O Om site disposal system O
Public O Private O Check if s0
2.1
SECTION 2: PROPERTY OWNERSHIP'
Qwgtpr'of R eco rd: I , �jo✓�N Cj T
I iJL9 �) '� ✓'�
Name(Print) Address for Service:
c, g `15
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek AN that apply)
New Construction O Existing Building O 1 Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other Specify:
Brief Description of Proposed Work :
NJMV Jr00 r //2 Al i (Ao e -
SECTION I: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f 1. Budding Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical f O Total Project Cost(Item 6)a in Itiplier a
) Plumbing f 2. Other Fees: f �
4. Mechanical IHVAC) f List:
t Mechanical (Fire f Total All Fees. f
Su rorwon
Check No. _Check Amount:- Cash Amount:
6 Total Project Cose. f S 5 ❑ Paid in Full ❑Ountandmg Balance Due
504 W ��rVIT� 57
A
SECTION !: CONSTRUCTION SERVICES ,
5.1 Licensed Construction Supit r ICSL) / C 5 '9 6 292
r• ' 1�i ��/.Q PIS%I! L�ccnsc.Number E%pniuonDale
Nyoe ul'CSL/Hyldn Lnl t.SL Type IxY hclow)
Address rmw Description
U Unrestricted(u to)),000('u. FI.
StaM1Y O lg�'1 R Restricted IA2 Famd Dwellin
� 9�1a `/Dy5 H Na
RC Residential Roofing Covenn
Telephone wS Residential Window and Sidm
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.1 R 1 tered Ho Impoovemeel Contractor(HIC) C
�70
HIC Company N e or HIC Registrant Nye Regis mason Number
er? pld�oti cI19;2�
�j %O y o9 Addrinas
Expiration Date
is
Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2!C(6))
Workers Compensation Insurance affidavit must be completed and submined with this application. Failure to provide
this aBdavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Was........ . 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.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the sutemenu and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
St ned under the pains and penalties ofperjury)
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 ggg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing-(CSL)can be found in 780 CMR Regulations 110.R6 and 110.1115. respectively.
2. When substantial work is planned.provide the information below
Tout floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. FL) Habitable room count
INumberof rreplaces Number of bedrooms
Number of bathrooms Number of half.baihs
Tvpe ofheating system Number of decks/porches
I s pe of cooling system Enclo,cd Open
1 'Total Project Square Footage"may he suhamuted for 'Total Project Cost"
1
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,nr:: n t r.initia I
\I .1��N I_'C�.�+I IL\l,;,iV$1'HIIr 4 S.\I I'M. St.\sSAI
fr1: 978.W4395 • 1'.tx:979-740- .446
Construction Debris Disposal Af idavit
(required 1'ur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 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
I 11. S 150A.
The debris will be transported by:
C' "
(name of hauler)
The debris will be disposed of in :
(name of aci uy)
laddrexs of facility)
7;i ure of permit applicant
� -
dale
Icln i.�ll d�
CITY OF S.U.Ea`I, INLkss k HL'SETTS
Bt:a.DLNG DEPARTMENT
1r 120 WASHINGTON STILEST, 3'o FLOOR
TEL (978) 745.9595
FAX(978) 740.91346
K .%(BE,UZY DRISCOLL 1110" iST.PM"A
MAYOR D iRECroa OP PL aLIC P11OPERTY/SC QDDIG CON UISSION EA
Workers' Compensation Insurance All7davit: Builders/ContractorslElectriclans/Plumbers
A r llcant In(hrrinallets
s Pleasef
Name lduainera.Or/ymratiorr))Istdsrcdtrall: C� Q��70 ��"'
Address- �( f{d /"M
City/StatdZip: Oc(11 V-0 Phone M: 9 C2 9 l� Yam
Are yen as employer?Check the appropriate boa: Type of project(raquke*.
l.R I am a crmploya with Qom_ 4. 0 1 am a gen mid compactor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. ❑Now construction
2.El 1 am a cola proprietor to panrter- listed on the anarJud sheet :
7. 0 Remodeling
+hip and have no employe= Then sub-eonteoewes have V. 0 Demolition
.working for me in any capacity. worksn'Comp,innorancis 9. 0 building addition
I No workers'tomµ insurance S. Owe are a corporation and its
mquireil.) officers have exercised chair 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption pa MGL 11.0 Plumbing regain or additions
myself.(No workers'comp. C. I52.41(4).and we have no 12.0'Roof repairs
insurance requited) ► employee.two workers' I I.❑Other
COMP. insurance rt quind.J
-Any appacan ihr chaale boa 11 noon aim fix tnd the taction below Ainviae their wokam'co ti ma dan policy a.inRtmotle
't l.mcrwnaa who saltine Ohio amd m tleek indicating they a ere so wmek sad than him wsib emanating hoer wchma a nano afQcYvp indiarng nwL
:<%n miart thno ebeek this ben mtM attachod an addiiiunol.hone sMwing an,one,or ran al►seatmelom and thshr-ghee'comp.pettey idormanea
/are an employer that trOro rld/ng workers'coorpenesidee lnstatem"for my emp/oyOtes SNoer b I/Yi peHa�ewd JaI rear
in/brmadow.
Insurance Company.Name: /7 G
Pal icy M or Self-ins. Lic. #, wGGCDC) 2 5 S l� /2 2il9 Expitaliom Data-, L4 c
Job Site Address: I I ✓�i✓I r 5 Ciry/StatdZip: /�
A hack a copy of the workers'compessatba policy declaration pap(showing Ibe polky number and esplrades dots)6
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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 S230.00 r day allainst the violator. Ile advi.ral that a copy of this statement maybe forwarded to the OMce of
I nceaotgatium of ilia MA for insurance cavcraae verification,
l t/o hereby certify und"a p•points and yenaldn ojperJary'Aat rAa inforwadow provided above is true and carrrel
�i=,altcre: 9 /� Data �. .2
O/Jlrial we aady, Do n M write its this area, robe.atwpbed by city of toww n/JBral
City or few n: YcrmiUl.lecnst M I
Issuing.ttulhurity (circle une):
I. Iloard uD Ilvullh 2. Ruilding Department 3. Cicytrown Clerk J. Electrical Impector S. Plumbing inspector
6. Other
L.uteact Perron:__ _ ._ ___ Pliant it:
JOHN WALSH INSURANCE Fax:9787459557 Dec 29 2009 15:25 P. 01
OATETMWDD/YYYY). ..
. CERTIFICATE OF LIABILITY INSURANCE 9E o 12 29/D9
P
RODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
t. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
9talah Iris Agency, Ino HOLDER-THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ox .alsh _ ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW t '"01970 6'4'D7 ',. •o: 979-745-3300 Fax:978-745-9557 INSURERS AFFORDING COVERAGE ' NJUC S'
INSURED ',
... . ..:
wSURER A: Commerce Insurance CQ=PanY 34754 "
,. . ... MSUREA B: Aaaec:w�A EnP1'oyece ma co. .
Ebersole Construction LLC INSURER „Citation Insurance C ny
aAridrn Ebersole ....
.63. Adam St . . iNsukoz
^'IYano'ers^^TWIA>=923:ic ,. .a. ... .
iNSURME . �•..'w .. n�,:. n=rll.TF:.�. _
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 MAYBE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDEDBY 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:'
LTR NSR TYPE OF INSUR
ANCE POLICY NUMBER DA E MMM T DATE MMlp LIMITS
Od1ERAL LWBILfT1,'''. : :,. .. .. ', . . EACH OOCURRENCE: :$.I':000000 ..:.'.
A X.' COMMERCIALGENERALLIA91LITY YT7977 08/22/09 O8/22/10 PREMISES(Ea ocdlMe ) $56006
" CLAIMSMADE OOCCUR MEDE%p(AnyanPpa[sun) $'5QO.O
K� SuNB3.rieds Owners PERSONAL AOVINJURY sibboobot
GENERAL A(iGREGATEF ,$,2D0A0001 ., ('... ..
GEN'L AGGREGPTE',LIMTrAPPLIES PER` PRODLHTS COaIM/OP'AGG $ lO':O'O000_
POLICY JECT Loa
AVTOMbmLELIP9,BITY COMBINED SINGLE'CIMIT $
ANY AUTO lf.': ..:... •';: ..(Ea addOwID
ALLOWNEDAUTOS - BODLLY$iJURV $ '
SCHEDIILED�AUTO$ IRSr Permn) e
HIRED AUTOS. BODILY INJURY $
.: '..
.. NON OWNED AUTOS (Pen8xWMD... .:
PROPERTY DAMAGE _
' (Pw aQJdvd)
GARAGE LIABILITY;• :.'..... '. '.' i. Y' - '. ..'. AUTO.ONLY-EAACCIDENT S
ANYAUTOOT14ER EA.AGC $
. AUTO,
LYN '..fA'GG S
IXce$S/UMBR¢LALJABWTY . . EACH OCCURRENCE':. $
OCCUR !CLAIMS MADE AGGREGATE $
DEDucnBLe S
RETENTIONS
:COMPENSATION.
AND wPLMkV LN9111TY TORY LBAR$ " ER '..
B MY PROPRIETORPARTNERiMCUTIVE0 WCC S0 0 62 55012 0 0 9 o4/20/09 04/20/10 EL EACH ACCIDENT I$500000
OFFICERRVIEMBER EXCLUDED'+
(Mw0gWrrin NH). ELOISEASE EA.FMKOYEE $500000 .
H yyeeqq d.Wb wear b .
SPECUL PROVSIONS I— EL DISEASE=Eai(; :L91R $500000 '
,OTHER-
DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Job performed @: 11 Gardner Street, Salem, MA 01970
CERTIFICATE HOLDER CANCELLATION
SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
0001003 DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 BAYS WRITTEN .
NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT,BUT FAILURE TO 00$0$HALL
City of Salem IMPOSE NO OBLIGATION OR LIABILITY OF ANY NOND UPON THE INSURER,ITS AGENTS OR
Building Inspector
120 Washington St REPRESENTATIVES. 1 u III I
QED R
Salem MA 01970 Mark w_ PHREtSEtNeAnTco urt �
ACORD 25(2009/01) L91988-2009 ACORD COFFPRATION. All rigl}t ggse_O
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